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   Table of Contents - Current issue
January-February 2020
Volume 13 | Issue 1
Page Nos. 1-96

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Coaching classes… competency-based curriculum… bed of procrustes… deck chairs on the Titanic Highly accessed article p. 1
Amitav Banerjee
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Understanding transdisciplinary level of integration in medical education p. 3
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
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Employing analyze, design, develop, implement, and evaluate model for the successful planning, implementation, and evaluation of integrated teaching program in India p. 5
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
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Handling disruptive educational innovations: What determines the difference while embracing changes? p. 8
V Dinesh Kumar, Mrinmayee Deb Barma, S S. S N. Rajasekhar
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Medical professionals and patients: The legal relationship in India p. 11
Arun Gupta, Neeti Goyal, Puja Dudeja, Kamalpreet Singh
Background: Medical professionals being subject to law suits is increasing at feverish pace in India. Knowledge of Law applicable to medical care givers will not only keep them in good stead in court of law but also help in avoiding court cases by taking corrective measures in time. Issues: Professional negligence is at the heart of any medical law suit. It can be civil or criminal. It can be countered by the medical professional with contributory negligence, in which patient himself is responsible wholly or partly for the harm. Also, hospitals and employer can be made responsible, by virtue of Vicarious responsibility. Redressal: Institutions from where a patient can ask for redressal are Medical Council of India, Consumer Protection Courts, Civil Courts, Criminal Courts and Military Courts. MCI can suspend registration of medical practitioner for varying period of time and Consumer court can give monetary relief to the patient. Care giver who gives care completely free of cost is exempted under Consumer Protection Act. Civil and Criminal courts have powers to sentence convicted medical practitioner of fine or imprisonment or both. Action Skills: Medical professionals can avoid law suits against them by good communication with patients and relatives, meticulous record keeping, taking real consent, meeting BRAND criteria, following standard protocols, avoiding negative criticism of fellow care givers and keeping themselves abreast with laws and acts of the land.
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Assessing the learning outcomes and perceptions of focused didactic training workshop in micrometry skills p. 16
V Dinesh Kumar, Yogesh Ashok Sontakke, HY Suma, K Aravindhan
Context: Micrometry skills, a combination of visual, cognitive, technical, and spatial expertise, are useful for ascertaining the quantitative research outcomes with concreteness. We conducted a workshop, based on modified Peyton's approach, which is aimed at transferring these skills for optimal research practice. Aims: Our principal aim was to document the perceived learning outcomes and knowledge gained from the focused didactic training workshop on micrometry skills. Settings and Design: In the 1-day hands-on workshop, basic concepts of micrometry skills were taught using ImageJ software. The learning gains of workshop were evaluated using Moore's expanded outcomes framework. Subjects and Methods: To achieve this, we administered pre- and post-tests along with a postworkshop evaluation survey form. Statistical Analysis Used: Descriptive statistical analysis was used to estimate the measures of central tendency. Results: Significant knowledge transfer could be demonstrated by increase in posttest scores. The feedback responses of the participants were overtly positive. Conclusions: To the best of our knowledge, this is the first documentation of the focused didactic micrometry skills training workshop using modified Peyton's approach. The framework might serve as a formidable base for conducting similar workshops in other medical schools.
