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   Table of Contents - Current issue
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September-October 2020
Volume 13 | Issue 5
Page Nos. 425-574

Online since Monday, September 7, 2020

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EDITORIAL  

Chasing the virus: Not only difficult but impossible. Are we going to hit a dead end? Highly accessed article p. 425
Amitav Banerjee
DOI:10.4103/mjdrdypu.mjdrdypu_424_20  
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REVIEW ARTICLES Top

To spray and pray? The “disinfectant spray” conundrum Highly accessed article p. 427
Mudera P Cariappa, Rohit D Bavdekar, Narinder Kumar, Aravind Veiraiah, Ranjith K Nair
DOI:10.4103/mjdrdypu.mjdrdypu_281_20  
To contain the spread of the coronavirus, governments have instituted various stringent preventive measures including spraying disinfectants onto open spaces and people too, to reduce the spread of the virus. There is panic driving such responses especially in rural areas, where internally displaced workforces are now returning to their native villages. We seek to analyze the potential impact of such practices as a starting point for further scientific debate. We believe that findings of past studies on disinfection practices are not applicable to the spraying of open spaces or people as the conditions are totally different. We need to balance benefits with the potential for adverse risks of any public disinfection activities. As with other chemicals, spraying disinfectants into the environment is also likely to cause harm in some instances. While public authorities would wish to be seen to be doing something to reduce transmission and allay anxiety in the public, spraying disinfectant over public spaces and onto people could backfire substantially, if real or perceived adverse effects appear. Unanticipated consequences can result if consideration is not given to the Principle of Harm, which determines when Public health interventions are ethically justifiable and there is no attempt to minimize harm in the face of uncertainty. We recommend a systems approach to reporting of unintended harms from such interventions through a community based participatory process and further evaluation before implementation of such measures.
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Is India ready to be “stroke ready”? An appraisal of our stroke preparedness Highly accessed article p. 431
Sachin Ajitkumar Adukia, Radhika Shriprakash Ruhatiya, Gagan Naresh Jain
DOI:10.4103/mjdrdypu.mjdrdypu_332_19  
A recent trend of being a “stroke ready center” has been finding roots. But such centers are too far and few to reach many beneficiaries. And so, like all else, the burden of stroke preparedness also falls on the physician to brace and embrace. This review will address the physician's role in early assessment and management of acute stroke. Therapeutics such as thrombolysis with alteplase and tenecteplase will be appraised. Indian statistics on acute stroke management in comparison to Western standards will be discussed. Issues such as public education forums and cost considerations will be addressed. Government initiatives for the facelift of the Indian medical infrastructure will be mentioned wherever relevant. But an idea not coupled with action will never get any bigger than the brain cell it occupied. Therefore, we will conclude with actionable key points for physicians.
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ORIGINAL ARTICLES Top

Our experience with stroke thrombolysis at a tertiary care center in South India p. 437
Veeramalla Madhavarao, Owais Mohammed, Chandrasekhar Valupadas
DOI:10.4103/mjdrdypu.mjdrdypu_181_19  
Introduction: Intravenous (IV) thrombolysis is the cornerstone of the treatment of acute ischemic stroke in modern stroke era. Alteplase, also known as recombinant tissue plasminogen activator, is currently the only approved drug for IV thrombolysis worldwide and is used for the treatment of acute ischemic stroke. Objective: The objective was to study the clinical efficacy and safety of IV thrombolysis with alteplase in acute ischemic stroke. Materials and Methods: We consecutively enrolled acute ischemic stroke patients who underwent IV thrombolysis with alteplase from October 2017 to May 2018. Primary clinical efficacy outcome was defined as an improvement in the National Institute of Health Stroke Scale (NIHSS) score of ≥4 points at 24 h. The secondary clinical efficacy outcome was the favorable outcome on the modified Rankin scale at 90 days, which is defined as a score of 0 or 1. The safety endpoints were death rate at 90 days and symptomatic intracranial hemorrhage (SICH). Results: The mean NIHSS scores at baseline and 24 h were 13.56 (±4.56) and 9.92 (±6.13), respectively, the difference being statistically significant (P < 0.001). In this study, 15 patients (60%) met the primary clinical efficacy outcome, and the same number achieved the secondary clinical efficacy outcome. Three patients (12%) developed SICH but without any deaths. Conclusion: This study confirms the efficacy and safety of alteplase for stroke thrombolysis in our clinical setting.
