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   Table of Contents - Current issue
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July-September 2019
Volume 14 | Issue 3
Page Nos. 115-282

Online since Saturday, May 2, 2020

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ORIGINAL ARTICLES  

Ventriculosubgaleal shunt in children with hydrocephalus Highly accessed article p. 115
Sandeep Iratwar, Akshay Patil, Chetan Rathod, Paresh Korde, Vijay Mundhe, H Deshpande
DOI:10.4103/jdmimsu.jdmimsu_169_19  
Objective: To determine the rate of conversion to ventriculoperitoneal (VP) shunt in children treated with ventriculosubgaleal (VSG) shunt for hydrocephalus of infective and noninfective etiology. Materials and Methods: A prospective, observational study was conducted at the department of neurosurgery in a tertiary care medical institute in children who underwent VSG shunt for congenital and acquired hydrocephalus of infective and noninfective etiology. Primary outcome measure was rate of conversion to VP shunt. Results: In total 58 children, 65.5% were aged 5 days to 12 months and 67.2% were male. Meningitis (70.7%) was the most common cause of hydrocephalus, followed by hemorrhage (20.7%) and congenital causes (8.6%). The rate of conversion to VP shunt was 58.6%. Moreover, 25.9% of the children had spontaneous resolution of hydrocephalus with no further requirement of shunt, whereas 15.5% required endoscopic third ventriculostomy. Shunt revision was required in 6.9% of the children and shunt malfunction rate was 5.2%. Other complications such as cerebrospinal fluid (CSF) leak (3.4%), wound infection (1.7%), and shunt tip migration (1.7%) were uncommon. Conclusion: VSG shunt is a simple and effective treatment for temporary diversion of CSF for infective and noninfective hydrocephalus in children who are not ideal for a permanent method of CSF diversion even in the presence of active meningitis and shunt infection. In experienced hands and in selected cases, VSG shunt alone can help resolve the hydrocephalus.
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Ocular manifestations in patients with intracranial space-occupying lesions Highly accessed article p. 119
Vrushali Shende, Sandeep Iratwar, Sachin Daigavane
DOI:10.4103/jdmimsu.jdmimsu_174_19  
Aim: This study aims to study the ocular manifestations in patients with intracranial space-occupying lesions (ICSOLs). Materials and Methods: Cross-sectional hospital-based study. Minimum of 70 patients diagnosed and undiagnosed with ICSOL coming to ophthalmology OPD, neurosurgery OPD, and admitted patients to any ward of Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, were selected. Selected patients underwent detailed clinical history, neurological and ocular examination depending on presenting ocular complaints. Results: The study included 36 males and 34 females. 68.57% of ICSOLs were found in the supratentorial compartment of the brain. The most common ocular symptom was diminution of vision followed by doubling of vision, loss of vision, drooping of eyelids, and protrusion of the eyeball. Commonly seen ocular sign was papilledema followed by visual field defect. Glioma (18.57%) and meningioma (18.57%) were encountered to be the most common ICSOLs followed by vestibular schwannoma (17.14%). Other ICSOLs were pituitary adenoma (11.43%), chronic subdural hemorrhage (8.57%), craniopharyngioma, epidermoid cyst, etc. It was observed that symptoms and signs correlated with the location of ICSOL. Conclusion: Ophthalmologists play important role in intracranial localization of ICSOLs depending on ocular symptoms and signs; thus, early diagnosis and referral to neurosurgeon promote early treatment.
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Cardiac involvement in acute pancreatitis and its effect on morbidity and mortality Highly accessed article p. 125
Atul Gawande, Vijendra Kirnake
DOI:10.4103/jdmimsu.jdmimsu_226_19  
Aim: Early identification of cardiac involvement in acute pancreatitis and their appropriate management can decrease significant morbidity and mortality. Very few studies have focused prospectively on cardiac involvement and its association with prognosis in acute pancreatitis. Materials and Methods: Forty-two patients admitted in Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, were enrolled in this study and were divided based on PaO2into Group 1 (PaO2> 60 mmHg) and Group 2 (PaO2< 60 mmHg). Hologram with peripheral smear, blood sugar both fasting and postprandial, hemoglobin A1C, blood urea, creatinine, serum bilirubin, aspartate transaminase, alanine transaminase, alkaline phosphatase, cardiac enzymes, serum amylase, and lipase were measured. Prothrombin time, activated partial thromboplastin time, and lipid profile were measured and arterial blood gas analysis was done. All patients had undergone plane chest X-ray, ultrasonography of the abdomen, contrast-enhanced computed tomography of the abdomen, electrocardiogram (ECG), and two-dimensional (2D) echocardiography (ECHO). Results: 2D echocardiographic changes were more common in Group 2 as compared to Group 1 and were statistically significant (P = 0.004). Pericardial effusion and diastolic dysfunction were more common in Group 2 and were statistically significant (P = 0.006 and 0.031, respectively) whereas the difference between the association of regional wall motion abnormality (RWMA) in the two groups was statistically insignificant (P = 0.110). Both ECG and 2D echocardiogram (ECHO) changes were reversible and were statistically significant (P = 0.05 and 0.003, respectively). The need for admission in the intensive care unit (ICU) was significantly associated with pericardial effusion (P < 0.001) and diastolic dysfunction (P = 0.013) but not associated with RWMA (P = 0.710). ECG abnormalities at admission were not related to the need for mechanical ventilation and admission to ICU (P = 0.802). Conclusion: 2D ECHO abnormalities and not the ECG abnormalities were associated with a poor prognosis. Early recognition of echocardiographic changes in acute pancreatitis can predict the severity of disease and can help in the triage of patients requiring rigorous monitoring of respiratory and hemodynamic status.