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The observed seasonal variation pattern and changing epidemiology of Lassa viral hemorrhagic fever disease in Ondo State, Nigeria p. 22
Patrick Olanrewaju Osho, Olumuyiwa John Fasipe, Evelyn Salewa Osho, Bosede Samuel Adu, Oluwaseyi Joseph Akinrotimi, Waheed Abolaji Folayan, Wasiu Olalekan Adebimpe
Background: The Lassa viral hemorrhagic fever disease (LVHFD) outbreak usually occurs in the Northern senatorial district of Ondo State, Nigeria. Precisely local government areas (LGAs) such as Ose and Owo LGAs; these are the adjacent LGAs to Edo State in Nigeria where LVHFD outbreak has been recorded highest in the country at recent times. Aim: This research was designed to disseminate a general public awareness message about the recent trend regarding the observed seasonal variation pattern in the epidemiological transmission, outbreak, and status of Lassa viral hemorrhagic fever disease in Ondo State, Nigeria. Materials and Methods: This was a retrospective observational longitudinal study carried out to report the recent trend regarding the observed seasonal variation pattern and changing epidemiology of Lassa viral hemorrhagic fever disease in Ondo State, Nigeria. The data in this study were sourced and collected from the state epidemiological records on Lassa fever (LF) at the Department of Public Health Services, Epidemiology Unit, State Ministry of Health, Akure, Ondo State, Nigeria. Results and Findings: The outbreak of the disease has been recurring since 2014 up till date (2018). LF outbreak in the period under consideration showed an increasing trend, except in 2015, where the rate of seropositively infected and confirmed cases reduced by 62.5% (dropped from 8 to 3 cases). The rate of confirmed seropositive cases increased by 533.3% in 2016 compared to 2015, 300% in 2017 compared to 2016, and 19.7% increase in 2018 compared to 2017 events. The mortality rate recorded which was also directly dependent on the rate of confirmed seropositively infected cases; it was 50% in 2014, 0% in 2015, 63.1% in 2016, 23.6% in 2017, and 25.3% in 2018. Furthermore, the peak seropositive outbreak cases for Lassa viral hemorrhagic fever disease in the year 2017 analyses occurred during February (12 cases) and August (12 cases), and then followed by June (11 cases) and December (9 cases). Conclusion: The observed seasonal variation pattern and changing epidemiology of Lassa viral hemorrhagic fever disease in Ondo State, Nigeria, can be attributed the challenging poor socioeconomic factors and persistent situations peculiar to the outbreak. The year 2017 analyses revealed that there was an all year round disease outbreak for LF in the state. This was contrary to the widely circulating report that LF outbreak is being influenced by dry seasons. The peak of the disease outbreak in the year 2017 occurred during February and August, as this is the peak months of dry seasons and wet seasons, respectively, in Ondo State, Nigeria.
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Lassa viral hemorrhagic fever p. 28
Viroj Wiwanitkit
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A study of correlation of perceived stress and thyroid function among females in a rural population of reproductive age group p. 30
Arunima Chaudhuri, Samarjit Koner
Background: Thyroid dysfunction may be associated with increased perceived stress. Aims: We aimed to study the correlation of perceived stress and thyroid function among females in a rural population of reproductive age group. Materials and Methods: This pilot study was conducted in Burdwan Medical College on 200 newly diagnosed female hypothyroid patients in a period of 12 months after taking institutional ethical clearance and informed consent of the participants. Parameters studied were body mass index (BMI), Presumptive Stressful Life Event Stress Scale (PSLES) scores, Perceived Stress Scale scores (PSS scores), thyroid-stimulating hormone (TSH), and free thyroxine (fT4) levels. To avoid stress effects of the premenstrual phase, we examined our participants during the postmenstrual phase. All the participants were on nonvegetarian diet and their dietary habits were nearly similar. Participants were divided into two groups: G1 – hypothyroid patients and G2 – patients with subclinical hypothyroidism. The computer software “Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc., Released 2007. SPSS for Windows, version 16.0. SPSS Inc., Chicago, Illinois, USA)” was used to analyze the data. Results: Two hundred newly diagnosed hypothyroid females were included in the present study. Among them, 130 were clinical hypothyroid (G1) and 70 were subclinical hypothyroid patients (G2). A significant difference was found between clinical and subclinical hypothyroid females for mean PSS scores (P = 0.002). There was no significant difference in PSLES scores between the two groups. A significant difference was found between clinical and subclinical hypothyroid females for BMI (P = 0.002), TSH (P < 0.0001), and fT4 (P < 0.0001). There was no significant difference in age between the two groups. There was a significant positive correlation between PSS scores and TSH levels with r value of 0.97 in G1 and r value of 0.26 in G2, respectively. Conclusion: Females of reproductive age group with clinical and subclinical hypothyroidism faced the same amount of stressful life events. However, their perception of stress was significantly different. High TSH was positively correlated with high score on PSS. Clinical hypothyroidism is associated with hypercortisolemia and also depression. However, a cause–effect relation is yet to be established. Moreover, depression and serum cortisol were not assessed, so no further conclusions can be drawn from the present study.
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Anxiety and depression in menopausal transition: A hospital-based study from Kashmir p. 37
Shabir Ahmad Dar, Zaid Ahmad Wani, Bilal Ahmad Bhat, Shanoo Sheikh, Junaid Nabi, Aaliya Khanam, Deeba Nazir, Mudasir Nazir
Background: Menopausal transition (MT) is the period of irregular menstrual activity which directly precedes menopause and is characterized by widely fluctuating hormone levels and reproductive, metabolic, and psychological disturbances. We aimed to study the prevalence of psychiatric comorbidity among ambulatory women in MT. Materials and Methods: One hundred consecutive ambulatory women in MT were assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria by means of the Mini-International Neuropsychiatric Interview, English version 5.0.0. The diagnosis of MT was made according to the Stages of Reproductive Aging Workshop. Results: About 28% of the cases had major depressive disorder (MDD), 14% had anxiety disorders, and 7% had anxiety with depression. A statistically significant difference in psychiatric comorbidity was found between the age groups of 45–50 years and 51–55 years. There was a statistically significant difference between onset of menarche and psychiatric comorbidity. Women in the late MT had statistically significant sleep disturbances. Conclusion: A high prevalence of mental disorders was observed which included MDD and other anxiety disorders. The results suggested that screening and appropriate management for psychiatric disorders should be part of the routine evaluation that would help in early recognition of symptoms and reduction in discomfort of these symptoms.