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Bacteriological profile of surgical site infections and its resistogram in Sangli district, Maharashtra p. 441
Girish S Sharnathe, SA Gadgil
DOI:10.4103/mjdrdypu.mjdrdypu_298_19  
Introduction: Surgical site infection (SSI) is one of the most common hospitals acquired infection. The present study describes resistogram of bacterial pathogens in SSIs in the hospitals in and around Sangli, Maharashtra, India. Materials and Methods: The resistogram pattern was studied by modified Kirby-Bauer disc diffusion method. Results: A total of 1491 pus samples from patients clinically diagnosed of SSIs were processed and 911 isolates were obtained. The most common Gram-positive isolates were Staphylococcus aureus(53.92%), coagulase-negative Staphylococci (31.17%), Enterococcus (10.58%), and Streptococcus pyogens (4.31%); while Gram-negative isolates were Escherichia coli (33.16%), Klebsiella spp. (28.92%), Citrobacter species (4.98%), Pseudomonas aeruginosa (12.96%), Acinetobacter species (1.99%), Proteus mirabilis (10.97%), and Proteus vulgaris (6.98%). The frequency of methicillin-resistant S. aureus (MRSA) was 28% whereas the frequency of methicillin sensitive S. aureus was 72%. The MRSA showed multidrug resistance pattern. Conclusion: Twenty-eight percent are MRSA which showed multidrug resistance pattern. While most of the Gram-positive isolates were resistance toward the amoxicillin/clavulanate, gentamicin, and ceftriaxone. Most of the Gram-negative isolates were resistant to ampicillin, ciprofloxacin and ceftriaxone.
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Prevalence of microbial agents associated with chronic nonhealing ulcers: A cross-sectional study p. 447
Pritilata Panda, Sarvodaya Tripathy
DOI:10.4103/mjdrdypu.mjdrdypu_248_19  
Background: Chronic nonhealing ulcers (NHUs) are responsible for considerable morbidity worldwide. Polymicrobial flora has been associated with most of the chronic ulcers. Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacteriaceae, Anaerobes, Mycobacteria, and Fungi have been shown to infect chronic NHUs. Objectives: The objective of the study was to evaluate the microbial agents associated with chronic NHUs. Materials and Methods: The study was a cross-sectional observational study conducted over 2 years. Basing on the inclusion criteria sample were collected from 168 patients. The standard protocol for the identification of microorganisms was followed. Results: Of the 168 cases examined 128 (76.2%) were male and 40 (23.8%) were female. Most of the cases were 41–60 years old. One hundred and thirty-two microbial isolates were obtained from 77 patients. In 32 patients' infections were monomicrobial and in the rest 45 infections were polymicrobial. A total of 112 out of 132 isolates obtained in the study were bacteria (both aerobic and anaerobic). Mycobacterial isolates were 11 and fungal isolates were 9 in number. Conclusion: The prevalence of microbial infections associated with a chronic NHU in this study population was 45.8%. The most common group of microbial agents were aerobic bacteria, S. aureus being the most common agent.
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Transabdominal ultrasonographic evaluation of hepatocellular carcinoma and its correlation with cytopathological findings p. 454
Md Shafiqul Ahsan, Rawnak Afrin, Sultana Naznin, Asifa Sattar, Khaleda Khanam, A K. M Maruf Raza, Suresh Kumar Tulsan, Vivek Podder, Mahfuzul Islam
DOI:10.4103/mjdrdypu.mjdrdypu_272_19  
Aims and Objectives: To compare the ultrasonographic findings of hepatocellular carcinoma (HCC) with that of cytopathology to asses the diagnostic validity of transabdominal ultrasonography (USG). Settings and Design: Cross-sectional study in Sir Salimullah Medical College and Mitford Hospital, Dhaka. Materials and Methods: This cross-sectional study was carried out in the department of radiology and imaging of Sir Salimullah Medical College and Mitford Hospital, Dhaka, during July, Dhaka, during July 2009–March 2011 to evaluate the transabdominal USG in the detection of HCC and its validity by determining sensitivity, specificity, accuracy, and positive and negative predictive values. For this purpose, a total of fifty patients were enrolled in the study. Cytopathology was done in all these patients. Statistical Analysis: Statistical analyses of the results were obtained using window-based computer software devised with Statistical Package for the Social Sciences (SPSS-13) (SPSS Inc., Chicago, IL, USA). The analysis of the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy was done using online OpenEpi, Version 3, an open-source calculator. Results: The current study found that the mean age of patients was 49.14 ± 13.79 years, ranging from 20 to 79 years. The USG detected HCC in 31 (62%) cases, of which 27 (87.1%) were cytopathologically proven. USG diagnosed 19 (38%) cases as lesions other than HCC, of which 4 (21.1%) cases were diagnosed as HCC cytopathologically (false negative). The rest of the 15 (78.9%) cases were diagnosed as other lesions including metastasis, by both USG and cytopathologically (true negative). The validity of USG was studied by calculating sensitivity, specificity, accuracy, PPV, and NPV, which were 87.1%, 78.95%, 87.1%, 78.95%, and 84%, respectively. Conclusions: In this study, the USG findings and the validity tests were found almost identical as observed by other investigators compared with cytopathological findings. Hence, it can be concluded that the USG is a useful diagnostic modality in the diagnosis of HCC.
