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   Table of Contents - Current issue
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May-June 2019
Volume 12 | Issue 3
Page Nos. 187-287

Online since Wednesday, May 15, 2019

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EDITORIAL  

Sleep that knits up the Ravel'd sleave of care…Nature's second course…the Bard said it all Highly accessed article p. 187
Amitav Banerjee
DOI:10.4103/mjdrdypu.mjdrdypu_51_19  
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GUEST EDITORIAL Top

Sleep assessment in psychiatry - To be awake to every possibility p. 189
Suprakash Chaudhury, Adnan Kadiani
DOI:10.4103/mjdrdypu.mjdrdypu_214_18  
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REVIEW ARTICLE Top

Chronic insomnia: A review Highly accessed article p. 193
Suprakash Chaudhury, Rakesh Kumar Singh, Dolly Kumari, Chetan Diwan, Swaleha Mujawar, Daniel Saldanha
DOI:10.4103/mjdrdypu.mjdrdypu_76_19  
Chronic insomnia is a fairly common condition affecting one-fourth of the clinical population. It has been variously defined and is related to a large number of conditions. A thorough assessment of the patient presenting with chronic insomnia is of vital importance for the treatment. Treatment consists of modifying sleep habits to reduce autonomic and cognitive factors and education about healthier sleep practice. Drug treatment should be reserved for the short-term alleviation of insomnia. Appropriate treatment of chronic insomnia improves the quality of life. The prevention of insomnia consists of a balance of rest, recreational exercise in combination with stress management and a healthy diet.
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MEDICAL EDUCATION TECHNOLOGY Top

Framing a De novo curriculum on sleep disorders for an Indian medical graduate using Kern's model p. 202
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/mjdrdypu.mjdrdypu_103_18  
The six-step Kern's model is used to develop a de novo curriculum and link the same to the health-care needs of the general population. The available estimated data from India suggest that the incidence of sleep disorders has increased in all the age groups. Considering the shortage of specialists dealing with sleep hygiene, at present, most of the patients either do not avail health care or are handled by some subspecialists. It is a fact that the current undergraduate curriculum offered to a medical student in India is not holistic and does not incorporate skills to identify and manage sleep disorders in all 4 years of the undergraduate course. In short, there is limited scope for an Indian medical graduate (IMG) to get sensitized about sleep medicine and thus is not competent to identify, evaluate, treat, and prevent sleep disorders. Thus, Kern's model was employed to develop a curriculum on sleep disorders which can be used for the benefit of an IMG.
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ORIGINAL ARTICLES Top