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Clinical profile of tuberculosis in children p. 43
Ira Shah, Naman S Shetty, Anmol Goyal, Nikhil Patankar, Sujeet M Chilkar
Aim: The study aimed to describe the clinical profile tuberculosis (TB) in children at various ages. Materials and Methods: Clinical profile of various types of TB and factors associated with them was compared. Results: A total of 135 children were diagnosed with TB in the study period. The mean age of the presentation was 5.3 ± 3.5 years. Common clinical features at presentation included fever in 112 (83%), cough in 63 (46.7%), and loss of appetite in 51 (37.8%). On biochemical evaluation, 72 (74.22%) of 97 records showed raised erythrocyte sedimentation rate (ESR) levels. One hundred and twenty-one (89.6%) children had received Bacille Calmette–Guérin (BCG) vaccination, 44 (32.6%) were found to be tuberculin skin test (TST) positive, and 58 (43%) were malnourished. On diagnosis, pulmonary TB was seen in 49 patients (36.3%), neuro TB in 20 (14.8%), TB lymphadenopathy in 12 (8.9%), abdominal TB, TB serositis and latent TB in 11 cases (8.2%) each, musculoskeletal involvement in 8 (5.9%) cases, and 6 (4.4%) showed disseminated form. The rest two of them were diagnosed with BCGosis and atypical mycobacterium infection. On statistical analysis, it was found that fever (P = 0.002) and raised ESR (P = 0.045) were least common in abdominal TB and disseminated TB, whereas loss of appetite was more common in disseminated TB and least in abdominal TB (P = 0.02). Conclusion: Pulmonary TB is the most common type of TB in children with boys more affected as compared to girls. TST is positive in less than half of the children with TB. Fever is the most common symptom of TB in children. In abdominal TB and disseminated TB, ESR was normal, and fever was absent. Loss of appetite is commonly seen in disseminated TB.
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Nasal myiasis among pediatric patients: Our experiences p. 48
Santosh Kumar Swain, Rachita Sarangi, Jatindra Nath Mohanty
Objective: The objective is to study the clinical profile, diagnostic method, treatment, and outcome of nasal myiasis among children at a tertiary care teaching hospital of east India. Materials and Methods: This is a prospective study on 28 children of either sex with the age group of 6–16 years suffering from nasal myiasis during the past 10 years. The details clinical pictures, treatment, and outcome of the nasal myiasis among children were studied. Nasal endoscopy was performed for the diagnosis and removal of crawling maggots by picking up with nasal forceps under direct vision. Results: The youngest child was of 6 years 3 months and oldest 16 years of age. More than half of the children (60.71%) were >10 years of age. Of 28 children, 18 (64.28%) were suffering from chronic rhinosinusitis, whereas 5 (17.85%) children with atrophic rhinosinusitis and 5 (17.85%) children were known case of sinonasal tumors. Main presenting symptoms were as follows: epistaxis (100%), a fouls smell (64.28%), passage or crawling sensation of worms (89.28%), and pain in the nose (75%). Endoscopic method was used in all cases for the removal of maggots from the nasal cavity. Conclusion: Nasal myiasis is an uncommon clinical condition in the pediatric age group due to improved living standards, but it still exists in developing and underdeveloped country. Quick and complete removal of maggots is needed for avoiding complications of nasal myiasis among children. The hygiene of the child should be improved for avoiding this dreaded clinical entity.
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Factors determining institutional delivery in rural India p. 53
Manas Pratim Roy
Introduction: For reducing maternal deaths, institutional delivery (ID) is a recognized strategy. India has introduced a combination of performance-based incentive and conditional transfer under Janani Suraksha Yojana to boost ID. The present study aims to find out factors deciding ID in rural India. Methods: Data were from nationally representative National Family Health Survey 4 (2015–2016). States were compared individually and in groups. Correlation was used for analysis. Results: Number of antenatal care visits (r = 0.807), early registration (r = 0.820), and consumption of 100 or more iron-folic acid tablets (r = 0.765) were significantly related to ID. Northeast states performed poorly, Nagaland being the worst performer (24% ID). Conclusion: Strategy for encouraging ID should focus around components of antenatal checkup, particularly in Northeast states.