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Profile of the tuberculosis patients enrolled in Nikshay portal (a web-based online portal) from Chittoor district: A monitoring tool for tuberculosis in India p. 460
D Surendra Babu, KR John, Ramesh Babu
DOI:10.4103/mjdrdypu.mjdrdypu_183_19  
Background: The Revised National TB Control Programme developed a case based web-based online reporting mechanism called NIKSHAY. A community-based survey conducted in 2011 reported that 46% of the tuberculosis (TB) patients in India were treated outside the public health system (private sector) and hence they are not the part of the national TB notification system. Methodology: The objective of the study was to assess the profile of the TB individuals in the Chittoor district in Andhra Pradesh, south India. A secondary data were retrieved from the district TB center NIKSHAY web-based online portal in Chittoor and analyzed using SPSS 21.0 version. Data were taken from the last 1 year (April 2017 to March 2018). Results: A total of 3952 individuals were registered in the web based online NIKSHAY portal during the study. Among them in 2918 (73.7%) were males and 1033 (26.2%) were females with the mean age of the patients was 44.6 years with a standard deviation of ± 16.3 ranges. The clinically confirmed cases were 587 patients and microbiologically positive were 2495 (79.8%) and negative were 633 (20.2%). Majority 3263 (82.5%) were had pulmonary and 452 (11.4%) had extra-pulmonary TB. Depending on the HIV-positive cases were 274 (6.9%) and 3560 (90.2%) were negative and the remaining 118 (2.9%) do not know the status of the HIV/AIDS. The CBNAAT results were 411 (10.5%) of the patients had rifampicin sensitivity and 26 (0.6%) of them were resistant. Conclusion: India had taken the nice initiative for the web-based online portal for the notification of the TB patients. Several ongoing efforts have been implemented to improve the quality of surveillance reporting. A series of trainings on quality assurance of TB data should be taken to all the field staff.
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Extranodal tuberculosis of the head and neck: Our experiences at a tertiary care teaching hospital of East India p. 465
Santosh Kumar Swain, Jatindra Nath Mohanty, Mahesh Chandra Sahu
DOI:10.4103/mjdrdypu.mjdrdypu_168_19  
Introduction: Extranodal tuberculosis of the head-and-neck area is a rare clinical entity and constitutes a less common type of extrapulmonary tuberculosis. It often creates challenges among head-and-neck physicians for its diagnosis and treatment. Objective: The aim of the study is to discuss the clinical presentations, diagnostic challenges, and treatment of extranodal tuberculosis of the head-and-neck area. Materials and Methods: There are 22 patients of extranodal locations of tuberculosis in the head-and-neck region managed at our teaching hospital between December 2014 and January 2019. Results: The sinonasal tract affected in 5 cases, the tonsils in 4 cases, the middle ear cleft in 4 cases, the nasopharynx in 3 cases, and the larynx in 3 cases. The parotid gland affected with tuberculosis in 2 cases and 1 case in the thyroid gland. The clinical presentations, imaging, and endoscopic pictures are not specific, whereas the diagnosis is based on histopathological examination. All the patients treated with antitubercular therapy. All patients showed favorable results after 1-year follow-up. Conclusion: Extranodal tuberculosis is a rare clinical entity and has no specific clinical features. It is often a differential diagnosis of head-and-neck malignancies and chronic infective or noninfective ulcers. Early diagnosis and its treatment may avoid complications and needless major surgery.
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Yield of direct sputum smear examination in pulmonary tuberculosis suspect cases with hemoptysis p. 470
Sushil Kumar Munjal, Karnail Singh, Ritu Singhal, Amartya Chakraborti
DOI:10.4103/mjdrdypu.mjdrdypu_267_19  
Introduction: Hemoptysis is one of the cardinal symptoms of pulmonary tuberculosis (PTB) as per the Revised National Tuberculosis Control Programme 2016 guidelines. Hemoptysis in tuberculosis patients usually occurs in those who have a large bacillary load like that in a cavity. Direct smear done from the sputum of a PTB suspect with hemoptysis should have a higher diagnostic yield due to the greater bacillary load in such patients. Keeping this intention in mind, our study was conducted to systematically inquire into the efficacy of a cheap and easily available test like direct sputum smear examination in PTB suspect cases of hemoptysis. Materials and Methods: This was a prospective, hospital-based, analytical study, conducted on 100 PTB suspects with hemoptysis, who were attending the Outpatient and Emergency Department of National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India. Patients were enrolled over a period of 8 months. All patients underwent routine clinical and radiological evaluation and sputum examination in the form of direct smear by Ziehl–Neelsen (ZN) staining and mycobacterium growth indicator tube (MGIT) culture. Results: Most of the patients (25%) belonged to the age bracket 16–25 years followed by 24% of patients who belonged to the age group of 26–35 years. Fifty-two percent of patients had the cavity in their chest X-ray findings in which mostly were the unilateral cavity (39%). Direct sputum microscopy was found to be positive in 56% of patients. In comparison to MGIT, it had a sensitivity of 79% and a positive predictive value of 92%. Conclusion: Direct smear examination in hemoptysis patients should be a first line essential investigation as it is a good, cheap, easily available, and quick test. The yield of the test increases if the patient is young, male, with a previous history of antitubercular therapy intake and cavitary lesions on the radiological findings.
