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Tuberculosis of the lymph nodes: Many facets, many hues
Avinash Gandhare, Ashok Mahashur
July-September 2017, 4(2):80-86
Lymph node tuberculosis (LNTB) is one of the most common extrapulmonary manifestations of tuberculosis. A high index of suspicion is needed for diagnosis of tuberculous lymphadenitis, which is known to mimic numerous pathological conditions. Availability of molecular technology has improved the ease of diagnosis. Molecular techniques are also useful for the early detection of drug resistance. With the advent of endobronchial ultrasound in the last decade, the diagnosis of mediastinal tuberculosis has also improved. Management of LNTB often has difficulties. However, most cases can be managed medically and surgical intervention is rarely required. The treatment is similar to pulmonary tuberculosis. However, paradoxical reaction, which is observed in 10–15% of immunocompetent and about 50% of human immunodeficiency virus positive patients needs a special mention for an appropriate management of LNTB.
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Textbook of radiology for residents and technicians
Jyotindu Debnath
January-March 2016, 2(4):221-221
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Stroke in the young: Newer concepts in etiopathogenesis and risk factors
Man Mohan Mehndiratta, Prachi Mehndiratta
April-June 2018, 5(1):26-32
Background: Stroke in young has become one of the major causes of mortality & morbidity lately. Incidence of stroke in young is on the rise. Recent studies show young stroke being one of the important differential diagnoses for any kind of acute lateralised neurological deficits in younger population. Along with various traditional risk factors, there are some emerging vascular, genetic and others unidentified risk factors implicated in the etiopathogenesis of stroke in young. Burden of the disease along with major long term socioeconomic impacts at the patients, their family & society level are enormous. Objective: Recognition of underlying vascular & genetic risk factors may improve physician's awareness & optimise the outcomes in young stroke patients. Recent advances in the imaging technologies and genetic testing may help the experts to develop effective guidelines for the prevention and treatment of young stroke patients. Conclusion: Considering the increasing burden of the disease, standardised methodology along with more research works have become an imperative need of time in order to decrease the morbidity & mortality in young stroke patients.
  24,664 2,282 1
Types of observational studies in medical research
Rajeev Kumar, Amir Maroof Khan, Pranab Chatterjee
July-September 2014, 1(2):154-159
Study design forms a core component of research, mainly determined by the study objectives, and it in turn further decides the type of statistical analyses to be carried out. Observational studies are devoid of the investigator's control over assignment of a subject to the treated or control group, in contrast to interventional studies Even though randomized controlled trials are seen as the best study design, evidence shows that properly conducted observational studies give similar results, and is relevant in medical research where ethics and feasibility concerns assume great significance. Observational studies point out towards possible causal associations, are less resource intensive than trials and have a better external validity. This review article discusses various types of observational study designs such as case reports, cross sectional, cohort, case-control and nested case-control studies with real literature examples.
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Drug-induced diffuse hair loss in females: An observational study
Taru Garg, Pravesh Yadav, Soumya Agarwal, Vibhu Mendiratta
July-September 2014, 1(2):80-83
Introduction: A large number of drugs may interfere with hair cycle and produce diffuse hair loss (DHL). This needs to be identified, as it may lead to poor compliance with the drug regimen. Material and Methods: History of drug intake in the recent past was taken from 255 females presenting with DHL. Sixty-seven patients (26.2%) revealed a history of drug intake. Out of these, a detailed history about nature and duration of drugs was taken from 57 patients (22.3%) who had a history of drug intake preceding the onset of DHL or had a history of aggravation in preexisting hair loss following drug intake. Results: Duration of DHL ranged from 1 month to 5 years with a mean duration of 9.8±13.1 months. The mean duration of drug intake was 49.1±80.8 months. History of intake of 100 suspected drugs was available, most common group being antihypertensives (23%), followed by hormones (12%), nonsteroidal antiinflammatory drugs (11%), antidiabetic (8%), oral contraceptive pills (6%), antitubercular treatment (5%), tricyclic antidepressants (4%), and vitamin supplements (4%). Among individual drugs, thyroxine (10%) was the most commonly implicated agent followed by amlodipine (5%), Amitriptyline (4%), atorvastatin, aspirin, metformin, ibuprofen, and vitamin B complex (3% each). Conclusions: Drugs should be suspected as a cause of DHL in females and a detailed history about the nature and duration of drug intake should be taken in such patients.