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Clinical Profile of Patients with Hepatic Encephalopathy in Cirrhosis of Liver Highly accessed article p. 130
Shilpa Bawankule, Sunil Kumar, Abhay Gaidhane, Mahalaque Quazi, Aman Pratap Singh
DOI:10.4103/jdmimsu.jdmimsu_88_18  
Backgroud: Hepatic encephalopathy (HE) is defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after exclusion of other known causes of brain disease. In India hepatic encephalopathy is considered as indicator of poor prognosis in patients of cirrhosis of liver with 1 year survival in just 42% patients and 3 year survival in 23% of patients. Aim and Objective: Study clinical profile for adverse outcome in patients of hepatic encephalopathy due to cirrhosis of liver. Methods and Methodology: This was a cohort type of study done for a period of 2 years from September 2016 to September 2018 on a study population of 130 patients. Cirrhosis of liver was confirmed by ultrasound of liver. Results: Study included 130 patients of HE secondary to cirrhosis of liver, 82% were males, 44% and 45 % of patients were in grade 2 and grade 3 of West Haven criteria respectively. Icterus, ascites and asterexis were present in almost 65% patients. Cirrhosis was associated with alcohol dependence among 75% of patients followed by NAFLD in 6.15% of patients. Other unknown causes were among 19(14.62%) patients. In our study lactulose was found as the leading treatment modality in 73.84% of patients. Conclusion: Most of the patients were in grade III of HE, alcohol was the most common etiology of cirrhosis, icterus was the most common sign of liver cell failure, most common drug used was lactulose.
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Platelet-Rich plasma in androgenic alopecia: Myth or an effective tool Highly accessed article p. 137
Yeshwant Lamture, Aditya Mundada, Varsha Gajbhiye
DOI:10.4103/jdmimsu.jdmimsu_45_19  
Introduction: Androgenic alopecia (AGA) is the most common form of alopecia, affecting up to 80% of men. Platelet-rich plasma (PRP) is an autologous preparation of plasma with concentrated platelets. PRP contains various growth factors and cytokines that enhance the body's inherent capacity to repair and regenerate. Materials and Methods: A study involves 20 patients suffering from AGA. The hair pull test was performed before the treatment session. The volume of 10 cc PRP was injected. The treatment was repeated every month for six times. The outcome was assessed after 6 months by clinical examination, global photos, hair pull test, and patient's overall satisfaction. Results: A significant improvement in hair loss was observed between the first and sixth injection of PRP. Hair count increased from the average number of 60 hair follicular units to 84 hair follicular units. The average mean gain in hair follicles is 24 units/cm2. After the 6th session, the pull test was negative in 17 patients. The average improvement before and after the procedure ranged from −2 to + 4 according to the 15-point Jaeschke scale. AGA is a disorder that is marked by the reduction in the diameter, length, and pigmentation of the hair. Growth factors in PRP are known to activate the proliferative phase and transdifferentiation of hair and stem cells and produce new follicular units. Conclusion: PRP injection is a simple, cost-effective, and feasible treatment option for AGA.
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Study of visual outcome and complications of iris-claw intraocular lens implantation to correct aphakia p. 141
Vishal Kalode, Sachin Daigavane
DOI:10.4103/jdmimsu.jdmimsu_3_19  
Aim: To study the visual outcome and complications of irisclaw intraocular lens implantation to correct aphakia. Objectives: To study the visual outcome in patients with irisclaw lens implantation. To document the various complications associated with irisclaw lens implantation. To evaluate the safety of irisclaw lens implantation. Materials and Methods: Patient's eyes with no capsular support that had iris claw intraocular lens to correct aphakia between 2016 to 2018. Results: The study comprises of 50 eyes of 50 patients who underwent iris claw intraocular lens implantation to correct aphakia with no posterior capsular support. In our study population, the maximum number (70%) of patients had the preoperative BCVA of logMAR 0.18, ranging 0.18–0.78, with a mean of 0.28 ± 0.18, At 6month postoperative followup, of the total patients, 4% had the BCVA of log MAR 0.78, 2% had the BCVA of logMAR 0.6, maximum 88% had the BCVA of logMAR 0.18, and 6% had the BCVA of logMAR 0.3. In the early postoperative complications, 22% of patients had raised IOP, which was controlled on a shortterm antiglaucoma drug (timolol e/d bd); 12% of patients had pupil distortion; and 12% had corneal edema, which subsides on subsequent followup. 6% of patients had anterior chamber reaction and hyphema. Conclusion: Irisclaw lens implantation gives the good visual outcome in the patients of cataract with inadequate capsular support. The anatomical position of IOL is well maintained by the technique. Minor complications were treatable with no visionthreatening complication. Few patients had the late postoperative complication, which needs to be minimized. The technique is easy to master, generally safe, and effective on shortterm followup.
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Comparative efficacy of laser and topical corticosteroid in the management of aphthous stomatitis p. 155
Neha Agrawal, Suwarna Dangore, Rahul Bhowate, Shailesh Agrawal, Amit Reche
DOI:10.4103/jdmimsu.jdmimsu_31_19  
Background: There are different modalities for the management of aphthous stomatitis. Laser therapy and topical corticosteroid are among these treatment options. The main focus of all these treatment modalities is toward the symptomatic relief and decrease in the duration of ulcer. Objectives: The aim of this study was to compare the efficacy of laser of 810 nm wavelength with topical corticosteroid in the management of aphthous stomatitis. Materials and Methods: A prospective clinical study comprised 77 patients ranging in the age group 20–40 years. Patients were divided into two groups – Group I patients were treated with laser therapy (810 nm) on the 1st day of the visit, while Group II patients underwent single local corticosteroid treatment (triamcinolone acetonide 0.1% in orabase). Size measurement, pain score, functional disability, and the level of erythema were measured immediately after application and on the 3rd day. Results: On follow-up visit, there was a significant statistical difference in pain score and functional disability in Group I patients. The level of erythema was significantly decreased in both the groups, more in Group II. Conclusion: Laser treatment showed superiority over corticosteroid in terms of instant pain relief and functional disability caused by the ulcer. However, both the therapies resulted in significant relief in symptoms at the end 3rd day.
