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   Table of Contents - Current issue
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October-December 2019
Volume 17 | Issue 4
Page Nos. 97-158

Online since Thursday, December 12, 2019

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EDITORIAL  

From the desk of the new editor Highly accessed article p. 97
Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_66_19  
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ORIGINAL ARTICLES Top

A retrospective study on the clinical profile of patients with open hand injury presenting to the emergency department of a tertiary care center in South India p. 98
Banhiam Carey Kharrngi, Darpanarayan Hazra, Joshua Vijay Joseph, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_38_19  
Background: The human hand is a vital part of our day-to-day activities. Most of the time, our body movements do not cause problems, but it is not surprising that symptoms develop from everyday wear and tear, overuse, or an injury. To reduce this risk, even the smallest hand injuries require proper medical care. Materials and Methods: We conducted a retrospective observational study of all trauma patients with open hand injuries presenting to our emergency department (ED). Details of the incident, injuries, management, and outcome were noted. Results: During the study period of 8 months, we received a total number of 4414 trauma patients to our ED, among which 291 (7%) had hand or upper extremity injuries. Most of these patients had crush injury (33.7%) or cut injuries (27.4%) that are mostly work related. Most of the injuries happened in the active age groups ranging from 0 to 30 years of age where cut injury and crush injury (13%) were the most common, Road traffic accidnets account for (26.3%), whereas cracker burst injuries were the cause in (8.9%). The index finger (17%) is the most commonly injured finger, followed by the thumb (16%). Fractures and amputations of the fingers and hands were seen in (24.7%) and (22.1%), respectively. Other injuries included lacerations (15.3%) and tendon injury (14.2%). Most patients (93%) were taken up for emergency procedures such as wound wash, debridement, suturing, or nailing of the fractures in the ED. Approximately half (48%) of the total patients were admitted in ward and had to undergo major surgical intervention. The rest were either discharged (45%) stable or discharged against medical advice (7%) after the primary care. Conclusions: This study showed the pattern of hand injuries in the children, the young, and the elderly. Public awareness and education, along with needed legislative enforcement for the betterment and well-being of the mass, is needed to prevent the catastrophe since these injuries are prevalent in the productive age groups.
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Acute undifferentiated febrile illness in the elderly: A clinical profile p. 103
Joanna Preritha Fernandes, Darpanarayan Hazra, Sandeep Nathanel David, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_39_19  
Introduction: Geriatric patients are more prone to have serious viral or bacterial infections that may present with acute febrile illness (acute undifferentiated febrile illness [AUFI]) and have significantly increased the risk for morbidity and mortality. It is important for the community to know the clinical presentation and local etiology of AUFI. Methodology: This is a subgroup analysis of a large prospective study on determining the etiology of AUFI. We included geriatric population (>60 years) for our analysis. Results: This cohort study included 126 elderly patients who presented with AUFI, in which 56.3% were men. Scrub typhus (57.4%) was the most common cause of AUFI followed by dengue (19.1%), malaria (3.2%), enteric fever (1%), and leptospirosis (0.8%). Both scrub typhus and dengue fever peaked during the monsoon season and the cooler months, whereas no seasonality was observed with enteric fever and malaria. The requirement of supplemental oxygen, invasive ventilation, and inotropes was highest among the scrub typhus patients followed by leptospirosis and malaria. Bleeding manifestations were seen in scrub typhus (6.8%), dengue (14.2%), and malaria (25%). The overall mortality rate was 6.3% and was highest with scrub typhus 5.4%. Conclusion: The similarity in clinical presentation and diversity of etiological agents demonstrate the complexity of diagnosis and treatment of AUFI in South India. Even though respiratory tract, urinary tract, and skin infections present with acute febrile illness in the elderly, other undifferentiated causes such as scrub typhus, dengue, malaria, enteric fever, and leptospirosis should also be considered while treating the elderly, especially in developing nations. Once a clinical profile is formed, the local population can be educated to identify the possible life-threatening complications based on endemicity and seasonal trends.
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A comparative study for screening human immunodeficiency virus 1/human immunodeficiency virus 2 with third-generation and fourth-generation human immunodeficiency virus ELISA kits in donors from a tertiary care hospital in Northeast India p. 108
Anupam Sarma, Rashmisnata Barman, Chandana Kalita, Jagannath Dev Sharma, Manigreeva Krishnatreya, Abhijit Talukdar, Manoj Kalita, Amal Chandra Kataki
DOI:10.4103/cmi.cmi_36_18  
Background: Blood transfusion is the most effective means of transmission of human immunodeficiency virus (HIV). The use of fourth-generation ELISA kits has significantly reduced the detection period of the viruses to its window period within 2–4 weeks. Objective: To analyze and compare the profile of blood donors who sero-converted to HIV positive. Materials and Methods: Blood donors reporting to the blood bank attached to a regional cancer center from January to December 2017 were included. The study was conducted in two phases. Phase 1 consists of random testing for HIV1/HIV2 reactive and nonreactive samples from clinical blood donors in the age group of 18–50 years. Phase 2 consists of confirmatory test with Western blot technique. Results: The fourth-generation kit confirmed 139 nonreactive out of 140 samples tested after running the samples with independent confirmatory test, whereas the third-generation ELISA test detected two HIV-reactive samples which were confirmed to be nonreactive by Western blot. Conclusions: For better clinical diagnosis and early detection of HIV, the use of fourth-generation test kits for screening of HIV infection is recommended.
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Determinants of teenage pregnancy in Ethiopia: A Case–control study, 2019 p. 112
Yohannes Fikadu Geda
DOI:10.4103/cmi.cmi_12_19  
Background: Approximately 16 million adolescent girls aged 15–19 years and 2 million adolescents under the age of 15 years give birth annually in the world. In Africa, where premarital sex is not accepted, especially for young women, unintended pregnancies mostly happen outside marriage. Recent data indicate that 18% of adolescent girls aged 15–19 years in eastern/southern region of Africa and 21% in western/central region of Africa had initiated childbearing. Teenage pregnancy and parenting remain important public health issues that deserve continued attention. The specific factors and beliefs that lead to contraceptive nonuse remain obscure, and up-to-date, evidence-based data on personal and environmental determinants of teenage pregnancy and case–control studies also are lacking in Ethiopia. Therefore, this study aimed to identify the determinants of teenage pregnancy to help policymakers, program managers, and health-care authorities with better decision-making in planning and problem-solving in Ethiopia. Methods: A case–control study was conducted using data set obtained from 2016 Ethiopia Demographic and Health Survey conducted throughout the country from January 18, 2016, to June 27, 2016. All teenagers who had a pregnancy history were enrolled as cases (381) and 1524 teenagers who were not pregnant were taken as controls.. Necessary variables were extracted from the DHS data set after literatures were revised. Then, variables with P ≤ 0.25 were analyzed with multivariable logistic regression. Results: Educational level, wealth index, knowledge of ovulatory cycle after period ended, knowledge of family planning method, contraceptive use, and reasons for not using contraceptives were higher among the cases and were statistically significant. Conclusion: Knowledge of family planning and ovulatory cycle, primary school educational level, richest wealth category, and contraception use were the determinants of teenage pregnancy. Hence, educational level, knowledge gap, and economy should be emphasized to eradicate teenage pregnancy from Ethiopia.
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REVIEW ARTICLES Top