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HIV positivity in presumptive tuberculosis cases in a tertiary respiratory care institute in New Delhi, India p. 475
Sushil Kumar Munjal, Vijender Mudavath, Amartya Chakraborti, Puneet Arora, Manpreet Bhall
DOI:10.4103/mjdrdypu.mjdrdypu_337_19  
Background: Routine screening of presumptive tuberculosis (TB) patients for HIV was advised by the Treatment and Operational Guidelines of TB in India in 2016. This was in contrast to the earlier policy in which only diagnosed TB cases underwent HIV screening. Keeping this in mind, our study was carried to look at the prevalence of HIV in presumptive TB cases in a tertiary respiratory disease hospital in New Delhi, India. Materials and Methods: This prospective observational study was carried out from 2015 to 2017 in which patients (>18 years of age) attending the outpatient department diagnosed as presumptive TB were enrolled. They underwent sputum examination in Revised National TB Control Programme Designated Microscopy Centre by fluorescence microscopy/Ziehl–Neelsen staining technique for the diagnosis of PTB, and they were taken to Integrated Counselling and Testing Centre in our hospital. Fine-needle aspiration cytology from lymph nodes and pleural or ascitic fluid studies were also done as per requirement for the diagnosis of extrapulmonary tuberculosis. Pretest counseling and HIV test were performed after informed consent. Results: Forty out of 1020 enrolled patients were HIV positive (3.9%). Fifteen out of 617 patients who were not suffering from TB came out to be HIV positive (2.4%). Our strategy led to an enhanced case finding of 15/25 (60%) new HIV-positive patients. Conclusion: Routine HIV screening in presumptive TB patients is a viable model to increase the case finding of HIV patients.
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Correlation between waiting time and satisfaction among those attending outpatient departments of a tertiary care social security hospital, Faridabad, Haryana p. 480
Mitasha Singh, Shivam Dixit, Rajesh Ranjan, Roopal Sharma, Rajat Singla, Pooja Goyal
DOI:10.4103/mjdrdypu.mjdrdypu_186_19  
Background: Patient satisfaction has been an area of interest among hospital administrators. One of the reasons of this perception quoted in the literature is waiting time and time spent with the service provider. Objective: The objective of this study is to calculate the self-reported waiting time and time spent for consultation and diagnostic procedure among those attending the outpatient departments (OPDs) at Employees State Insurance Corporation, Medical College and Hospital, Faridabad, and second whether this waiting time is a predictor of patient satisfaction. Methodology: A cross-sectional study was conducted in a tertiary level health center which caters to the insured population under the Employees State Insurance Scheme from June 2018 to August 2018. This study was conducted on 265 patients and attendants (age ≥18 years) attending the OPD from 10 a.m. to 01 p.m. The study population was stratified from three points (OPD, laboratory, and pharmacy). Multiple Linear Regression (MLR) model was run to identify whether waiting time was an independent predictor of satisfaction after accounting for confounders. Results: Median time taken by the study population from registration till visiting doctor was 50 min (interquartile range [IQR]: 60). The median time spent with doctor was 5 min (IQR: 5) at laboratory and pharmacy was 10 and 3 min, respectively. The total score for satisfaction ranged from 38 to 79 with a mean score of 61.256 (±2 standard deviation; 8.293). The MLR analysis revealed that the time taken from the laboratory or OPD to pharmacy for taking drugs and time spent in the laboratory had impact on satisfaction. (ß = 0.273, P = 0.03 and ß = 0.247, P = 0.03, respectively). Higher level of education was associated with lower satisfaction level in the current study. Conclusion: It is needed to focus upon the time spent with the patients by the doctors and the number of staff posted at a point of care who are actually working.
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Role of ultrasonography and fine-needle aspiration cytology in the evaluation of neck masses p. 486
Gaveshani Mantri, Ashwin Ashok Jaiswal, Rajeev Kumar Pal, Neeta Sharma
DOI:10.4103/mjdrdypu.mjdrdypu_206_19  
Objective: The objective of the study is to study the efficacy of ultrasonography (USG) and fine- needle aspiration cytology (FNAC) in the evaluation of neck masses and differentiating between cystic, inflammatory, benign, and malignant neck masses with a histopathological correlation. Study Design: Prospective study and observational study. Setting: J. L. N. Hospital and Research Centre, Bhilai (C. G). Study Period: June 1, 2016–May 30, 2017. Materials and Methods: Sonographically, neck masses were evaluated final diagnosis was made on the basis of FNAC and histopathology of excised specimens. Finally, the USG findings were correlated with FNAC report and histopathology reports (wherever possible) to evaluate their sensitivity, specificity, and accuracy by statistical methods. Results: Most of the cases clustered between 31 and 60 years of age group. Among all patients, males outnumbered the females with the M:F ratio 1.5:1. Hyperechoic and anechoic lesions suggested benign pathology, whereas chances of malignancy were highest with hypoechoic lesions. As diagnosed by USG, the majority was benign lesion (36.4%), followed by inflammatory neck masses (27.08%), then cystic neck masses (20.83%) and least was malignant masses (15.63%). FNAC impression diagnosed benign mass (32.29%), inflammatory mass (26.04%), cystic mass (19.79%), and malignant mass (15.63%). The diagnostic accuracy of USG, FNAC, and Histopathological Examination (HPE) was comparable as P ≤ 0.05 for inflammatory, cystic, benign, and malignant neck masses. Conclusion: High-resolution grayscale ultrasound can differentiate inflammatory, cystic, benign and malignant neck masses. FNAC can be considered highly efficacious in distinguishing benign and malignant neck masses. A team work between a cytopathologist, radiologist, and clinician maximizes the diagnostic utility of USG and FNAC.