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Correlation of Ki-67 labeling index in cervical intraepithelial neoplasia with histomorphologic grading system p. 162
Nihar Gupta, Pratibha Dawande, Samarth Shukla, Arvind Bhake
DOI:10.4103/jdmimsu.jdmimsu_44_19  
Background: Worldwide cervical cancer ranks as a major health problem for women. The cervical carcinoma is preceded by premalignant dysplastic changes in normal squamous epithelial layer which is called as cervical intraepithelial neoplasia (CIN). Aim: The aim of the study is to assess the utility of Ki-67 labeling index (LI) in grading of CIN. Objectives: The objective of the study is to identify potential corelation between histomorphological grading and Ki-67 LI of CIN. Materials and Methods: The present study was carried out as an observational type of study. The study was carried out from August 1, 2016, to July 31, 2018, in the Department of Pathology in co-ordination with the Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Sawangi (M), Wardha, Maharashtra. A total of 82 specimens which include cervical biopsies and hysterectomy specimen formed a part of the present study, of which 59 cases were prospective and remaining 23 cases considered were retrospective. Results: Tumor cell proliferation as measured by Ki-67 proliferative marker shows a linear correlation with histopathological grading of cervical dysplasia as per the WHO classification. With increasing grades of CIN, Ki-67 LI also increases. Conclusion: It can be stated that to determine the grades of cervical dysplasia, Ki-67 antigen should be used as an adjunct with histopathological grading which remains as the “Gold Standard.“
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Comparative Evaluation of 5th- and 7th-Generation Bonding Agents: An In vitro Study p. 166
Madhu Varma, Shweta Sedani, Pradnya Nikhade
DOI:10.4103/jdmimsu.jdmimsu_46_19  
Objective: The purpose of this study is to evaluate microleakage in 5th- and 7th-generation bonding agents. Materials and Methodology: A total of thirty recently extracted human premolars were subjected to this study. Class V cavity preparations were made on the lingual and buccal surfaces of extracted premolars. Occlusal margins were made in enamel and gingival margin in cementum/dentin. The teeth were divided into two groups of 15 each and 30 cavity preparation per group. The groups were treated with Single Bond 2 and Single Bond Universal as dentin-bonding agents. The prepared cavity was restored with resin composite (Clearfil APX) after the application of bonding agents. The specimens were thermocycled and stained with 2% methylene blue dye and were section for the evaluation of dye penetration. Data were analyzed using one-way analysis of variance test and Dunn's procedure for pairwise comparison of data. Results: This study showed that the preparations treated with Single Bond Universal showed less microleakage than Single Bond 2, and it had a better marginal sealing ability at enamel margins better than dentin. Interpretation and Conclusion: This study demonstrated that Single Bond Universal had a better sealing capacity at both coronal (enamel) and apical (dentin/cementum) margins compared with Single Bond 2 agent used.
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The Effect of Chewing Gum Containing Casein Phosphopeptide–Amorphous Calcium Phosphate on Salivary Streptococcus mutans p. 171
Nakul Arora, Alka Hande
DOI:10.4103/jdmimsu.jdmimsu_47_19  
Objectives: The aim of this study was to evaluate the effect of sugar-free chewing gum containing casein phosphopeptide–amorphous calcium phosphate (CPP-ACP) on salivary Streptococcus mutans. Materials and Methods: A total of 25 dental students of 20–25 years old, who volunteered after checking their health condition and signing informed consent, were randomly allocated to receive chewing gum containing CPP-ACP; individuals within the experimental groups were taken the gums 3 times daily after each meal for a period of 2 weeks. Pre- and postintervention unstimulated saliva samples were quantified for S. mutans counts. Results: A statistically significant reduction of salivary S. mutans was displayed with baseline (P < 0.05). Conclusion: Daily consumption of chewing gum containing CPP-ACP significantly reduces the level of salivary S. mutans.
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Comparison between Supraclavicular and Interscalene Brachial Plexus Block in Patients Undergoing Shoulder Surgery p. 175
Roona Singh, Amol Singam
DOI:10.4103/jdmimsu.jdmimsu_53_19  
Introduction: Interscalene approach of the brachial plexus block is considered the gold standard for shoulder anesthesia. However, this method is associated with a high incidence of side effects such as Horner's syndrome, phrenic nerve palsy and hoarseness of voice. The supraclavicular approach of the brachial plexus block is associated with a high success rate and provides anesthesia of the entire upper extremity in the most consistent, time-efficient manner. However, there is little information regarding its efficacy for providing analgesia for shoulder surgeries. This study was carried out to compare the success rate and complications associated with each technique. Materials and Methods: After the approval of Ethics Committee, this prospective, randomized comparative study was carried out on 60 American Society of Anesthesiologists Class I and II patients posted for elective and emergency shoulder surgeries. Sixty patients were randomly divided into two groups of 30 each, namely interscalene block (ISB) group and supraclavicular block (SCB) group. Both the blocks were given with 30 ml of 0.375% injection bupivacaine. Success rate, block performance time, patient requiring fentanyl, duration of analgesia and complications were noted. Results: The success rate and duration of analgesia were comparable in both the groups. Block performance time was significantly longer in SCB group as compared to ISB group. The requirement of intraoperative fentanyl was more in the SCB group. Complications such as Horner's syndrome, phrenic nerve palsy and hoarseness of voice were significantly higher in ISB group as compared to SCB group. Conclusion: SCB technique has an equal success rate and provides similar analgesic efficacy and duration of analgesia as ISB for shoulder surgeries. It is also associated with a lesser incidence of complications. SCB can thus be considered as a safe alternative to ISB for shoulder surgeries.
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Computed tomographic evaluation of intracerebral hemorrhage p. 179
Monika Pote, Suresh Phatak, Pallav Thakare
DOI:10.4103/jdmimsu.jdmimsu_75_19  
Context: Computed tomography (CT) has been the standard imaging modality for the initial evaluation of patients presenting with acute stroke symptoms. The primary diagnostic advantage of CT in the hyperacute phase is its ability to rule out the presence of hemorrhage. The accurate early detection of blood is crucial since a history of intracerebral hemorrhage is a contraindication to the use of thrombolytic agents. Aims: The aim of this study is to study the role of CT in the evaluation of intracerebral hemorrhage. Settings and Design: Prospesctive cross sectional observational study. Subjects and Methods: This was a prospective study of 110 patients irrespective of age group with a clinical suspicion of intracerebral hemorrhage done in the Department of Radiodiagnosis, AVBRH, DMIMS (DU), Sawangi (Meghe), Wardha, Maharashtra, India. Results: Out of 110 patients diagnosed with intracerebral hemorrhage, 67 (61%) patients were male and 43 (39%) were female. The main clinical presentation was abrupt onset severe headache, vomiting, difficulty in speech, seizures, weakness in limbs, altered mental sensorium, and sudden loss of consciousness. Among risk factors, the most common was hypertension present in 70 (63.6%) patients followed by diabetes in 62 (56.3%) patients. The putamen is the most common site of intracerebral hemorrhage involved in 47 (42.7%) patients followed by the thalamus in 24 (21.8%) patients. Conclusions: In the present day, CT is the initial modality of choice and is found to be very helpful in diagnosing intracerebral hemorrhage; it plays a crucial role in patient care by determining which course of treatment is called for.