Screening for sleep disorders and their medical and psychiatric comorbidities p. 207
Nikhil Sanjay Mankar, Sharmishtha S Deshpande
DOI:10.4103/mjdrdypu.mjdrdypu_130_18  
Background: Sleep disorders are common in medical out-patients. They are seldom addressed despite being known to worsen overall health of patients. Detailed evaluation to differentiate these into primary sleep disorders, psychiatric and medical co-morbidity or both can be done by a liaison Psychiatrist. Managing these is necessary for providing good quality recovery for the patient. Method: Cross-sectional survey of 148 randomly selected medical out-patients in a tertiary care hospital was carried out to assess various sleep disorders. Pittsburgh sleep quality index was used for assessment. They were assessed by qualified psychiatrist to establish Psychiatric diagnosis by clinical interview as per ICD-10 classification. Co-occurrence of these with chronic medical problems as diagnosed by clinician was documented. Results: Sleep disorders were common in medical out-patients (48.64%). Commonest among them was difficulty initiating sleep and reduced duration. A significant number screened to have sleep disorders, also had psychiatric co-morbidities (63.8%), Depressive disorders being the commonest (52.1%). Chronic medical illnesses were present in 50 (33.8%) of the all patients assessed for having sleep disorders. Co-occurrence of medical and psychiatric co-morbidities was not statistically significant. Conclusion: Considering high prevalence, patients should be routinely assessed for various sleep problems by Physician and referred to Psychiatrist for management as many of them also have psychiatric co-morbidities. Physician and Psychiatrist liaison is important in managing complex medical and psychiatric co-morbidities associated with sleep disorders.
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Sleep disturbance and its effect on work performance of staffs following shifting duties: A cross-sectional study in a medical college and hospital of Tripura p. 211
Kaushik Nag, Anjan Datta, Nabarun Karmakar, Tamal Chakraborty, Partha Bhattacharjee
DOI:10.4103/mjdrdypu.mjdrdypu_116_18  
Introduction: Sleep disturbance among night-shift workers results in serious adverse effects on their health affecting almost all the systems of the body. Recently, the World Health Organization has also identified night-shift work as being carcinogenic to human. Objective: The main objective is to study the prevalence of sleep disturbance and its effect on work performance of health-care staff working in shifts in a Medical College Hospital of Tripura. Materials and Methods: An institution-based cross-sectional study was conducted in February 2018, among 135 staffs working in shifts, including resident doctors, intern doctors, nursing staffs, security guards, technicians, ward boys, and ward girls of the Tripura Medical College and DR. BRAM Teaching Hospital. Systematic random sampling was used to collect the required samples with a predesigned and pretested interview schedule designed based on the Pittsburgh Sleep Quality Index. Data entry and analysis were done in the Statistical Package for the Social Sciences software version 16.0 (SPSS Inc. SPSS for Windows, Chicago, Illinois, USA). Data were represented in percentages in tables and charts, and the Chi-square test was applied to find out the statistical association. Results: Of the total 135 participants, the majority (28.9%) were interns and nursing staffs and paramedical students (26.7%). The prevalence of sleep disturbance was 54% among the participants, and it was significantly higher among those residing in hostel and quarter as compared to their own home (P = 0.003). Sleep disturbance was also found to be significantly decreasing their performance at work (P < 0.001). Conclusion: This study showed the high prevalence of sleep disturbance among shift workers, which significantly hampered their work performance in this institute. To find the measures to prevent sleep disturbance among staffs having a shifting duty, further research work can be done based on the findings of the study.
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A study on thyroid profile and prolactin level in hypothyroid females of a rural population of a developing country p. 217
Samarjit Koner, Arunima Chaudhuri, Abhijit Biswas, Debasis Adhya, Rajarshi Ray
DOI:10.4103/mjdrdypu.mjdrdypu_121_18  
Background: In patients with primary hypothyroidism, there are increased levels of thyrotropin-releasing hormone (TRH) which can cause rise of prolactin (PRL) levels and these patients may have galactorrhea. Aims: Considering the clinical importance of hyperprolactinemia in ovulation disorders, sterility, and menstruation disorders, the present study was conducted to observe the prevalence of hyperprolactinemia and related galactorrhea in newly diagnosed hypothyroid females and correlate serum PRL level with thyroid-stimulating hormone (TSH) in hypothyroid females in a rural population of East India. Materials and Methods: This pilot study was conducted in Burdwan Medical College on 200 newly diagnosed female hypothyroid participants after taking institutional ethical clearance and informed consent of the participants. Age and gender-matched 100 controls were taken. Serum TSH, serum free thyroxine (fT4), and serum PRL levels were assessed. A questionnaire was designed for the evaluation of hypothyroidism symptoms for all the participants. These symptoms were galactorrhea, dryness of skin, feeling cold, hair loss, weakness, weight gain, constipation, loss of libido, and menstrual abnormalities. A total number of hyperprolactinemic patients were 42; out of them, 30 females were clinical and 12 were subclinical hypothyroid patients. One hundred and fifty-eight patients had normal PRL level. Results: Significant difference was found between clinical and subclinical hypothyroid females for body mass index (BMI) (P = 0.002), TSH (P < 0.0001), fT4 (P < 0.0001), and PRL (P = 0.002). The prevalence of hyperprolactinemia was 21% in hypothyroid females, 23.07% in clinical or overt hypothyroid females, and 17.14% in subclinical hypothyroid females. The prevalence of galactorrhea is 1% in all hypothyroid females and 1.53% in clinical hypothyroid females. A significant positive correlation was found between TSH and PRL in hypothyroid patients. Conclusions: Incidence of hyperprolactinemia is found to be notable in hypothyroid females including clinical and subclinical hypothyroidism, and hypothyroid females show positive correlation between TSH and PRL levels. Hence, PRL levels need to be assessed in all hypothyroid females.
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COMMENTARY Top

Hyperprolactinemia and hypothyroidism p. 225
Viroj Wiwanitkit
DOI:10.4103/mjdrdypu.mjdrdypu_179_18  
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ORIGINAL ARTICLES Top