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Different diagnostic modalities for the study of Kumari (Aloe vera (l.) burm.) Swarasa (Juice) Bhavita Trivanga Bhasma with respect to baseline microbial profile p. 498
Pravin Jawanjal, MS Cholera, Prashant Bedarkar, BJ Patgiri, CR Harisha
DOI:10.4103/mjdrdypu.mjdrdypu_209_19  
Background: In Ayurveda, metal-based preparations, that is Bhasma (incinerated Rasaushadhi), are indicated for the treatment of several diseases. Trivanga Bhasma is a classical Ayurvedic preparation containing Bhasmas of three metals, namely Vanga (Tin), Naga (Lead), and Yashada (zinc), and it is indicated in Madhumeha (diabetes) and MutraRoga (urinary disorders), Napunasakta (impotency), Vandhyatva (Infertility), Swetapradara (Leucorrhea), Vata-Pittadosa, and as Shaktivardhaka(strength). Aims: The study was carried out the stability of Kumari Swarasa Bhavita Trivanga Bhasma concerning its microbial profile. Materials and Methods: A sample of Kumari Swarasa Bhavita Trivanga Bhasma was prepared and studied to check microbial contamination at regular intervals. Results: Every time, the sample was subjected to the microbiological study from the date of the preparation to the date of the last microbiological study. No contamination was found in the microbiological study. Discussion: Hence, the present study was carried out to observe the stability study of Kumari Swarasa Bhavita Trivanga Bhasma concerning microbial contamination of the sample prepared and preserved in different climatic and temperature conditions. Thus, a baseline microbial profile was studied at regular intervals. At the end of the study, it was found that the sample was not shown the presence of any microbes. Conclusion: In the microbiological study of Kumari Swarasa Bhavita Trivanga Bhasma, there was no growth found of microorganisms (bacterial or fungal), from the date of preparation, shown shelf life for 296 days. Hence, in the present study, the stability test of Kumari Swarasa Bhavita Trivanga Bhasma concerning microbiological findings was negative at room temperature, warm and cold, dry, and humid conditions.
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Prevalence and pattern of alcohol-induced psychosis and personality profile of male alcohol use disorder patients: A hospital-based study p. 512
Gowtham C Reddy, PS Murthy, Suprakash Chaudhury
DOI:10.4103/mjdrdypu.mjdrdypu_147_18  
Background: There is a paucity of data on the prevalence and pattern of alcohol-induced psychotic disorder (AIPD) and the role of personality traits in alcohol use disorders (AUDs) and AIPD. Aim: This study aims to study the prevalence and pattern of AIPD and personality profile in AUD and AIPD patients. Materials and Methods: Consecutive sample of 100 patients with AUD fulfilling Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5) criteria and between 18 and 60 years old were included in the study with their informed consent. Psychotic symptoms were assessed in keeping with DSM 5 criteria for substance (alcohol)-induced psychosis. The Eysenck Personality Questionnaire (EPQ) was used to explore personality traits. Results: In the present study, middle class and lower middle class people were found to develop AUD. Early age of initiation of alcohol intake placed the individual at risk of developing severe AUD and psychotic symptoms. Psychotic symptoms were seen in 9% of the individuals. Persons with severe alcohol dependence and longer duration of alcohol use were at increased risk for developing psychotic features. The most common psychotic symptom was auditory hallucination. The EPQ showed that 65.93% of the individuals had psychoticism trait; 67.03% were extroverts. Persons with psychoticism trait were found to start taking alcohol at an early age and develop severe AUD. In the neurotic dimension, 54.95% were highly neurotic; 45.05% had average emotional stability. Conclusions: Psychotic symptoms were seen in 9% of patients with AUD. Psychosis in AUD was associated with severity of alcohol dependence, early initiation, longer duration of alcohol intake, and psychoticism personality trait. Psychoticism and extraversion personality traits were predominant in AUD compared to neuroticism trait.