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Sonoelastographic Evaluation of Uterine Fibroids – Our Initial Experience p. 183
Suresh Phatak, Gulam Marfani
DOI:10.4103/jdmimsu.jdmimsu_78_19  
Context: Real-time elastography is a novel and dynamic imaging technique that is based on the softness or hardness of tissues or organs of interest under the appropriate compression and can be used with conventional ultrasonography(US) probes after performing grayscale imaging and Doppler US. Aims: It was to find out the diagnostic ability of sonoelastography in evaluation of uterine fibroids and whether evaluation with computed tomography (CT) or magnetic resonance imaging (MRI) can be avoided. Subjects and Methods: A prospective study was conducted from August 2017 to August 2018. A total of 87 females were included and underwent sonographic examination and a diagnosis was made, and later, elastogram was obtained and strain ratios were calculated and the final diagnosis was compared to histopathological diagnoses to evaluate the diagnostic accuracy of ultrasound with and without elastography. Statistical Analysis Used:Statistical analysis was done using descriptive and inferential statistics using Chi-square test, Student's unpaired test, sensitivity, and specificity, and software used in the analysis was SPSS 22.0 version and GrafhPad Prism 6.0 version. Results: Out of the total 87 patients, 10 cases were misdiagnosed on ultrasonography compared to 7 on elastography, of which the major pathology was adenomyosis and 1 case submucosal fibroid. Sensitivity, specificity, and diagnostic accuracy of ultrasound were found to be 90.28%, 80%, and 88.5%, respectively. Sensitivity, specificity, and diagnostic accuracy of sonography with elastography were 93.06%, 86.67%, and 91.95%, respectively, showing better results. Conclusions: Sonography coupled with elastography showed better results and can be used to avoid dependency on CT and MRI avoiding radiation exposures and increase cost, especially in a developing country such as India.
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Diaphyseal fractures in pediatric age group in rural area: A demographic study p. 189
Sridhar Reddy, Nareshkumar Dhaniwala
DOI:10.4103/jdmimsu.jdmimsu_79_19  
Introduction: Fractures in children are a common occurrence. Fractures have a considerable impact on daily living and activities of affected children and thus are an important topic of public health. The present study aims to study the demographic aspects of diaphyseal fractures in children. Materials and Methods: This is a prospective study conducted in a tertiary care rural hospital in Central India on children in the age group of 3–15 years between June 2017 and April 2019. A total of 38 fractures in 25 children were included in the study. Results: The incidence of fractures was found more common in boys (60%). Most of the fractures were seen in the age group of 11–15 years (68%). Fall from level ground while playing was reported to be the most common mode of trauma (56%), followed by road traffic accident. Twenty-eight percent of the patients presented to the hospital on the day of trauma. Among the bones fractured, both bone forearms were the most common (52%). Overall, left-sided fractures were more common (56%) than right sided (44%). Middle one-third shaft was the most commonly fractured level.Conclusions: Both bone forearms are the most common diaphyseal fractures in children and middle one-third is the most common level. Injury prevention programs will help in decreasing the incidence and morbidity associated with pediatric fractures.
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Sonographic evaluation of knee pain: A prospective observational study p. 192
Suresh Phatak, Sanjay Deshpande, Gaurav Mishra, Kaustubh Madurwar, Gulam Marfani, Bharat Lohchab
DOI:10.4103/jdmimsu.jdmimsu_81_19  
Context: Ultrasonography (USG) is a noninvasive imaging modality used for the assessment of the musculoskeletal system. The knee is one of the joints which can be extensively explored with ultrasound due to the presence of wide acoustic windows, which allows easy visualization of different anatomical structures. Aims: The aim of the study was to find out the common diseases causing knee pain and to characterize the sonographic features of each cause. Subjects and Methods: In a cross-sectional observational study conducted in Acharya Vinoba Bhave Rural Hospital of JNMC College, Sawangi, Wardha, after obtaining ethical committee clearance, 100 patients who presented with knee pain were evaluated with sonography during a period of 2 years. Results: The most common age group in this study was 31–40 years, followed by 41–50 years. The most common sonographic diagnosis was osteoarthritis, followed by joint effusion and Baker's cyst. Conclusions: USG is an excellent modality for the evaluation of knee pain, which is free of ionizing radiation, and its easy availability and affordability makes it a preferred modality of choice.
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The Effect of intrathecal magnesium sulfate to bupivacaine-fentanyl subarchanoid block for infraumblical surgeries p. 196
Shreshtha Singh, Jayashree Sen
DOI:10.4103/jdmimsu.jdmimsu_83_19  
Background: Subarachnoid block is a safe and inexpensive technique , most versatile regional block for infraumbilical surgeries. Adjuvants such as Fentanyl is the most commonly used. It has been shown that the duration of postoperative analgesia also can be prolonged when magnesium is given as an adjunct for peripheral nerve blocks. Aim and Objectives: the present study was designed to examine whether addition of intrathecal magnesium sulfate would enhance the analgesic efficacy of intrathecal bupivacaine and fentanyl in patients undergoing infra umbilical surgeries. And with the primary objective to study the efficacy, onset and duration of analgesia , hemodynamic variability during block and duration of motor block and secondary objective to know adverse effect of the drugs. Setting and Design Prospective, randomised controlled observational study. Material and Methods: 70 patients were selected , they were randomly allocated into two groups of 35 each using computer generated data. Group S: Intrathecal administration of 2.5 mL (12.5 mg) of hyperbaric bupivacaine + 0.5 mL (25 mcg) of fentanyl + 1 mL of normal saline. Group M: Intrathecal administration of 2.5 mL (12.5 mg) of hyperbaric bupivacaine + 0.5 mL (25 mcg) of fentanyl +1.0 ml (50 mg) of magnesium sulphate. Statistical Analysis- done by using descriptive and inferential statistics using chisquare test and student's unpaired t test and software used in the analysis were SPSS 22.0 version and Graph Pad Prism 6.0 version and p<0.05 is considered as level of significance. Results: We conclude that when magnesium is added in the mixture of bupivacaine and fentanyl through spinal route it significantly prolonged postoperative analgesia without any significant haemodynamic variations and adverse effects. Conclusion: Adding magnesium in the mixture of bupivacaine and fentanyl through spinal route for effective postoperative analgesia is without significant haemodynamic variations and adverse effects.