A Review of the epidemiology and management of urethral stricture disease in Sub-Saharan Africa p. 118
Irekpita Eshiobo, Udefiagbon Ernest
DOI:10.4103/cmi.cmi_37_19  
The prevalence of urethral stricture in Sub-Saharan Africa is unknown though a few epidemiological studies show that it constitutes a huge disease burden in the region. Over the years, there has been a global change in the epidemiology and management of urethral stricture the extent of which depends on the differences in the regional and subregional economy. The latter affects the pattern of disease distribution and the available tools and expertise for their management. Sixty-one published reports were obtained from Google for this review which critically analyzed the current epidemiology, treatment of urethral stricture disease, and the challenges associated with its treatment in Sub-Saharan Africa from 2011 to 2019. The review also assessed the subregional capacity to treat urethral stricture, taking into consideration available tools, expertise, standard treatment methods, and guidelines.
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Methemoglobinemia: When to suspect and how to treat p. 125
Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_55_19  
Methemoglobinemia is an altered state of the hemoglobin moiety resulting in impaired oxygen delivery to the tissues. It is a potentially fatal condition that occurs when the ferrous iron of heme is oxidized to ferric iron. Methemoglobinemia has been linked to a wide array of drugs, chemicals, and substances such as local anesthetics, industrial chemicals, and insecticides. Many of these compounds have no details of the composition and can result in severe methemoglobinemia. Clinical suspicion should be aroused with low oxygen saturation on pulse oximetry and the presence of chocolate-colored blood. Immediate administration of the antidote, methylene blue when indicated, effectively decreases methemoglobin levels to tolerable levels.
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Rodenticide poisoning: Literature review and management p. 129
Kundavaram Paul Prabhakar Abhilash, Jonathan Arul Jeevan Jayakaran
DOI:10.4103/cmi.cmi_54_19  
Rodenticide is a broad term, and there are a wide variety of such compounds depending on the geographical region and availability. These compounds differ in their chemical composition, mechanism of action, toxic doses, and lethal effects. Coumarins, aluminum phosphide, zinc phosphide, and yellow phosphorous are the most easily available and commonly used rodenticides for deliberate self-harm. Aluminum phosphide poisoning is rapidly fatal, whereas yellow phosphorous poisoning too is associated with a high mortality within 1–2 weeks of consumption.
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Eschar: A vital clue for diagnosis of scrub typhus p. 134
Kundavaram Paul Prabhakar Abhilash, Karthik Gunasekaran
DOI:10.4103/cmi.cmi_53_19  
The most pathognomonic sign of scrub typhus is the presence of an eschar, which represents the site of inoculation, where initial multiplication occurs before widespread dissemination. Transmission electron microscopy analysis of an eschar shows detectable Orientia tsutsugamushi in outermost layers of the perifocal inflamed skin and not in the central necrotic zone, which consists of dried skin layers only. The presence of eschar in a patient with scrub typhus varies widely in different studies from 9.5% to 86% of patients with higher values reported from the Orient. A characteristic difference is noted in the distribution of eschars over the body in both the sexes. In females, the chest (inframammary area) and abdomen are the most common sites of an eschar, while the axilla, groin, and genitalia are the most common sites of eschar in males. A thorough physical examination, especially of the hidden areas such as the genitalia, scalp, and postaural areas, is imperative in identifying this vital diagnostic clue of scrub typhus.
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CASE REPORTS Top