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Awareness of Indian medical practitioners about snakebite and its management – Is there a need to re-evaluate medical training? p. 519
Avadhesh Singh Malik, Kunal Chatterjee
DOI:10.4103/mjdrdypu.mjdrdypu_256_19  
Background: Snakebite envenomation is an important cause of morbidity and mortality worldwide, with India contributing to the majority of cases. Effective management is important to mitigate the impact of the condition. Medical practitioners dealing with snakebite victims need to be thoroughly aware of the current guidelines to provide effective care.Objectives: The aim of this study is to determine the knowledge and awareness of Indian medical practitioners about the current guidelines regarding the management of snakebite and their opinion about the cogency of their undergraduate medical training regarding the subject.Materials and Methods: Allopathic practitioners currently practicing in India were administered a pretested questionnaire to assess their knowledge about epidemiology, diagnosis, and the treatment of snakebite.Results: Of the 143 practitioners in the study, 79.4% underestimated the burden of morbidity due to snakebite in India. About 6.8% had correct knowledge about the number of species of the highest medical importance. About 52.2%, 91.7%, and 20.2% were aware of the common presentation of Common Krait, other neurotoxic elapids (e.g., Indian Cobra) and Viper envenomation, respectively. About 32.6% had correct knowledge about the management of adverse reactions to anti-snake venom. About 72.3% responded that their undergraduate medical education was inadequate to deal with snakebite and 91.4% responded that the topic of snakebite needs more emphasis at the undergraduate level.Conclusions:The current undergraduate medical education in India, about the management of snakebite is limited to outdated concepts or those gained from Western literature, leading to gaps in knowledge in several key areas. A clinically oriented approach suited to the Indian scenario needs to be emphasized.
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Diagnostic utility of medical thoracoscopy in undiagnosed exudative pleural effusions p. 525
Vikas Marwah, D Bhattacharyya, Mohamed Falih Ali, Ashok Kumar Rajput, Prashant Sengupta, Gaurav Bhati
DOI:10.4103/mjdrdypu.mjdrdypu_277_19  
Background: Medical thoracoscopy is a minimally invasive technique to inspect the pleural space and to perform biopsy of pleural lesions under direct vision. In this study, the diagnostic utility of thoracoscopy for undiagnosed exudative lymphocytic pleural effusions from a tertiary care respiratory center will be discussed. Materials and Methods: In a retrospective analysis of thoracoscopic procedures, we performed between September 2017 and August 2019, the yield of thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed exudative lymphocytic pleural effusions was evaluated. Undiagnosed exudative pleural effusions were defined as pleural effusions where an etiologic diagnosis could not be ascertained by initial pleural fluid biochemical and microbiological analysis, including protein, sugar, lactate dehydrogenase, Gram and acid-fast bacilli stains and Mycobacterium tuberculosis culture, pleural fluid adenosine deaminase levels, and at least two pleural fluid cytologies negative for malignant cells or other definite causes. We analyzed the clinical, radiological, cytological, and histopathological data of the patients and also the complications of thoracoscopy. Results: We performed thoracoscopy in 68 cases of undiagnosed exudative pleural effusions using the rigid thoracoscope. The overall diagnostic yield of thoracoscopic pleural biopsy was 95.6% in patients with undiagnosed exudative pleural effusions. Malignant pleural effusion was diagnosed in 67.6% of patients, while tuberculosis was diagnosed with pleural biopsy in 25% of patients. Three cases of subcutaneous emphysema, 2 cases of postprocedure fever were observed, and one patient had prolonged air leak. Conclusion: Medical thoracoscopy has a good diagnostic yield in patients with undiagnosed exudative lymphocytic pleural effusions and is a safe procedure as well.
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Evaluation of episiotomy in present day obstetric practice p. 529
Manasi Thakur, Himadri Bal, Vikas Tambe, Nikhila Singireddy
DOI:10.4103/mjdrdypu.mjdrdypu_338_19  
Background: Episiotomy, a surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor is one of the most performed surgical procedures in the world, especially for nulliparous women. Episiotomy itself is comparable to a 2nd degree perineal injury. The concept of restrictive episiotomy came where its use is restricted to only high-risk cases such as shoulder dystocia, short rigid perineum, face to pubis delivery, vaginal breech delivery, and instrumental deliveries. We decided to carry out a study to evaluate this common obstetric procedure and try to decipher its role in the present day obstetric practice. Methodology: This was a prospective cohort study on 200 women admitted to the labor room and satisfying the inclusion/exclusion criteria. The cases were then divided into two groups of 100 each by simple randomization by chit method. The participants of one group (Group A) were not given episiotomy unless it was inescapable and was considered as the study group and in the other group (Group B) episiotomy was given to all the patients and was considered as the control group. Results: The overall rate of episiotomy in the control group was 100% as per study protocol and that in study group 27%. The restricted use of episiotomy resulted in a significant reduction in overall episiotomy rate. Conclusion: This study was conducted to evaluate the practice of restrictive episiotomy and compare it with routine episiotomy. We found that the net outcome of restrictive episiotomy was better than routine episiotomy and this was statistically significant with respect to parturition-related perineal trauma, postpartum pain, and maternal satisfaction of the entire birthing process.