Neurological soft signs in positive and negative subtypes of schizophrenia p. 227
Spandana Devabhaktuni, Daniel Saldanha, Suprakash Chaudhury, Samiksha Sahu
DOI:10.4103/mjdrdypu.mjdrdypu_26_18  
Background: Schizophrenia, a heterogeneous clinical syndrome, has fascinated researchers since times immemorial. An increasing number of studies have implicated multiple brain regions, variations in the localization, and severity of brain impairments in schizophrenic patients that could ultimately lead to unraveling the etiopathogenesis of schizophrenia. A direct, easily administered, and inexpensive way of investigating brain dysfunction in schizophrenia is the study of neurological soft signs (NSS). Aim: To document the presence of NSS in positive and negative subtypes of schizophrenia and compare them with normal controls. Materials and Methods: The study was conducted on 52 schizophrenic patients diagnosed according to the International Classification of Diseases 10 Diagnostic Criteria for Research and 52 normal controls matched for age and education. All the patients gave written informed consent. NSS were assessed using Neurological Evaluation Scale (NES). Results: The prevalence of NSS in this study was estimated to be 77%. Statistically significant correlations were observed between the negative symptom subscale of Positive and Negative Syndrome Scale and the NES scores among the patients with schizophrenia. Conclusions: The comparison of the mean NES scores among cases and controls in this study reveals a very highly significant difference between the two groups studied. This suggests that NSS are highly prevalent among patients with schizophrenia.
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Handwashing practices among caregivers of children p. 233
Ibrahim Aliyu, Abdulsalam Mohammed, Bashir Mariat Zubayr, Godpower Chinedu Michael, Bukar Alhaji Grema, Umar Isah Umar, Mahmud Jahun Gambo, Halima Umar Ibrahim
DOI:10.4103/mjdrdypu.mjdrdypu_159_18  
Introduction: Handwashing has been proven to reduce the risk of acquiring infection; this is why every 15th October is being set aside as Global Handwashing Day, which aims at improving global awareness on the importance of handwashing. Materials and Methods: The study was cross-sectional, parents/caregivers were consecutively recruited over 8 months, and pretested questionnaire was administered by the researchers and trained assistants. Results: There were 102 (32%) males and 217 (68%) females with a male-to-female ratio of 1:2.1. A total of 279 (87.5%) respondents reported that they were aware of the moments of hand hygiene. Their relations (38.3%) were the most common source of information on hand hygiene. However, soap and water (72.4%) were the predominant items used for handwashing. Furthermore, 317 (99.1%) respondents were incorrect on the steps of handwashing technique. All respondents (100%) reported washing their hands after using the restroom. However, their educational and social status had no significant relationship with their ability to mention the steps in handwashing and the critical moments in hand hygiene, respectively, (educational status: ‡Fisher's exact = 0.440; P = 1.00, and $Fisher's exact = 3.308; P = 0.282, respectively) and (social class: ‡‡Fisher's exact = 0.756; P = 1.00 and $$Fisher's exact = 1.232; P = 1.00, respectively). However, there were statistically significant relation with adhering to the principles of handwashing (educational status: †χ2 = 7.835; df = 2; P = 0.019) and (social class: ††χ2 = 7.952; df = 2; P = 0.019), respectively. Conclusion: Majority of the respondents wash their hands especially after soiling with dirt; and water and soap were mostly used; however, the technique of handwashing was poorly understood by caregivers and this was shown to be less influenced by their educational or social status.
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Magnetic resonance imaging in evaluation of traumatic and nontraumatic ankle joint and foot pathologies p. 239
Amit Kharat, Arijit Ghosh, Kunaal Jain, Pooja Karanjule, Siddappa G Gandage
DOI:10.4103/mjdrdypu.mjdrdypu_143_18  
Background: The ankle joint is one of the most frequently injured joints in the body. Magnetic resonance imaging (MRI) is an emerging modality which is being used routinely for evaluation and diagnosis of pathologies of the ankle joint and foot as it can demonstrate pathologies before they become evident on other imaging modalities. Materials and Methods: We carried out a descriptive study on fifty patients over a period of 2 years to evaluate role of MRI in diagnosing various pathologies of the ankle joint and foot as demonstrated by many illustrative cases in this article. Conclusion: MRI must be the primary imaging modality of choice for optimal detection of pathologies of the tendons, ligaments, and other soft-tissue structures of the ankle joint complex and the foot.
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Ocular involvements, its complications, visual outcome, and treatment response of herpes zoster ophthalmicus: Review of 35 patients from Andaman and Nicobar Island p. 250
Sujit Das, B Pradeep, Chhanda Mandal
DOI:10.4103/mjdrdypu.mjdrdypu_87_18  
Aim: The aim of this study is to evaluate the ocular involvements, its complications, visual outcome, and treatment response of herpes zoster ophthalmicus (HZO). Design: This was an observational and retrospective study. Methods: All clinically diagnosed cases were included in the study. All were subjected to corneal staining, corneal sensation, best-corrected visual acuity (BCVA), intraocular pressure, and fundus examination. All were treated with oral acyclovir (800 mg) 1 tablet 5 times a day for 5 days along with tablet pregabalin (150 mg twice/day) and neurobion forte (1 tablet/day). Acyclovir eye ointment was given 5 times a day for 14 days with antibiotic and cycloplegic drops. Mean follow-up was 12 months. Results: Mean age of presentation was 51–55 years (40%) with male predominance (88.6%). Unilateral eye involvement was 32 (91.4%) and bilateral was three (8.6%). Blepharitis was (80%) the most common ocular involvement followed by punctuate keratitis (77.1). Ocular complications were neurotrophic keratopathy (5.7%), corneal opacity (5.7%), and postherpetic neuralgia (62.9%). Mean BCVA was 20/20 in 33 eyes (94.3%). The sensitivity of acyclovir was found 100%. Conclusion: Rapid diagnosis and early institution of antiviral therapy are necessary to prevent ocular morbidity. History of chickenpox, low immunity, and environmental factors (hot climate, humidity, and rainfall,) greatly influences the occurrence of HZO. The overall visual outcome is good with early institution of antiviral therapy.
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Comparative study of stainless steel and titanium limited contact-dynamic compression plate application in the fractures of radius and ulna p. 256
GR Joshi, BM Naveen
DOI:10.4103/mjdrdypu.mjdrdypu_140_18  
Background: Stainless steel and titanium are two different metals with different mechanical and metallurgical properties. Stainless steel is twice more stiffer than titanium. Internal fixation of fractures with stainless steel plates is likely to produce more rigid fixation than titanium plates. Hence, stainless steel plate fixation is likely to produce healing of fracture site with minimum callus/primary healing. This study analyzes whether these properties of the metals influence the healing of the fractures and their outcomes. Materials and Methods: Thirty-five cases of fractures of radius and ulna were treated by internal fixation using stainless steel limited contact-dynamic compression plate (LC-DCP) (Group I) in 17 patients and titanium LC-DCP (Group II) in 18 patients. Follow-up was done at 6 weeks, 12 weeks, 6 months, and 1 year for clinical and radiological healing and complications. Results: All the fractures united in time. 10 (62.5%) patients in Group I and 9 (56.2%) patients in Group II showed primary union and 6 (37.5%) patients in Group I and 7 (43.2%) patients in Group II showed union with callus formation. No complications were observed. Conclusion: Stainless steel and titanium are two different metals with different mechanical and metallurgical properties. However, fixation of fractures with these metals failed to show the difference in the patterns of fracture healing.
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CASE REPORTS Top