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Fine-needle aspiration cytology of thyroid nodule(s) at a tertiary hospital in West Bengal, India: A 5-year experience p. 57
Krishnendu Das, Mausumi Basu, Susmita Sarkar, Sita Chatterjee
Introduction: Thyroid nodules are a common clinical finding which is important due to their malignant potential. Fine-needle aspiration cytology (FNAC) is routinely used for first-line diagnosis of thyroid lesions and to differentiate benign from malignant nodules. Objective: The objective was to evaluate the advantage of FNAC as a simple procedure for the diagnosis of thyroid swelling. Materials and Methods: This is a retrospective study conducted at the department of pathology of a tertiary care hospital among 681 diagnosed patients of thyroid swelling who underwent FNAC. The results were interpreted according to the Bethesda nomenclature. Results: The most common age group affected was 20–29 years (29.22%), female patients were 90.46% and that of males were 09.54%, benign cases constituted 91.63%, follicular lesion of undetermined significance were 00.33%, follicular neoplasm were 02.93%, suspicious cases were 00.44%, malignant cases were 4.40%, and unsatisfactory were 00.33%). Among benign group, 45.03% of cases were of colloid goiter and 23.72% were of Hashimoto's thyroiditis. The malignant diagnoses yielded 83.33% of papillary carcinoma, 10% of medullary carcinoma, and 3.33% of anaplastic carcinoma. Conclusion: FNAC is a rapid and cost-effective screening test for accurate diagnosis of thyroid swellings.
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The effect of differential site of application of the pulse oximeter in critically ill children seen in a tertiary health center p. 63
Ibrahim Aliyu, Abubakar M Shakur, Zainab F Ibrahim
Introduction: Pulse oximeter is useful in the management of the critically ill child; it gives meaningful information for immediate clinical decision-making. The fingertip probe is the most common supplied probe in most hospitals, especially in resource-limited settings, and these may not fit all pediatric age groups; hence, it is not uncommon to see such probes been applied to bigger sized digits such as the toe in younger aged children. This study therefore sought to determine if there was any difference in the SpO2 readings from those varied sites. Materials and Methods: This study was cross sectional involving 100 children seen in our pediatric emergency unit. Results: There were 59 (59.0%) males and 41 (41.0%) females with male to female ratio of 1.4:1. The age ranged from 1 to 12 years with mean of 6.0 ± 3.4 years. The mean pulse oximetry between the various pairs was almost similar for all the sites; however, this observation was not statistically significant (t = 0.269, df = 70, P = 0.789). There were significant agreements between all the studied methods of comparison of SpO2. However, this was most noticeable for the right index finger and left index finger. Conclusion: This study showed that SpO2 can be measured from any digit.
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An observational study to assess hand hygiene compliance rate among health care workers at a tertiary care hospital p. 66
VK Mumtaz Rahim, Kanwaljit Kaur, Sonal Yadav, Vadlamannati Srinivas, Smita Devrani, Harpreet Singh, Abhijit Chakravarty
Background: Wearing of gloves by health-care workers (HCWs) reduces the transmission of pathogens between patient contacts. However, it is not a substitute for hand washing. The present study aimed to observe the gloving behavior versus its indications and hand hygiene (HH) compliance with and without gloves. Materials and Methods: HCWs working in intensive care units (ICUs) and acute care setup of a tertiary care hospital were observed for the use of gloves and HH practices as laid down by the World Health Organization (WHO). Results: Of a total 4301 opportunities, HH actions were performed in 2312 (53.74%) opportunities. In ICU, of 2053 opportunities, HH actions were performed in 1169 (56.94%) opportunities, which was better than other acute care settings where HH was performed in only 50.8% occasions. Out of 1989 missed opportunities where HH was not performed, in 525 occasions (26.39%) the gloves were worn. Conclusion: The rate of HH compliance was higher in ICU than other acute wards. At the same time, HH rate was lower when gloves are worn. Sensitizing HCWs about the WHO five moments of HH and glove pyramid can improve HH practices and gloving practices.