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The effectiveness of box trainers in improving laparoscopic suturing skills in surgery p. 202
Yeshwant Lamture, Varsha Gajbhiye, Ujwal Gajbe
DOI:10.4103/jdmimsu.jdmimsu_88_19  
Background: Simulation training is an integral part of the laparoscopic training curriculum. To recognize the role of laparoscopy in modern surgery, residency programs rapidly incorporated it into their training regimen. Box trainers are useful to practice laparoscopic skills. Laparoscopy requires a long-learning curve. The simulation training model gives opportunities to practice the procedures efficiently until competency is achieved without exposing the live patient to undue risk. Hence, this study was conducted to assess the overall effectiveness of the box training to improve the skills in laparoscopic suturing. Materials and Methods: This was a prospective and observational study conducted over a period of 6 months including 30 residents of the surgery department. The department of surgery has an indoor laboratory that consists of an isolated room with two box-trainers. Participants were given a task to perform suturing by using box trainers for 2 h/week for 6 months. For the quantitative and qualitative assessment, a direct observation checklist was prepared, i.e., task-specific checklist having a maximum score of 15. Each participant performed a suturing task. Pre- and posttraining score was calculated and was compared to see the efficacy of the box trainers. Results: Around 30 participants’ surgery, residents were enrolled. Twenty-six male and 4 female residents were included in the training, with the age of all residents ranges from 26 to 30 years. The mean pretraining score was 3.1667, and it is improved significantly to 12.3667 after training. The unpaired t-test was calculated (20.5050). The two-tailed P is less than 0.0001; hence, it is statistically significant. Conclusions: This study proves the efficacy of box trainers in improving laparoscopic suturing skills.
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Distribution of diseases in orthopedic indoor patients in a rural tertiary care center in central India p. 206
Nareshkumar Dhaniwala, Mukund Dhaniwala
DOI:10.4103/jdmimsu.jdmimsu_103_19  
Introduction: Orthopedic diseases can be grouped in two broad categories, one consisting of various traumatic fractures and associated injuries and the other consisting of cold orthopedic diseases including infection, congenital and developmental conditions, tumors, degenerative disorders, and nutritional disorders, etc., involving bones, joints, muscles, and other soft tissues. Distribution of these in outpatient department and emergency department vary and has been studied by some authors. The distribution of orthopedic diseases in admitted/inpatients has not been studied much. The present article is an analysis of orthopedic indoor patients to find out the distribution of diseases in admitted orthopedic patients. Materials and Methods: Indoor patients of orthopedic wards admitted under a particular unit during 2 months were analyzed for the age, sex, rural/urban background, hospital stay, diagnosis, and treatment given. This analysis was performed retrospectively from the discharge records. Observations and Results: The total number of cases studied was 62. Males (47) admission was three times more common than females (15). The maximum admitted patients were in the age group of 20–40 years (37.09%), and > than 40–60 years (32.25%) together making about 70% of admissions. About 62.90% of patients were from rural background. Hospital stay less than a week was noted in 38.70% of patients, between 1 and 2 weeks in 22.58% of patients, between 2 and 4 weeks in 29.03% cases and more than 4 weeks in 9.67%. Trauma cases (58.06%) exceeded nontraumatic cases (41.93%). Fifty-five (88.70%) patients were admitted as new cases, whereas seven (11.29%) were admitted as follow-up cases. Treatment with anti-inflammatory drugs, reduction of fracture with closed manipulation, cast or open reduction, and internal fixation were the most common methods of treatment done. Tumor excision, debridement of wound, and decompression of the spine were the common methods to treat orthopedic nontraumatic disorders. Conclusion: Tumor excision, debridement of wound, and decompression of the spine were the common methods to treat orthopedic nontraumatic disorders.
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Clinical profile and survival outcome of acute respiratory distress syndrome in a rural tertiary care hospital p. 210
Nakul Kadam, Sourya Acharya, Samarth Shukla, Nitin Raisinghani, Aditya Khandekar
DOI:10.4103/jdmimsu.jdmimsu_116_19  
Background: Acute respiratory distress syndrome (ARDS) is characterized by rapid onset severe dyspnea, hypoxemia, and diffuse bilateral pulmonary infiltrates leading to respiratory failure. This syndrome can occur even without primary damage to the lung parenchyma, and thus, they are more often classified as ARDS due to pulmonary and extrapulmonary causes. Mortality estimates range from 26% to 44% in different studies. There are several critical care scores that are in vogue in intensive care units. This study was undertaken to describe the clinical profile of ARDS and along with that the study also intended to correlate the outcome of ARDS patients with reference to these critical care scores and try to establish which score would be best to prognosticate ARDS. Aims: This study aims to study the clinical profile and survival outcome of ARDS in a rural tertiary care hospital. Materials and Methods: All patients fulfilling the inclusion criteria as per the 1994 American European Consensus Conference on ARDS definition of ARDS were included in the study. The severity of ARDS was measured by various critical care scores such as the Acute Physiology and Chronic Health Evaluation Score, Multiple Organ Dysfunction Score (MODS), Lung Injury Score (LIS), and Sequential Organ Dysfunction Assessment (SOFA score). Results: The ratio of male and female (male: female) was 1.7:1.0. Proportion of males (62.5%) was significantly higher than that of females (37.5%) (Z = 3.53;P < 0.001). Clinical disorders pneumonia (35%), sepsis with multiorgan failure (27.5%), and tropical infections (21.5%) were significantly higher than that of other etiologies (Z = 3.68;P < 0.0001). The mean age, APACHE-II score, SOFA score, LIS, and MODS were significantly higher of the patients who died during treatment as compared to the patients who were discharged alive (P < 0.0001). In receiver operating characteristics/area under curve (AUC) analysis, AUC of MODS followed by SOFA score was higher than that of other scores. Thus, MODS Score was as good as SOFA score to predict death. Conclusion: In this study, the primary pulmonary infection/pneumonia, septicemia, and tropical infections were the leading causes of ARDS. Among the various scores; MODS and SOFA score predicted the mortality more accurately.