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The uncommon syndrome of pancreatic encephalopathy
Saumya H Mittal, Salony Mittal, Tuhina Govil
January-March 2016, 2(4):185-186
Even though first described in 1923, the syndrome of pancreatic encephalopathy is an uncommon complication of acute pancreatitis. A multiple organ dysfunction syndrome, it generally occurs in early stage of severe acute pancreatitis and carries a high mortality of up to 57% and more. The syndrome must be distinguished from Wernicke encephalopathy, which may follow as a part of neurological complications in the last or restoration stage of acute pancreatitis, and occurs as a result of long fasting, hyperemesis and total parenteral nutrition without thiamine. Poorly recognized by clinicians, a large dose of Vitamin B1 is effective in the management of Wernicke encephalopathy. The present article draws attention to the two lesser recognized complications of acute pancreatitis and briefly dwells on their pathogenesis and management.
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The neurology timeline: Of demon holes, sacred pathways and great triumphs
Yatish Agarwal, Pranav Ish, Neera Chaudhry, Ravinder S Sethi
April-June 2018, 5(1):10-25
The first chapter in neurology was composed in the prescience era. Chiseled with flint stones, grisly in nature, it was a narrative where men trephined human skull to treat such maladies as head injury, epilepsy, and disturbed mind. The ungodly practice survived from the late Stone Age until the renaissance. The first written reference to brain is found in the Edwin Smith surgical papyri. Written around 3000 BCE in Egypt, the papyri describe certain cognitive defects of head injuries. The first sapient exploration into the functions and diseases of brain opened in the sixth to fourth century BCE. It began with the Alexandrian anatomists and Hippocratic doctors, gathered steam in the classical era of science with Galen in the first century, and reached its peak with Vesalius during renaissance. Modern neurology, particularly the localization of brain functions, began with German physician Franz Joseph Gall's work on phrenology in the late 18th century and, over the next hundred years, was followed by the discovery of language, motor, and sensory cortical areas. The idea that the nervous system is made up of discrete nerve cells was born out of the neuroanatomical work of Camillo Golgi and a Spanish doctor, Santiago Ramón y Cajal, at the end of 19th century. Major 20th-century developments include advances in understanding of the frontal lobes, the role of visual cortex in perception, the function of hippocampus in memory, lateralization of cortical function, and the introduction of all revealing cross-sectional and functional imaging. While practitioners of medicine across the world unraveled the secrets of maladies that strike the seat of senses and intellect, other accomplished players struck sweet melodies of life by discovering potent molecules, devices, and surgical techniques which could work a remedy and cure.
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The tuberculosis timeline: Of white plague, a birthday present, and vignettes of myriad hues
Yatish Agarwal, Rajesh K Chopra, Dipendra K Gupta, Ravinder S Sethi
April-June 2017, 4(1):7-26
Researchers have been digging hard to unearth the hoary past of tuberculosis. Unbelievable as it may seem, growing evidence exists that the first ancestors of Mycobacterium tuberculosis inhabited earth more than 2.6 million years ago. Eons before the hominoids set their feet on this godly planet, and Adam and Eve and their children came into being! Some ancient skeletal and mummified fossils belonging to diverse species, including dinosaurs, Pleistocene bison, and other bovines like goats and cows, have been found stamped with classic tubercular lesions and bearing the irrefutable molecular genetics inscription of mycobacteria. Of the human tuberculosis, the most ancient evidence has been found in the remains of half a million year old hominid. Old medical texts emanating from different parts of the world – in ancient lands of India, China, Egypt, Babylonia, and Greece – portray the disease through its umpteen names and nuances. Known by such grisly appellations as “the Robber of Youth”, “the Graveyard Cough”, “the White Plague”, tuberculosis burnt a deadly trail claiming millions of lives down the ages. The first major breakthrough against it came in 1882, when the German physician Robert Koch isolated the culprit organism. By mid 20th century, a chain of therapeutic molecules had been found to thwart the malevolent bacteria. Still, “the Captain of the Men of Death” carried on its death-game, finding staunch allies in hunger, malnutrition and poverty. Came the 1980s, it found new vigor by teaming with a new half-brother, the human immunodeficiency virus. Epidemics returned to lands where the disease had stood previously diminished; pushing for the discovery of newer treatments and novel therapies. The wicked dance of tuberculosis, however, continues to rage. Current estimates indicate that nearly a third of the world's population is infected with the bacillus, 10.4 million people carry active disease, and more than 2 million perish of the disease each year. The global community has declared a war on the disease and given the clarion call of “End TB strategy”. Yet, only time shall tell who will score the last hurrah: the bacillus or man!