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Comparison of oocyte fertilization rates using different culture systems: A prospective cohort study p. 535
Sandeep Karunakaran, Uttara Aiyer Kohli
DOI:10.4103/mjdrdypu.mjdrdypu_263_19  
Context: The success of clinicalin vitro fertilization (IVF) may be hampered by suboptimal oocyte culture. Research over the past 25 years has resulted in the development of more physiological and effective culture systems capable of maintaining both development and viability of the preimplantation embryo, resulting in the increase in the overall success rates of human-assisted conception per cycle. However, the perfect culture system has not yet been determined.Aims: The aim of the study was to compare the difference in the fertilization rates of oocytes using two different culture systems – cohort co-culture and microdroplet culture methods.Settings and Design: This was an observational, prospective cohort study carried out in a tertiary care hospital with an assisted reproductive center between June 2017 and August 2018.Materials and Methods: Oocytes from normoresponsive patients undergoing IVF and meeting the inclusion and exclusion criteria were divided into two groups and cultured using either the cohort (group) or the microdroplet culture methods using conventional IVF.Statistical Analysis Used: Details of all cases were recorded on a structured format and analyzed with the help of registered version of SPSS version 21 using the Chi-square test and Student's t-test. Statistical significance was assessed at P < 0.05.Results: Three hundred and twenty-seven patients (159 [1031 oocytes] in cohort and 168 [1067 oocytes] in microdroplet culture) were included in the study. No significant difference (P = 0.08) was found in the fertilization rates in the two culture systems; however, denudation of oocyte was faster in the microdroplet group.Conclusions: The difference in the fertilization rates of oocytes using cohort culture or microdroplet culture systems was not statistically significant.
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Pharmaceutical standardization of Agastyaharitaki Avaleha p. 541
Vasundhara Jaluthriya, Swapnil Chaudhari, Biswajyoti Patgiri, Prashant Bedarkar
DOI:10.4103/mjdrdypu.mjdrdypu_151_19  
Background: Agastyaharitaki Avaleha(AHA) is an important ayurvedic polyherbal formulation, mentioned in the Ayurvedic Formulary of India (AFI, Part III). It is routinely prescribed in Pratishyaya(chronic rhinitis), kasa(cough), and shwasa(asthma) by ayurvedic physicians. Aim: The objective was to develop the standard manufacturing procedure (SMP) and quality standards of AHA. Materials and methods: In the current research work, AHA was prepared in three batches as per standard guidelines mentioned in AFI. The drug was prepared in three batches to generate SMP. Results: Average percentage yield of Prakshepa(Pippali) was 88.67%; during the procedure of Avaleha, the temperature was maintained in between 90°C and 100°C and observed Darvi Pralepatvam at 93°C, Tantumatvam at 94°C, Apsumajjanam at 94°C, and sthiratvam at 95°C. Average yield was found as 9570 g. It took 20.10 h to complete the preparation of avaleha. Conclusion: The current study reflects standardization and opens a new concept to standardize the product.
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Nuances of human anatomical waste management in a secondary care government hospital p. 546
Vishan Dev Singh Jamwal, Shallu Jamwal, Sushil Kumar, Arun Kumar Yadav
DOI:10.4103/mjdrdypu.mjdrdypu_139_18  
Introduction: The last century has witnessed rapid growth of the health-care institutions in both the public and the private sector as per the demand from the growing population. This has resulted in substantial amount of the biomedical waste (BMW) is generated which presents a health hazard. Objectives: The objective is to study the BMW management (BMWM) practices of the secondary care government hospital and to suggest measures for improvement of the current BMW practices for evolving a better and more efficient system of BMWM. Materials and Methods: The study design was a descriptive study in which various stakeholders and facets of BMWM system in government hospitals were taken into consideration. Samples drawn were purposive, with the objective of studying BMWM in a secondary care hospital. The observations, interviews, and focus group discussions were used for data collection. Results: The various categories of waste generated in a 345 bedded secondary care government hospital and the quantity on a monthly average basis was calculated. Total BMW collected and treated by health-care facility in kg/day is 12 kg, and the same amount is disposed of in a day. Conclusion: There is a dire need for making appropriate technologies, imparting professional training, and allocating adequate financial resources for effective and safe BMW disposal. Public-private partnership and total commitment of the top management will help in proper handling and disposal of BMW.
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Diagnosis of fetal asphyxia depending on the change of blood flow of fetal middle cerebral artery and umbilical artery using color Doppler ultrasonography p. 552
Sung-Kuk Kim, Mi-Yong Paek, Il-Kyong Ko
DOI:10.4103/mjdrdypu.mjdrdypu_83_19  
Introduction: Ultrasonography has been used in the medical field for more than 50 years and estimated to be safe. The aim of the study was to set the criteria for the diagnosis of fetal asphyxia depending on the indices of fetal middle cerebral artery (FMCA) and umbilical artery (UA). Subjects and Methods: Color Doppler ultrasound (ALOKA-SSD1700) was used to confirm the dynamics of blood flow indices in fetal arteries. Among 417 pregnant women (327 normal and 90 with fetal distress), various arterial velocimetric parameters (ratio of systole to diastole and pulsatility and resistance indexes) were evaluated in the FMCA and UA. t-test and Chi-square test were used for the comparison of average and ratios, respectively, and Ridit test for grading of data. Results: The normal values of blood flow indices of FMCA with gestational age in normal pregnancy reached their peak at the 30th week and then gradually decreased. As for funicular artery, the indices reached their peak at the 28th week and then gradually decreased. The criterion for the diagnosis of fetal asphyxia depending on the blood flow of FMCA and UA is the ratio of resistance indices in the MCA or UA =.10, and the sensitivity, specificity, and accuracy of diagnosis were 86.7%, 98.8%, and 96.2%, respectively. Conclusion: The study confirmed the normal values and dynamics of the blood flow indices of FMCA and UA according to the number of weeks of normal pregnancy and determined criteria for the diagnosis of fetal asphyxia depending on those indices.