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Perception of mental health problems and coping strategies among rural women living in vidarbha region p. 215
Jaya Gawai, Vaishali Tendolkar
DOI:10.4103/jdmimsu.jdmimsu_179_19  
Background: Mental Health of women is the most neglected area worldwide. In India due to poverty, unemployment, low level of education contributes to the inferior status of women in homes and in society. In addition, the introvert culture in many parts restricts the women any access to the health services leave along the mental health services. Under the circumstances the investigator seeks to do an in-depth study on, how the rural women are experiencing mental health problems and their coping strategies. Aim:To evaluate the perception of mental health problems and coping strategies practiced by rural women of the Vidarbha region. Research Design: Qualitative study Participants: Rural women above 18 years. Setting of the study: Two villages namely, Mohi and Ghorad; of Vidarbha region in Maharashtra state of Central India. Results: Married women had common somatic complaints like sleeping disorders, headache, chest pain, tiredness, and giddiness etc. not related to physical efforts. They were using certain maladaptive coping strategies like physically abusing their children, tobacco addiction and forcing their children for school dropout. Among the unmarried women, poor academic performance, school dropouts and peer and family pressure for early marriage were the major issues for mental distress leading to helplessness, and inadequate knowledge. Conclusion: The rural women perceive and attribute mental health problems to physical exertion and factors like lack of mental health care services. Hence a targeted intervention is needed to bring awareness among women of rural Vidarbha for promoting mental health and well-defined scientific coping strategies.
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Objectively structured assessment of surgical skill of orthopedic postgraduates p. 221
Samir Dwidmuthe, Sonali Choudhari, Tripti Srivastava
DOI:10.4103/jdmimsu.jdmimsu_210_19  
Introduction: Assessment of “Surgical or Operative skills” is essential for a postgraduate student in surgery and allied subjects including orthopedics. This assessment is more relevant as formative than only on the day of summative examination. However, formal and regular assessment of “Surgical or operative skills” of the postgraduate students seems to be a neglected area since it is challenging to conduct such assessment in setting like operation theatres and paucity of valid and reliable tools. In the present study, Objectively Structured Assessment of Technical Skill Score (OSATS) was used as tool to analyze the feasibility and inter observer reliability for assessment of identified surgical skill/competency of orthopedics postgraduates. Methodology: This cross-sectional study was conducted in Department of Orthopaedics of a tertiary care teaching hospital in Central India, from May to August 2018. Seven postgraduate students of the department were included in the study. Two trained faculty members observed the performance by postgraduates for a skill of “Skin suturing in a hip surgery” and scored them using Global rating scale of OSATS on a Likert scale and a Task specific checklist (TSC). Results: The mean OSATS score was 29.28 (Range 24–35). Task specific score was lower in 2nd year postgraduate (9.5) as compared to scores of 3rd year students. No statistically significant difference was found between OSATS and TSC scoring by both the observers. Inter-rater reliability using Spearman's correlation was found to be r = 0.947074863 for OSATS and 0.886844053 for TSC. There was significant difference for evaluation of OSATS and TSC scoring between JR-II and JR-III students for both the observers. Conclusion: OSATS scores along with TSC are reliable with good interobserver correlation for assessment of surgical/technical skill of orthopedic residents. Validated TSC needs to be created for all the identified technical skills to be assessed.
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Knowledge, attitude, and practice of general dentists toward cone-beam computed tomography and dental radiology p. 226
Aditi Thakkar, Amit Reche, Shivangi Srivastava, Nandini Nade, Sukeshani Jagtap, Gargi Nimbulakar
DOI:10.4103/jdmimsu.jdmimsu_212_19  
Background: Oral cavity is a sort of “No Man's Land” to the general practitioners of medicine and dentistry. As dentistry moves into medical and wellness model, the incorporation and proper utilization of advanced diagnostic technologies is essential. Diagnostics have a decisive impact of continuum of care and this early diagnosis help in disease prevention, knowing early disease stage when symptoms are just beginning to appear. The introduction of cone-beam computed tomography (CBCT) heralds true paradigm shift from two-dimensional to three-dimensional approach to data acquisition and image reconstruction. Aim: The aim of this study was to evaluate’ knowledge, attitude, and practice of general dentists toward CBCT and dental radiology. Objectives: This study was conducted to assess the knowledge, attitude, and practice of general dentist toward CBCT and dental radiology. Materials and Methods: A questionnaire survey dealing with knowledge, attitude, and practice used in dental radiology was conducted among 250 dental practitioners in Sharad Pawar Dental College, Sawangi (Meghe), Wardha and private dental clinics of Vidharbha region of Central India. Furthermore, written consent was taken from each individual who were willing to participate in the study. A total of 250 dentists participated in the survey, including Master of Dental Surgery (MDS) and Bachelor of Dental Surgery (BDS), working as a faculty and/or general practitioner, intern, and postgraduate. The questionnaire consisted of two principle parts – the first part requested the demographic details of respondents. In the second part, they were questioned about the clinical method relating to the use of CBCT, the type of radiography they use, the guidelines they follow, and the technologies they prefer. The analysis was done using SPSS version 16.0. Results: There were 63.6% of BDS practitioners and about 35.7% MDS practitioners; it was observed that more than 63% of the practitioners had advised their patients for CBCT scan. Furthermore, around 81.6% of practitioners were satisfied with the use of CBCT and 72% of them had the view that it should be used for selected dental applications in the future as well. There were 88.8% of the practitioners who believed that there should be regular training or hands-on courses or evaluation o CBCT scan. Around 41.2% of participants opiated that workshop will help enhance the knowledge concerned with CBCT. Conclusion: Therefore, the present study showed better awareness of CBCT among dental practitioners and it also highlighted that majority of participants believed that CBCT was an ultimate diagnostic tool in dentistry and research.
