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   Table of Contents - Current issue
January-March 2018
Volume 4 | Issue 4
Page Nos. 201-264

Online since Monday, October 29, 2018

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Let the people's idiom be the syntax of river of medicine Highly accessed article p. 201
Yatish Agarwal, Rashmikant Dave, RS Sethi
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Evaluation of platelet indices as additional diagnostic tool for neonatal sepsis Highly accessed article p. 205
Aliza Mittal, Sugandha Arya, Laxman S Charan, Sumita Saluja, Harish Chellani
Introduction: Search for newer markers to enhance sensitivity and specificity of the existing sepsis screen and attempts toward this has been in place for a long time. Platelet indices are one such marker. Materials and Methods: Babies with signs and symptoms or born with risk factors for sepsis were enrolled. Those with positive culture or with clinical sepsis as per Centre for Disease Control definition were classified under the group “cases” (n = 188), whereas all neonates initially suspected to have sepsis but who had a negative blood culture and no clinical sepsis as per definition were classified under the group “control” (n = 188). Blood culture, sepsis screen, and platelet indices [platelet count, mean platelet volume (MPV), platelet distribution width (PDW)] were performed on all these babies. Results: The platelet count was decreased, whereas PDW and MPV were increased in septic babies (P < 0.0001). Thrombocytopenia and increased MPV were frequently observed in babies with late-onset sepsis (P = 0.012). Thrombocytopenia was the most predictive marker for culture positivity in septic babies (83.08%), and when all the platelet indices (MPV + PDW + PC) or (MPV + PDW) were combined (46.34%) it was found to be highly specific marker for prediction of sepsis. Platelet indices had a better sensitivity (83.08%) than sepsis screen (60%). When sepsis screen and platelet indices were combined, it increased the specificity (62.6%). The receiver operating characteristics curve suggested that MPV is a good marker having highest area under curve. Conclusion: Although data on platelet indices are still nascent, platelet indices may be used as a sensitive marker and combined with sepsis screen to exclude a non-septic case.
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Antibiotic susceptibility pattern of multidrug-resistant Enterobacteriaceae in urinary isolates and detection of suspected carbapenemase production p. 210
Prasanna L Kakarla, Anil K Bilolikar, Cheruvu V Sarma
Context: Urinary tract infection (UTI) is one of the most common bacterial infections. Multidrug-resistant (MDR) Enterobacteriaceae producing carbapenemases pose a challenge for treatment. The modified Hodge test (MHT) detects carbapenemase production in isolates of Enterobacteriaceae. It is simple, accessible, inexpensive, and recommended by Clinical and Laboratory Standards Institute (CLSI). Aims: (1) To study the antibiotic susceptibility pattern of MDR urinary isolates of Enterobacteriaceae. (2) To determine percentage of carbapenem resistance due to carbapenemase production by using MHT. Settings and Design: Prospective laboratory-based observational cross-sectional study in a tertiary care hospital. Patients and Methods: Urine samples (clean and catheter catch) from both inpatients and outpatients were inoculated on cystine lactose electrolyte deficient agar by semi-quantitative method. Significance of growth was established; identification and susceptibility testing was done by using VITEK 2 compact (bioMerieux). Results were interpreted according to CLSI guidelines. MDR Enterobacteriaceae isolates were identified and further tested by MHT as described by CLSI. Statistical Analysis Used: Data were analyzed using Statistical Package for the Social Sciences version 20 (IBM Inc., SPSS Inc., Chicago, IL, USA) software. Descriptive statistics and Chi-square test were used. P values < 0.05 were considered statistically significant. Results: MDR was noted in 25.79% of Enterobacteriaceae isolates. Escherichia coli and Klebsiella pneumoniae together accounted for 87.3% of MDR isolates. Susceptible antibiotics were colistin (91.02%) and amikacin (51.15%). Pandrug resistance (PDR) was noted in 20 isolates. MHT positivity was noted in 72.3% of isolates. Conclusions: Majority of isolates were MHT positive indicating high carbapenemase production. Low susceptibility profile and occurrence of PDR in this setup deter the use of common empiric treatment for all suspected UTI cases.