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CASE SERIES Top

An innovative approach to the intubation of cervical lipomas: Taking the easy way in! p. 557
Gauri Raman Gangakhedkar, Devika Poduval, Harsha Hemraj Narkhede, Madhavi Buddhi, Rajendra Dahyabhai Patel
DOI:10.4103/mjdrdypu.mjdrdypu_165_19  
The use of videolaryngoscopes for difficult intubation as an adjunct has been established in the various international airway guidelines. However, planning a case of difficult intubation mandates the use of proper positioning in order that the intubation is successful and atraumatic. Various methods to facilitate proper positioning have been described that include the use of bolsters, preformed pillows, and ramps. The trials faced by anesthetists who attempt to successfully negotiate the difficult airway posed by cervical lipomas consist of difficulty faced during positioning for intubation, need for additional need for workforce during positioning, and the need to transfer an intubated, anesthetized patient for surgery while facing the risk of accidental disconnection and extubation. This case series describes an innovative method of positioning to assist intubation that requires no additional equipment, reduces the chances of accidents during positioning, and in conjunction with the use of videolaryngoscope simplifies a difficult airway procedure.
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CASE REPORTS Top

Unusual association of anorectal malformation and macrocystic lymphatic malformation p. 560
Dileep Garg, Aditya Pratap Singh
DOI:10.4103/mjdrdypu.mjdrdypu_178_19  
Anorectal malformations (ARMs) are common congenital anomalies encountered in pediatric surgery. ARMs are often associated with other anomalies. The estimated incidences of associated anomalies are 40%–70%. We report a case of low ARM with lymphangioma neck.
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Nonsystemic vasculitic neuropathy p. 562
Shalesh Rohatgi, Dhaval Dave, Furqan Khan
DOI:10.4103/mjdrdypu.mjdrdypu_193_19  
A 21-year-old female born of nonconsanguineous marriage presented with gradually progressive quadriplegia for 3 years. Weakness was distal more than proximal, with wasting. She also had moderate pain in extremities. She had significant weight loss. Clinically, she had lower motor neuron flaccid quadriplegia with absent deep tendon jerks. Sensations of touch and pain were diminished in bilateral feet till ankle joints. Peripheral nerves were not thickened. Nerve conduction study was suggestive of pure axonal sensorimotor polyneuropathy. All routine hematological and biochemical parameters, erythrocyte sedimentation rate, antinuclear antibodies, and antinuclear cytoplasmic antibodies were negative. Cerebrospinal fluid showed no cells, normal sugar, and raised proteins. Biopsy of sural nerve was suggestive of vasculitic neuropathy. This was a case of nonsystemic vasculitic neuropathy that responded to steroids.
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Do pneumoperitoneum in a stable extreme low-birth-weight infant always need laparotomy? A clinical conundrum p. 564
Krishna Revanna Gopagondanahalli, Sharon Go Si Min, Suresh Chandran, TR Sai Prasad
DOI:10.4103/mjdrdypu.mjdrdypu_212_19  
A premature female neonate born at 27 weeks of gestational age with a birth weight of 1000 g, developed spontaneous pneumoperitoneum on day 10 of life. The baby remained clinically stable with constant serial blood gases and inflammatory markers. In view of clinical stability, she was managed conservatively with parenteral nutrition and intravenous antibiotics and monitored closely for any clinical deterioration. After 7 days of conservative management, serial radiological images showed complete resolution of pneumoperitoneum. This case challenges the default notion of presumed necrotizing enterocolitis/spontaneous intestinal perforation and urgent laparotomy in an extreme preterm baby with pneumoperitoneum. Successful conservative management of this case also demands a question whether all pneumoperitoneum should be subjected to laparotomy.
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LETTERS TO THE EDITOR Top

Vestibular migraine p. 567
Caner Sahin, Gozde Orhan Kubat
DOI:10.4103/mjdrdypu.mjdrdypu_355_19  
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Sustaining measles immunization services amid the ongoing coronavirus disease 2019 pandemic p. 568
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/mjdrdypu.mjdrdypu_188_20  
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COVID-19: The curious case of the dog that did not bark – Some insights p. 569
Yatin Dholakia
DOI:10.4103/mjdrdypu.mjdrdypu_249_20  
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Lessons from COVID-19 in India: Extended lockdowns: At what cost? A counterview p. 570
Yatin Dholakia
DOI:10.4103/mjdrdypu.mjdrdypu_289_20  
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AUTHORS RESPONSE Top

Lessons from COVID-19 in India: Extended lockdowns – At what cost? A counterview p. 573
Sachin Ramchandra Atre
DOI:10.4103/mjdrdypu.mjdrdypu_338_20  
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