A case report of sinonasal undifferentiated carcinoma in a 60-year-old female in clinical practice p. 262
Salewa Evelyn Osho, Bolanle Olubunmi Ibitoye, Patrick Olanrewaju Osho, Olumuyiwa John Fasipe, Oluwatosin Beatrice Ibiyemi-Fasipe
DOI:10.4103/mjdrdypu.mjdrdypu_104_18  
This was a rare case of sinonasal undifferentiated carcinoma (SNUC) in a 60-year-old female who presented with complaints of progressive right cheek swelling, associated headache, nasal obstruction, and mucopurulent nasal discharge. Conventional plane radiograph of the cranial paranasal air sinuses revealed opacification of the right maxillary sinus with erosion of the floor of the orbit. The cranial computed tomographic (CT) scan images revealed opacification of the right maxillary sinus, both ethmoidal sinuses and the entire right and medial half of the left frontal sinus. There was erosion of the floor of the anterior cranial fossa on the right side close to the midline. Furthermore, there was extensive and expansile mixed density mass lesion filling the entire right maxillary sinus, both ethmoidal sinuses, right sphenoidal sinus, frontal sinus, and both nasal cavities with medial displacement and infiltration of the right medial rectus muscle. A radiological assessment of extensive, locally advanced right antronasal mass was made on cranial CT scan. At surgery, a cheesy and friable tumor involving the roof, medial wall, and part of the floor of the maxillary sinus extending into the ethmoidal sinuses was seen with associated mucocele of the frontal sinus. Biopsy, histology, and immunohistochemistry of the mass showed SNUC.
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Liquid-based cytological diagnosis of achylous unilateral bancroftian pleural effusion: An uncommon presentation of a common problem p. 267
Pinki Pandey, Megha Ralli, Savita Agarwal, Ranjan Agarwal
DOI:10.4103/mjdrdypu.mjdrdypu_132_18  
Lymphatic filariasis is endemic and common in India. Filariasis is a widespread public health problem seen commonly in tropical countries. Filarial organism can be detected in cytological smears from various sites of the body in clinically unsuspected cases of filariasis. Incidental detection of filarial organism has been reported in cytological smears from almost any part of the body; however, it is very rare to detect these organisms in achylous hemorrhagic pleural fluid specimen. Demonstration of microfilaria in liquid-based cytological smears is rarely reported. To the best of our knowledge, the present case of achylous bancroftian pleural effusion diagnosed on liquid-based cytology (LBC) is the first one from the Indian subcontinent. We report a case with microfilariae of Wuchereria bancrofti in an 80-year-old male patient who presented with achylous, hemorrhagic unilateral pleural effusion in LBC.
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COMMENTARY Top