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Clinical significance of brainstem evoked response audiometry in patients with diabetes mellitus p. 217
Ankur Gupta, Shantanu Mandal
Background: Brainstem evoked response audiotry (BERA) is an objective, noninvasive, electrodiagnostic test that not only evaluates the functional integrity of the subcortical auditory pathway but also provides topodiagnosis of hearing loss. Diabetes mellitus (DM) causes pathophysiological changes in multiple organ systems. The brainstem auditory response represents a simple procedure to detect both acoustic nerve and central nervous system pathway damage. The objective of this study was to find the evidence of central neuropathy in diabetes patients by analyzing brainstem audiometry electric response obtained by auditory evoked potentials, quantify the characteristic of auditory brain response in long standing diabetes, and to study the utility of auditory evoked potential in detecting the type, site, and nature of lesions. Aims and Objectives: To compare the auditory brainstem responses (ABRs) of diabetic patients to those of age and sex-matched controls with respect to absolute latencies of waves I, III, and V. Materials and Methods: This study included 30 diabetic patients who were symptomatic for more than 2 years and 30 age and sex-matched control participants. The waveforms in ABRs were recorded and analyzed in each diabetic patient and control participant. Results: The mean absolute latency of wave I was found to be significantly increased in both ears at 90, 70, and 50 dB in diabetic patients compared to the control group, whereas the mean absolute latencies of wave III was significantly increased at 50 dB in both ears and at 70 dB in the right ear. In diabetic patients, the mean absolute latencies of wave V were significantly increased compared to control participants at 90 dB in both ears and at 70 and 50 dB in the left ear.
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Comparison of psoas compartment block and epidural block for postoperative analgesia in hip surgeries p. 221
Rajni Singh, Jeetendra K Bajaj, Davinderjit Singh
Context: Psoas compartment block via lumbar paravertebral approach has been compared with epidural block for postoperative pain relief following hip surgery. Settings and Design: This prospective, randomized study was conducted in the department of Anesthesia in a tertiary care hospital. Materials and Methods: This study was conducted on 60 patients undergoing unilateral hip surgery. They were randomly assigned to either psoas compartment (P) or epidural (E) group (30 in each group). A lumbar paravertebral (psoas compartment) or epidural catheter was placed before the start of surgery. A subarachnoid block using 0.5% hyperbaric bupivacaine and fentanyl was subsequently administered. After 2 h, a loading dose of 10 ml of 0.25% bupivacaine was given, and infusion of the same drug started at 5 ml/h in group P and 5 ml/h of 0.125% bupivacaine in group E using an elastomeric infusion pump. The patients were observed for 24 h and quality of pain relief with both the techniques was compared. Statistical Analysis: Categorical variables were analyzed with Chi-square test while continuous variables were analyzed with Student's t-test. Visual analog scale was expressed as median and was analyzed with Mann–Whitney test. A software program (SPSS 21) was used. P <0.05 was considered significant. Results: The mean duration of postoperative analgesia in the epidural group was 551.11 min compared to 427.25 min in the psoas compartment group (P > 0.05), which was not statistically significant. Mean pain scores at 4 and 8 h postoperatively were higher in the psoas compartment block resulting in greater rescue analgesic requirement in this group. Conclusions: Psoas compartment block can be considered an alternative in patients with relative contraindications to epidural block such as those on deep vein thrombosis prophylaxis with anticoagulants.