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Going back to basics: Improving hand hygiene compliance p. 71
Sarit Sharma
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Thyroid hormone levels and ultrasonographic changes in thyroid gland of patients on long-term lithium treatment for affective disorders: A controlled study p. 73
Shabir Ahmad Dar, Bilal Ahmad Bhat, Aaliya Khanam, Zaid Ahmad Wani, Junaid Nabi, Shanoo Sheikh
Background: Although lithium is known to cause thyroid dysfunction and increased thyroid gland volume, clinical examination and biochemical assessment are fundamental to thyroid workup of patients on lithium treatment. We aimed to determine the thyroid gland volume and the thyroid hormone levels of patients who have been receiving lithium treatment for affective disorders in comparison to voluntary healthy controls. Materials and Methods: This was a cross-sectional, hospital-based observational study, performed in 43 patients on long-term lithium treatment for bipolar disorder, major depressive disorder, and schizoaffective disorder. Patients with documented continuous and adequate serum lithium levels for more than or equal to 6 months recruited consecutively underwent ultrasonographic examination of the thyroid gland. Ultrasonographic examinations were also done in all gender- and age-matched healthy controls. All cases and controls underwent biochemical thyroid function tests. Results: There were no statistically significant differences in gender (P = 0.198; χ2 = 1.654) of cases and controls. Most of the cases were married; maximum number of them unemployed and belonged to the lower socioeconomic status. Total thyroid volume was significantly greater in the lithium-treated group than the control group (9.40 ± 1.41 vs. 4.79 ± 0.45). Clinical inspection and palpation only detected goiter in six (n = 6, 13.95%) of patients on lithium and none among controls. The mean triiodothyronine (T3), mean thyroxine (T4), and mean scores for thyroid-stimulating hormone were significantly increased in patients receiving lithium therapy as compared to controls. Conclusion: It would seem wise from a clinical point of view to include ultrasonographic examination of the thyroid gland as part of the standard thyroid workup before initiating lithium treatment.
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How to conduct medical ward rounds p. 79
Vishnu Sharma Moleyar, Anupama Noojibail
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Adrenal myelolipoma: A rare entity p. 82
Shubhangi Tayade, Akshay R Bondge, Archana Buch, Harsh Kumar
Adrenal myelolipoma is an uncommon benign tumor of the adrenal gland, usually asymptomatic, unilateral, and nonsecreting. Adrenal myelolipoma is usually an incidental finding. It is composed of variable mixture of mature adipose tissue and trilineage hematopoietic elements. We report a case of 26-year-old female patient with complaints of headache, acne, hoarseness of voice, facial hair growth, poor breast growth, and enlarged clitoris. On investigating, serum testosterone, serum cortisol, serum androstenedione, and serum adrenocorticotropic hormone levels were found increased. The patient was operated for left adrenalectomy. On histopathology, it showed predominantly adipose tissue and areas of hemorrhage with foci of hematopoietic elements, comprising lymphocytes, plasma cells, megakaryocytes, as well as myeloid and erythroid cells. The case is presented to highlight this rare large functional tumor in a young adult female.
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Adrenal myelolipoma: A rare entity p. 85
Subhashish Das
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Imaging in a case of chyluria presenting as hematuria p. 86
Vinay Maurya, Manoj Gopinath, Krishnendu Sarkar, Puneet Aggarwal
Chyluria is a debilitating disease characterized by passage of milky white urine. The cases of chyluria usually pose no problem in diagnosis as the characteristic milky white urine on naked examination is virtually diagnostic. However, if hematuria is a predominant finding it may mask the chyluria and lead to delayed diagnosis. In such cases imaging may play a vital role in diagnosing these cases. MRI findings of dilated retroperitoneal lymphatics are characteristic and help in early diagnosis and management of these cases.
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Juvenile granulosa cell tumor of the ovary in a 7-year-old girl: Rare case report p. 89
Aditya Pratap Singh, Arun Kumar Gupta, Arpita Jindal, Maryem Ansari
Ovarian granulosa cell tumor (GCT) is a rare ovarian neoplasm, which typically occurs in children and young women. More than 90% of the patients are diagnosed in Stage IA, who can be cured by unilateral oophorectomy. Meanwhile, the remaining is diagnosed in more advanced stages, wherein tumors may exhibit aggressive behavior. In this stage, surgery and adjuvant chemotherapy may be required. Isosexual precocious puberty in girls is mostly idiopathic in origin. However, this is a diagnosis of exclusion, and many differential diagnoses have to be thought of in evaluation of precocity in girls. We are presenting here a case of isosexual precocity in a 7-year-old girl due to juvenile GCT of ovary, a rare etiology of precocity.
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An unusual case of transition from pemphigus vulgaris to pemphigus foliaceus p. 93
Rashmi B Aderao, Uddhao S Zambare, Swagata A Tambe, Chitra S Nayak
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Study of dermal vascular changes in inflammatory skin diseases p. 95
Subhashish Das
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