Liquid-based cytological diagnosis of achylous unilateral bancroftian pleural effusion: An uncommon presentation of a common problem p. 270
Subhashish Das
DOI:10.4103/mjdrdypu.mjdrdypu_228_18  
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CASE REPORTS Top

Unusual association of the neonatal herpes simplex virus hepatitis with congenital hydrocephalus p. 272
Aditya Pratap Singh, Ramesh Tanger, Arun Kumar Gupta, Dileep Garg
DOI:10.4103/mjdrdypu.mjdrdypu_69_18  
We report a 2-month-old male baby who presented with yellow discoloration of skin, high-colored urine, and intermittent clay-colored stools since 15 days of life. Head size was apparently looking large with dilated veins over the scalp. The baby was diagnosed and treated as neonatal herpes simplex virus hepatitis that led to cholestatic jaundice and cerebral aqueductal stenosis with hydrocephalus. It is a very rare association and less reported earlier in the literature.
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Retained rectal foreign body in a child operated for high anorectal malformation p. 275
Rajendra Kumar Ghritlaharey
DOI:10.4103/mjdrdypu.mjdrdypu_173_18  
Foreign body ingestion is not uncommon in pediatric age group. Foreign bodies including coin retention/impaction at the colorectal regions are less frequently reported in children and extremely rare in the operated cases of anorectal malformation (ARM). The present case is a 5.8-year-old boy who had retention of ingested foreign body (coin) in his rectum for 4 months. His history revealed that he was a case of high ARM which was managed with three-staged procedures. His clinical examination and radiological investigations revealed an anal stricture and a foreign body (coin) in his rectum. He was managed well with anal dilatation and removal of coin under general anesthesia. The intention for presenting the case is its rarity.
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Peripheral pulmonary embolism: A missed entity p. 278
J Sankar, Manish Unniyal, R Ramprasad, Atul Khullar
DOI:10.4103/mjdrdypu.mjdrdypu_144_18  
Pulmonary embolism (PE) is common, but often under-diagnosed or misdiagnosed entity. Pulmonary infarct is often caused by embolus in the peripheral branches, and timely diagnosis is often more challenging. Although peripheral pulmonary infarct is not fatal, it can be misdiagnosed as pneumonia or pleural effusion. Accurate diagnosis is also essential not only to rule out risk factors and prothrombotic states but also to prevent future thrombotic events. We report a case of 35-year-old male who presented with a history of isolated right-sided pleuritic chest pain of 1-week duration, diagnosed as a case of PE with a peripheral infarct. After 3 months of anticoagulation, he underwent screening for thrombophilia and detected to have factor V Leiden mutation. This case report highlights the fact that PE should be considered in the differential diagnosis of pleuritic chest pain.
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COMMENTARY Top

Invited commentary: A patient of pulmonary embolism and online conversational learning among global medical students through a journal review platform p. 281
Vivek Podder, Madhava Sai Sivapuram, Avinash Kumar Gupta, Rakesh Biswas
DOI:10.4103/mjdrdypu.mjdrdypu_230_18  
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LETTERS TO THE EDITOR Top

Use of E-learning tools for assessment in medical education p. 284
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/mjdrdypu.mjdrdypu_45_19  
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Power factor: Promises and perils of rotational headship in academic departments p. 285
V Dinesh Kumar
DOI:10.4103/mjdrdypu.mjdrdypu_117_18  
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Chemo brain – The need to defog the cognitive offshoot of chemotherapeutics p. 286
Suhas Chandran, Shalini Perugu
DOI:10.4103/mjdrdypu.mjdrdypu_131_18  
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