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Relationship between learning goals set by undergraduate medical students at the commencement and learning outcomes achieved at the end of early clinical phase p. 232
Reem Abraham, Lavinia Shamugam, Thurgai Sehgar, Rozalind Romeli, Bavani Manogran
DOI:10.4103/jdmimsu.jdmimsu_21_18  
Background: Medical students entering the clinical term are in a transition phase, wherein the structured classroom environment suddenly changes to one that requires them to face practical as well as emotional challenges. It has been postulated that goal setting would prepare students to face the clinical environment with more readiness than experiencing a “shock of practice.” Aims: This study intended to assess the extent to which undergraduate medical students who experienced the transition phase from preclinical to clinical phase achieved their predetermined learning goals, at the end of clinical phase. Methodology: In the present study, undergraduate medical students (n = 220) at Melaka Manipal Medical College, Manipal Campus, India, on the commencement day of clinical phase, were requested to identify ten learning goals they wished to achieve. At the end of clinical phase, students were again requested to respond to a questionnaire, indicating the extent to which learning goals have culminated as learning outcomes, following which a frequency analysis of the responses was done. Results: Forty learning goals were identified by students, of which thirty learning goals were identified by more than 75% of students, at the commencement of clinical phase. At the end of clinical phase, ten learning goals among these thirty, for example, history taking (89.9%) and communication skills (75.8%), were reported to have achieved as learning outcomes to a great extent by more than 75% of students. Four learning goals, for example, diagnose diseases (42.3%) and manage emergency situations (31.5%), were reported to have achieved as learning outcomes to a great extent by <50% of students. The learning goals identified by students were found to be in line with the course objectives. Conclusions: The present study revealed that students could achieve most of the learning goals identified by them, if not all, which were enlisted in the course objectives, as reported by them.
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Studies on the Association of DEFB1 Gene Polymorphism (rs11362 and rs1799946) and Dental Caries in South Indian Population p. 237
B Akilpprienka, M Malarkodi, R Vivedharani, Sindhu Varghese, V Anitha, Karunanithi Rajamanickam, Gowtham Kumar Subbaraj
DOI:10.4103/jdmimsu.jdmimsu_102_17  
Background: Caries development in the teeth is multifactorial diseases where the environment, and the genetic factors play an important role in the onset and recurrence. Defensins are small, cationic, cysteine-rich peptides found to be active against microorganisms including bacteria, fungi and many non-enveloped and enveloped viruses. It play a significant role in defense against numerous pathogens, and they are deliberated part of the innate immunity. They have usually been considered to contribute to mucosal health. Defensin (DEFB1) gene polymorphisms may modulate human beta defensin (HBD-1) levels might be related to pathogenesis of numerous ailments. Aim: The present investigation was aimed to understand the association of two single-nucleotide polymorphisms (rs1799946 and rs11362) of DEFB1 gene with dental caries. Results: we could found that the single-nucleotide polymorphism (SNP) rs11362 is positively associated with the progression of dental caries in the tested population. Conclusion: our analysis possibly identified the accentuate relationship between dental caries and the SNP rs11362 polymorphism of the defensin gene (DEFB1), innate immune players in the oral area.
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Awareness about behavioral risk factors of noncommunicable diseases and practices related to healthy lifestyle among class IV female employees in a tertiary care hospital of Eastern India p. 241
Saswatika Beura, Lipilekha Patnaik, Sumitra Pattanaik, Trilochan Sahu
DOI:10.4103/jdmimsu.jdmimsu_102_19  
Background: Noncommunicable diseases (NCDs) represent the biggest threat to women's health in developing countries in their most productive years. Working women have to manage both work and their family which may increase the risk of NCDs. Objective: The objectives of this study were (1) to assess the awareness about behavioral risk factors of NCDs and (2) to know the practices related to healthy lifestyle. Subjects and Methods: This was a cross-sectional study conducted among Class IV female employees of a tertiary care hospital between September and October 2018. A total of 102 female employees were included in the study. Data were collected using predesigned and pretested interview schedule. Descriptive statistics and Chi-square test were used for analysis. Results: The mean age was 36.86 ± 9.89 years, among them 98% were Hindu, 82.4% belonged to general caste, 62.7% had nuclear family, and 56.9% were married. It was observed that 94.2% of employees heard about NCDs such as diabetes, cancer, and cardiovascular diseases. About 86% knew about risk factors of NCDs; the major risk factors stated by them were tobacco and alcohol use and stress. About 40% of employees were chewing tobacco. The mean stress score was 16.10 ± 2.7. None of the employees were doing exercises or walking, and all were doing moderate activity at the workplace. Conclusion: Fair knowledge of behavioral risk factors of NCDs was found among women but practices related to healthy lifestyle were found inadequate. Interventions should be targeted to bring healthy lifestyle practices among female employees.
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Knowledge, attitude, and practice regarding risk factors and lifestyle modifications in people with coronary artery disease in a rural area of Western Maharashtra p. 247
Urmila Jain, Varoon Jaiswal, Sneha Ghuman, Snehal Ghodey
DOI:10.4103/jdmimsu.jdmimsu_68_19  
Aims: This study was done to assess knowledge, attitude, and practice (KAP) regarding risk factors and lifestyle modifications among people with coronary artery disease using a self-validated questionnaire. Design: It was a cross-sectional study. The sampling type was simple random sampling. A sample size of 82 was obtained. Methods: A self-validated questionnaire was used to conduct the survey. Informed consent was obtained from participants before filling of the questionnaire. Statistical Analysis: Frequency and percentages were calculated. Results: Only a few respondents had knowledge regarding exercising in exercise class/gym and that walking and gardening cannot be considered as exercises. A similar trend was seen for practice where few percent of the participants exercised for more than 20 min 3 days/week and under the supervision of a physiotherapist. An overall fair attitude was seen toward lifestyle modifications among the respondents. Conclusion: From this study, it was concluded that the lack of knowledge regarding certain factors also influenced the attitude and practice toward it. Furthermore, despite having knowledge regarding certain factors, people showed less willingness to make lifestyle changes which also affected their practices. Hence, it is necessary to study KAP of the population to educate people better and aid the planning of health promotion activities.
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CASE REPORTS Top

A rare case of odontogenic myxoma of the mandible p. 250
Preethi Sharma, Minal Chaudhary, Madhuri Gawande, Shraddha Patel
DOI:10.4103/jdmimsu.jdmimsu_52_19  
Odontogenic myxoma (OM) is a benign tumor originating from the embryonic mesenchymal component of the tooth germ. In 2003, World Health classification, OM is classified as benign tumor under odontogenic ectomesenchymal origin with or without included odontogenic epithelium. It is a rare benign locally aggressive odontogenic neoplasm attributed to the biological nature of lesion. The bones mostly affected are the jawbones. Clinically, it presents as a painless, slow-growing, expansile lesion of the jaws chiefly involving the mandible. Here, we report a rare case of OM in a 14-year-old female, where a large portion of the mandible was involved within a short span of 1 year. The lesion revealed typical clinical, radiographical, and histopathological characteristics of a myxoma.