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Morphometric changes in lumbar vertebral bodies and intervertebral discs in tandem with diminution in bone mineral density p. 227
Neha Bagri, Tushar Madage, Ranjan Chandra, Rajesh Chopra, Yatish Agarwal, Neetika Gupta
Background: Morphometry of vertebral body (VB) and intervertebral disc space (IVD) is a reflection of the osseous strength, which primarily depends on the bone mineral density (BMD) and a host of other factors. As an individual ages, the internal hormonal milieu and the BMD undergoes a change. This is a ubiquitous phenomenon that impacts the quality of life and increases morbidity and mortality. The pathophysiologic process that causes changes in the BMD tends to alter the morphology of VB and the adjacent IVD as well. Aim: To correlate the morphological changes in the lumbar VBs and IVDs using MRI with changes in BMD in the Indian population. Materials and Methods: A total of 100 ambulatory adults in the age group 40–70 years were included in the study. The lumbar BMD was measured using a dual-energy X-ray absorptiometry (DEXA). Morphometry of the VBs and IVDs was performed using 1.5-T MRI, T2-weighted sagittal images and their heights (at various levels) and volumes were measured. Continuous variables were examined by analysis of covariance after correction for height and age. Results: There was no age difference among the subjects of normal BMD, osteopenia, and osteoporosis. Lower BMD was associated with a decrease in anterior, middle, and posterior heights (Ha, Hm, and Hp, respectively) and antero-posterior dimension (AP) of the vertebral body, leading to an increased biconcavity index. With regard to IVD, decrease in BMD was associated with a decline in Ha and Hp and AP dimension and increase in middle height, leading to an increased biconvexity index in both genders. Lower BMD was further associated with an overall decrease in both VB and IVD volume. Conclusion: The change in BMD in subjects with osteopenia and osteoporosis affects the morphology of spinal vertebra and adjacent IVDs and is associated with a decrease in VB and IVD volumes. MRI morphometry correlates well with the BMD measurements.
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Renal vasculature: Spectrum of anatomical variations and the significance from a surgeon's standpoint p. 233
Swarna , Yatish Agarwal, Shalabh Jain, Avneet Singh Chawla
Background: Renal vasculature is known for having a broad spectrum of variants, and some of them hold important implications at the time of renal surgeries, particularly for the renal transplant. Materials and Methods: This observational study was performed using multidetector computed tomography (MDCT) angiography in patients with various renal and other abdominal disorders and advised for pathologies in which MDCT angiography was indicated. A total of 760 patients were evaluated. Various parameters that have surgical importance were studied. Results: This study includes 123 (16%) patients that had accessory renal artery on right side and 152 (20%) patients that had on the left side. Among the right-side renal artery patients, 72 (58.5%) were hilar and 51 (41.5%) were polar arteries, and of left-side patients, 94 (61.8%) were hilar and 58 (38.2%) were polar arteries. The average diameter of the right and left renal artery was 5.1 and 5.07 mm, respectively. The average diameter of the right and left accessory renal artery was 2.4 and 2.6 mm, respectively. Early segmentary bifurcation of the right renal artery was seen in 651 patients (85.6%) with 319 (42%) being retro-caval, and early segmentary bifurcation of the left renal artery was seen in 94 patients (12.3%). Double right and left renal veins were seen in 96 (12.6%) and 37 (4.8%) patients, respectively. Late right renal vein confluence was seen in 50.6% of patients (340/671). Late left renal vein confluence was seen in 181 out of 700 patients (25.85%); 60 (7.9%) patients had circum-/retro-aortic renal vein. Conclusion: CT angiography is highly accurate modality for evaluation of renal vasculature. Although the increasing number of laparoscopic nephrectomies being performed as part of renal transplant procedure, it is becoming important for the radiologists to better understand the anatomy, its variations, its implications, and to accurately demonstrate vascular anatomy on imaging to the surgical team.
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Pituitary tumors: Changing paradigms in understanding, nomenclature and the newer basis of classification p. 240
Sadhana Tiwari, Ishita Pant, Sujata Chaturvedi
The pituitary gland is embryologically divided into two main lobes: adenohypophysis (anterior) and neurohypophysis (posterior). Last five decades have witnessed changes in the tumor classifications – anterior pituitary in 2017 and posterior in 2016, based on hormonal immunohistochemistry, molecular profiles, and pituitary specific transcription factors. Few newer entities/terms have been added and at the same time certain terms have been modified/discarded. In this article, relevant anatomy, development, histology, incidence, and clinical manifestations of pituitary tumors evolution of various classification systems and recommended current classification of pituitary tumors; the genetic alterations and the diagnostic implications for today's pathologist have been reviewed in a comprehensive manner.