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Diagnostic approach to histopathology of central nervous system papillary tumors
Ishita Pant, Sujata Chaturvedi
July-September 2014, 1(2):124-131
Tumors of the central nervous system (CNS) exhibiting a papillary pattern constitute a remarkably diverse group of neoplasms that can occur at virtually any site and in patients of any age. Since the first classification of nervous system tumors in 1926, formulated by Percival Bailey and Harvey Cushing based on the presumed parallels between embryologic and neoplastic cells to the World Health Organization (WHO) classification of tumors of the CNS 2007, CNS tumors have come a long way. WHO classification of tumors of the CNS 2007, lists several new entities. However, despite the advancements and the rapid progress with various classification systems in place, as a first step, brain tumors are still characterized largely by the typical patterns and their histopathological features. This pictorial essay represents the histopathology of one of these patterns comprised of various papillary tumors of the CNS, highlighting the diagnostic approach.
  14,577 1,548 2
Radiology of ventilatory, feeding, and circulatory lines and tubes in the critically sick
Narainder K Gupta
July-September 2014, 1(2):104-123
A variety of supportive ventilatory, feeding and circulatory devices are employed in the management of critically sick patients. The hardware ranges from endotracheal, tracheostomy and chest tubes, nasogastric and nasoenteric feeding tubes, to central venous lines, umbilical venous and arterial catheters, pacers and automatic implantable cardioverter defibrillators, intraaortic balloon pumps and ventricular assist devices. The accurate positioning of this hardware is critical to the well being of a patient. However, these devices may not be positioned appropriately. Faults may occur at the time of their insertion, or the hardware may get dislodged while in use. A portable chest radiograph can be extremely useful in identifying such mishaps. This pictorial review captures some of the critical scenarios which must be known to radiologists and the treating intensivists.
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Spectrum of histopathology in spinal lesions
Ishita Pant, Sujata Chaturvedi
January-March 2016, 2(4):187-199
Spinal lesions are broadly categorized as lesions encountered in the spine and epidural space, lesions of spinal meninges, lesions of spinal nerve roots, and lesions of spinal cord. These are further sub classified into congenital malformations, inflammatory disorders, degenerative and reactive processes, cystic lesions, vascular malformations, and neoplasms. This pictorial essay highlights the histopathology of these lesions along with the clinical and radiology findings, where relevant.
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Clinical neurosciences: Where do we go from here?
Yatish Agarwal, Rashmikant Dave
April-June 2018, 5(1):1-4
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Unravelling the exciting new therapeutic pathways in clinical neurology
Majaz Moonis
April-June 2018, 5(1):5-9
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Recognizing ulegyria—the lesser known form of hypoxic ischemic encephalopathy
Manish Kumar, Rohini Gupta, Bhawna Kaul, Yatish Agarwal
January-March 2016, 2(4):209-210
Derived from the Latin term ule, which means scarring, ulegyria is a manifestation of hypoxic ischemic encephalopathy. Recognizable on the magnetic resonance imaging sequences because of its characteristic features, the diagnosis is critical from the standpoint of clinical management. Seizures caused by ulegyria are refractory to pharmacotherapy and often do well with surgery.
  11,554 837 1
Nontuberculous mycobacterial diseases: Current diagnosis and treatment
Shubham Sharma, Raja Dhar
April-June 2017, 4(1):67-74
There has been an ever-expanding list of isolation of organisms in the genus Mycobacterium. Leprosy and tuberculosis are specific diseases caused by mycobacteria; there are now several other mycobacteria that cause human diseases and can be widely found in the environment. These other mycobacteria are called as nontuberculous mycobacteria (NTM) or mycobacteria other than tubercle bacilli (MOTT) or atypical mycobacteria. They cause various human infections in the lungs, lymph glands, skin, wounds, or bone. They may also produce disseminated disease, especially in the immunocompromised. Various molecular, biochemical, and chemical techniques have been developed for rapid identification of these species. While it might be difficult to treat these infections, with duration of treatment longer than that for tuberculosis or leprosy, many drugs such as rifampicin, rifabutin, ethambutol, clofazimine, amikacin, new generation quinolones, and macrolides effective against mycobacterial infections are available that can be used in appropriate combinations and dosage to treat the NTM.