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Lipoleiomyoma – A rare benign neoplasm p. 254
Sakshi Daga, Suresh Phatak, Konika Chaudhari
DOI:10.4103/jdmimsu.jdmimsu_55_19  
Lipoleiomyomas are quite rare benign neoplasms, accounting for 0.03%–0.2% incidences. Here, we report the case of a 45-year-old female who presented with complaints of abnormal uterine bleeding and pelvic pain. Imaging plays a crucial role in the diagnosis of such conditions. Ultrasonography serves as an initial imaging modality of choice for such benign neoplasms. Magnetic resonance imaging confirms the uterine origin and fatty component of tumor.
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Traumatic low fistula-in-ano p. 256
Suresh Chandak, S Niveditha, Sandip Shinde
DOI:10.4103/jdmimsu.jdmimsu_76_19  
Trauma is a rare cause of fistula-in-ano. Moreover, treatment option varies as per the patient presentation. A 23-year-old male patient presented with a complaint of fistula-in-ano after penetrating injury with iron rod a month back. The diagnosis of fistula was confirmed after probing under anesthesia. As this was a simple superficial fistula, the patient was treated with fistulectomy with healing by secondary intention.
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Tubular ectasia of bilateral epididymis in a postvasectomy patient: Sonography, doppler, and strain elastography appearance p. 258
Bharat Lohchab, Suresh Phatak, Suvarna Deshpande
DOI:10.4103/jdmimsu.jdmimsu_36_19  
Tubular ectasia of epididymis is a benign condition affecting patients predominantly in the age group of 50–60 years. It is a cystic dilatation of tubules of epididymis with stippled appearance appearing hypovascular on color Doppler and demonstrates soft colors on sonoelastography. Here, we present a case report of a 58-year-old postvasectomy male patient who presented with complaints of dull-aching pain and the palpable lump in the scrotum for 10 months. Subsequent ultrasound imaging demonstrated anechoic dilated cystic tubular structures in bilateral epididymis suggesting tubular ectasia. Doppler and sonoelastography helped in confirming the diagnosis.
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Rhabdomyosarcoma of the forearm: USG, doppler, elastography, and magnetic resonance imaging with pathological correlation p. 261
Sakshi Daga, Suresh Phatak
DOI:10.4103/jdmimsu.jdmimsu_85_19  
Rhabdomyosarcoma is a soft-tissue malignancy of skeletal muscle origin, with < 20% occurrence in extremities. We report the case of a 3-year-old boy who presented with a history of soft-tissue swelling over the anteromedial aspect of the left forearm. Radiological and histopathological findings were suggestive of rhabdomyosarcoma.
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Malignant melanoma of chest wall: Ultrasonography, doppler, and elastography imaging with pathological correlation p. 265
Rohankumar Singh, Suresh Phatak
DOI:10.4103/jdmimsu.jdmimsu_98_19  
Melanoma arises from melanocytes of the basal layer of epidermis and may originate on the trunk, extremities, face, eyes, and rarely from other visceral organs. Eighty percent of malignant melanoma is due to excessive sunlight mainly in childhood. Even the least common skin cancer malignant melanoma is the almost deadly. Earlier diagnosis and management of primary cutaneous melanoma mainly relied on clinical and histological characteristics but in recent years, there has been a tremendous growth in the usage of ultrasound, Doppler, and elastography for noninvasive evaluation of melanoma. We present a case of a 50-year-old female who presented with a history of blackish nodular mass over the right chest wall. Gray-scale ultrasound, color Doppler, and sonoelastography findings are discussed.
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COMMUNICATIONS Top

Role of caspases in periodontal diseases p. 268
Vidya Baliga, Prasad Dhadse, Gayatri Ragit, Ruchika Lulla, Sudhindra Baliga, Akanksha Nibudey
DOI:10.4103/jdmimsu.jdmimsu_39_19  
Periodontitis is initiated by various Gram-negative bacteria characterized by the destruction of the periodontal tissue. Intracellular proteases, caspases that are the key mediators of apoptosis, are shown to involve in disease progression. The activation of caspase-3 and caspase-7 is considerably enhanced in the gingival tissue from patients with periodontitis. A considerable number of cells in the gingival epithelium and connective tissue revealed active caspases, whereas in healthy tissue, almost no caspase activation was observed. These results therefore suggest that caspase activation may be functionally involved in periodontitis-associated tissue damage.
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Interprofessional education: Need and implications for dentistry in India p. 272
Priyanka Niranjane, Pallavi Diagavane, Sonali Shelke
DOI:10.4103/jdmimsu.jdmimsu_70_19  
Interprofessional education (IPE) is a step toward providing high-quality patient care by producing collaborative and ready to practice health-care professionals. The oral health care needs of the 21st century including increased awareness of oral-systemic connections, an aging population, the shift of the burden of illness from acute to chronic care, and lack of access to basic oral care have made it imperative for health-care professionals including dentists to work in interprofessional teams. This article briefly discusses the historical background and the advancement of IPE in dentistry. It also describes the burden of oral health care in India and the need for IPE and collaborative care in dentistry in India. The article also highlights the barriers/challenges and recommendations for the implementation of IPE in dentistry in India.
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Dry mouth: An emerging epidemic p. 276
S Sujatha, R Priyadharshini, Rizwana Azmi
DOI:10.4103/jdmimsu.jdmimsu_109_17  
Dry mouth is a common and emerging concern among the young and old alike, causing significant discomfort and oropharyngeal infections and impairing the quality of life of the individual. The etiology ranges from simple obstruction of salivary gland ducts, physiological stress and anxiety to a plethora of underlying salivary gland pathologies and systemic conditions. This review is focused to discuss the various clinical conditions predisposing to dry mouth. Understanding the etiology of the condition prompts appropriate early intervention to treat the underlying pathology, alleviate symptoms and prevent undesirable consequences that compromise the quality of life of an individual. Prompt diagnosis helps to alleviate symptoms in both curable and noncurable conditions contributing to dry mouth.
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LETTER TO EDITOR Top

Mycophenolate mofetil induced hepatotoxicityin a case of myasthenia gravis p. 281
Akshay Dafal, Sourya Acharya, Harika Vidiyala, Samarth Shukla
DOI:10.4103/jdmimsu.jdmimsu_108_19  
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