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Mammographic and breast tomosynthesis findings in patients following breast conservative therapy p. 251
Neeraj Jain, Namita Mohindra, Sunil Kumar, Gaurav Agarwal
Breast conservative therapy (BCT) involves removal of tumor along with tumor-free margin followed by radiotherapy. Owing to improvement in imaging methods, patient awareness, and screening programs, more and more patients are becoming eligible for BCT; however, this procedure results in various changes in breast parenchyma, whose mammographic appearances may be confused with residual or recurrent lesion. Therefore, awareness of expected and unexpected mammographic findings following BCT is essential for optimal evaluation of these patients. This pictorial essay intends to demonstrate digital mammographic findings in post BCT patients with emphasis on differentiation between expected and unexpected findings.
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Management of posttraumatic abdominal hernia p. 256
Ajay Rajyaguru, Vikrant Patel, Jatin Bhatt
Introduction: Traumatic abdominal wall hernias (TAWHs) are extremely uncommon type of abdominal wall hernia as far as the etiology is concerned. Materials and Methods: We encountered 10 cases of TAWHs during a period of 5 years at the PDU Medical College. The study duration of 5 year included 1 year of follow up for wound dehiscence and incisional hernia. After routine investigations all undergone primary surgical treatment under spinal or general anaesthesia. All the patients were discharged successfully without any major complication. Discussion: TAWH should be suspected in a patient with tender, localized swellings of the abdominal wall following blunt trauma. USG and computed tomography of the abdominal are the helpful investigations to diagnose the hernia and associated intra-abdominal injuries. In all cases of wall defects with bowel herniation, one must take up urgent surgical measures to prevent further bowel injury and to avoid complications. Incisions directly over the defects, instead of midline incisions are preferred for proper repair of the defect. Mesh repair is desirable in the elderly with weak anterior abdominal wall so as to prevent the long-term complications of recurrences.
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Revisiting the enigmatic abdominal cocoon p. 259
Rushil Jain, Vimal Jain, Shalit Jolly
Abdominal cocoon, the idiopathic form of sclerosing encapsulating peritonitis (SEP) is a rare condition of unknown etiology that results in intestinal obstruction due to partial or total encapsulation of the small bowel by a thick fibrotic membrane in a concertina like fashion, hence the name cocoon. It primarily affects adolescent girls living in tropical and subtropical regions. The early clinical features and findings of imaging diagnostic tools are non specific and difficult to make definitive diagnosis preoperatively. Surprisingly, with proper surgical management, there is complete recovery and recurrence-free later life. We report an unusual presentation in an elderly female who presented with acute intestinal obstruction. The diagnosis could be made only peroperatively when on laparotomy the entire small bowel was cocooned and enclosed in a yellowish white fibrotic membrane resulting in obstruction of small intestine. The membrane was carefully peeled off the intestines and adhesiolysis was done. Patient had complete recovery. Histopathology report was consistent with the diagnosis of primary abdominal cocoon. We are reporting this case so that surgeons are better aware of this condition as a possible cause of intestinal obstruction to facilitate preoperative diagnosis and prevent unnecessary bowel resection at laparotomy for good surgical outcome.
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Renal agenesis, blind ending ureteral remnant, and ectopic ureterocele p. 262
Aanchal Bhayana, Swarna Jain
We wish to highlight the importance of multi-modality imaging in patients with renal agenesis who may present with lower urinary tract obstruction symptoms. Our case features a rare entity comprising three associated urinary tract anomalies, namely, a blind ending ureter, ectopic uretrocele, and ipsilateral renal agenesis, in a 20-year-old male patient.
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