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The expanding canvas of rapid molecular tests in detection of tuberculosis and drug resistance
Anand Shah, Camilla Rodrigues
April-June 2017, 4(1):34-44
In many developed countries, tuberculosis (TB) is considered a disease of the past. However, the impact of this disease can be devastating even today, especially in resource poor countries suffering from high burdens of both TB and human immunodeficiency virus (HIV). One of the greatest threats to global TB control is the growing prevalence of drug-resistant bacilli. Correctly diagnosing drug-resistant TB patients is more problematic in resource-limited settings as there is no or limited infrastructure for drug susceptibility testing (DST) of TB bacilli. The conventional phenotypic DST method for TB takes weeks before declaring the results and initiating proper anti-TB treatment. The evolution of molecular diagnostic methods has revolutionized the TB diagnostics. These methods are accurate, rapid, easy to perform, and can solve controversial issues related to TB diagnosis as well as drug susceptibility. It is important to link these rapid molecular techniques with the conventional methods to determine the impact of the disease.
  11,054 597 3
Development of post graduate program in emergency medicine in India: Current status, scope and career pathways
Manish Jain, Bipin Batra, Elizabeth G Clark, Tamorish Kole
October-December 2014, 1(3):218-221
Recent epidemiologic and demographic public health data highlight the growing need for emergency medicine (EM) services in India and highlight its importance as a recognized medical specialty. Developing a comprehensive and recognized EM program for training physicians in India is of utmost priority and should not be neglected at any point of time. This review article attempts to highlight the development of a post-graduate program in EM in the country.
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Clinical manifestations and complications of scrub typhus: A hospital-based study from North Andhra
Nrushen Peesapati, Rohit Lakkapragada, S Sunitha, PV Sivaram
October-December 2015, 2(3):116-120
Aims and Objectives: To describe the diversity of clinical manifestations, laboratory findings, and outcome of scrub typhus in hospitalized patients of Tirumala Hospital, Vizianagaram, during 2014–2015. Materials and Methods: All cases of acute febrile illness diagnosed as scrub typhus were analyzed. Diagnosis was made by ELISA-based IgM serology. Observations and Results: A total of sixty patients were included in the study. All of them presented with fever; the other major symptoms were headache, cough, dyspnea, and myalgias. On examination, patients had hepatosplenomegaly, lymphadenopathy, and eschar. On investigation, elevated serum glutamic-oxaloacetic transaminase, serum glutamic pyruvic transaminase with normal and elevated bilirubin levels were the most common findings. Other laboratory findings were thrombocytopenia and deranged renal function tests.Other complications were multiorgan dysfunction syndrome, acute respiratory distress syndrome, hypotension, and meningoencephalitis. Majority responded to doxycycline. Conclusion: Scrub typhus though prevalent is under-reported in our country. It should be considered as an important differential diagnosis in a febrile patient with thrombocytopenia, deranged liver or renal functions, Early diagnosis and appropriate treatment is rewarding and prevents morbidity and mortality.
  9,394 591 3
Foreign bodies in maxillary sinus: Causes and management
Shilpi Agarwal, Sanjeev Kumar
July-September 2014, 1(2):89-92
Foreign bodies in maxillary sinus, whatever their origin or nature, are unusual. However unilateral unexplained chronic rhinosinusitis should arouse clinical suscipicion. The diagnosis is based on radiological findings. The range of such foreign bodies is wide; those of dental origin such as tooth roots, burs, dental impression material, root-filling materials, dental implants, and needles take precedence over all others, but rarely, they may relate to blast injuries and penetrating objects. This special report highlights the unusual case of a pressure cooker nozzle lodged in maxillary sinus of a 28-year-old female who suffered a facial injury caused by explosion of a pressure cooker at home. The acuteness of the event and the flight of the foreign body were such that neither the casualty felt the ingress of foreign body nor was the diagnosis entertained by the surgeon who first examined her. Each blast injury therefore must be thoroughly evaluated for such possibility. While a radiological examination can clinch the diagnosis, treatment lies in endoscopic or surgical foreign body removal, with Caldwell luc procedure being a preferred technique.
  9,112 593 2
Post traumatic external auditory canal stenosis causing conductive hearing loss
Ashok Kumar, Aniruddha Sarkar, Shailendra Kumar
October-December 2016, 3(3):174-176
Acquired external auditory canal stenosis is an uncommon entity which can arise from a number of different causes including infection, trauma, neoplasia, inflammation, and radiotherapy. Posttrauma stenosis is extremely rare; only 10% of stenosis is caused by trauma in many series. Patients generally suffer from conductive hearing loss. Surgery is the treatment of choice for posttraumatic canal stenosis. The main objective of the surgery is to produce a dry, patent ear canal by removing the stenotic segment, enlarging the bony canal, and performing wide meatoplasty. In this paper, we report a case of posttraumatic external auditory canal stenosis, following foreign body reaction which was entrapped in the canal during trauma, which was managed successfully 1 year after the trauma.
  9,089 450 1
Textbook of prosthodontics
SP Aggarwal
July-September 2014, 1(2):161-161
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Practical significance of exercise stress test in individuals at low risk for atherosclerotic coronary artery disease
Sanjeev V Mangrulkar, Pramod Katare, Ashiwini Joshi
January-March 2017, 3(4):196-200
Background: Despite not finding favor with a number of apex global bodies including the American Heart Association, American College of Cardiology, United States Preventive Services Task Force, exercise stress test continues to be performed customarily among asymptomatic individuals to screen for potential presence of ischemic heart disease. Materials and Methods: This retrospective study comprises a successive total of 2042 individuals who were put through a screening stress test as a part of their health checkup package. A telephonic communication was made with all the persons who had been advised further assessment such as repeat stress test, drug therapy, stress thallium testing, or coronary angiography. The compliance of this group to the advice offered was noted along with their subjective sense of satisfaction with the overall process. Based on these inputs the practical utility of stress test was calculated as either good or poor. Results: Out of 2042 individuals who underwent stress test, 183 (9%) were reported as positive. Out of these 183 individuals only 132 with positive stress test could be contacted telephonically. After a detailed analysis of their compliance with the advice offered, it was noted that the screening had best practical utility when the test report was negative. Only one person with a positive report had followed the advice to the logical end by undergoing coronary artery bypass grafting and had a likely good practical utility. In rest of the scenarios, the practical utility was poor. Conclusion: The screening exercise stress tests are sought by most individuals as means of reassurance about health. Its practical significance in all other scenarios is poor. Therefore, unless definite indications exist, stress test should not be performed as a screening test.
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Tuberculosis in special situations: Co-morbid conditions, physiological states and contraception
Harjit Dumra
July-September 2017, 4(2):100-107
Till date we believed that multidrug-resistant and extensively drug resistant were our deadliest foes when dealing with tuberculosis. However, conditions commonly encountered in daily practice such as diabetes, liver, renal, psychiatric disorders, and pregnancy tend to frequently overlap with tuberculosis. These multimorbid conditions prove to be equally challenging for an average medical practitioner. Inappropriate prescriptions in the above situations prove to be a significant impediment to the overall control of tuberculosis in the community at large. The advent of solid organ transplantation and aggressive use of immunosuppressive medication for malignancies and chronic inflammatory disorders has added a new dimension to the already preexisting challenges faced by practicing clinicians, particularly in the context of treating tuberculosis in the immunocompromised and drug-drug interactions. This is another area which needs special attention. Pediatric multidrug resistant tuberculosis is a growing menace and needs to be controlled before it becomes an insurmountable problem. In addition, the emerging epidemics of metabolic syndrome, substance abuse, and drug dependence have only compounded the problem. Tuberculosis in the above populations, particularly if drug resistant can be one of the worst nightmares for the treating clinician. This article tries to highlight these prevalent issues and offers practical and evidence-based solutions to help clinicians in their endeavor to achieve a tuberculosis free world.
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Pituitary tumors: Changing paradigms in understanding, nomenclature and the newer basis of classification
Sadhana Tiwari, Ishita Pant, Sujata Chaturvedi
January-March 2018, 4(4):240-250
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.
  7,974 710 2
Combating corruption in health care organizations: Methods, tools, and good practices
Sujata Chaturvedi
July-September 2014, 1(2):150-153
Although corruption in health care reflects the ills of the society in general, some key areas to be focused upon are as follows: procurement processes; the so-called 'speed money'; theft, pilferage and malpractices; and staff recruitment. Each organization needs to devise its own mechanisms for transparency and accountability in procurements. A two-bid system of technical and price bid, asking for users' list, demonstration, or onsite visits to ascertain the functioning of equipments, 'Publish What You Pay' type of initiative, participation of users as in Rogi Kalyan Samitis, anticorruption networks are some of the tools to address corruption in hospital procurement. The menace of informal payments or speed money can be addressed by encouraging and facilitating users' feedback, involving hospital neighborhoods in anticorruption squads and having CCTV surveillance in key areas. Theft, pilferage, and malpractice siphons off goods and services meant for the ailing. Administrative vigilance and strict handling of the instances reported may serve as a deterrent. Having a labor law professional or a trustworthy NGO on the panel may help reduce corruption, especially seen in the case of contractual jobs. Phenomenon of corruption is difficult to capture in a single definition or measure. Sincere, intense, and sustained anticorruption measures have to be adopted and pursued by health care facilities top-down as well as bottom-up, providers as well as users, ex ante as well as post facto. All anticorruption measures have a use-by-date to them. Innovations would be required. Key ingredient would be sincerity of the management.
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