Recurrent pilonidal sinus with mycobacterial infection: Implications p. 138
Sasank Kalipatnapu, Gigi Varghese
DOI:10.4103/cmi.cmi_46_19  
Pilonidal sinus disease is a chronic inflammatory disease classically found in the sacrococcygeal region. We describe a rare case of pilonidal disease associated with mycobacterial infection which resolved only after appropriate surgery and adequate antimycobacterial therapy.
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Management of superior mesenteric artery syndrome: Two paths to go by p. 140
Nitin Paul Ambrose, Pranay Gaikwad, Srujan Lam Sharma
DOI:10.4103/cmi.cmi_47_19  
Superior mesenteric artery (SMA) syndrome is a rare gastrointestinal disorder characterized by vascular compression of the third part of the duodenum in the angle between the aorta and the SMA, causing partial or complete duodenal obstruction. Symptoms include postprandial vomiting, epigastric pain, and weight loss. Conservative management is the initial treatment; however, in case of failure of conservative management, surgical therapy is unavoidable. We report two cases that were diagnosed to have SMA syndrome. Both the patients were managed differently with successful outcomes. This short case series reviews the literature on the various aspects of SMA syndrome.
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Abdominal tuberculosis: An old disease surprising young surgeons p. 144
Royson Jerome Dsouza, Vijay Abraham, S Suraj, Myla Yacob
DOI:10.4103/cmi.cmi_43_19  
A 21-year-old male with no prior illnesses presented to the emergency department with features of small bowel obstruction. Contrast-enhanced computed tomography of the abdomen showed features of ileal obstruction and contained perforation secondary to probable Crohn's disease. However, on exploratory laparotomy, he underwent adhesiolysis, terminal ileal resection, and end ileostomy. The biopsy showed multiple tubercles and other pathognomic characteristics of tuberculosis (TB). The findings were conclusive of abdominal TB involving the peritoneum and terminal ileum. On initiation of antitubercular therapy, his condition improved symptomatically, and he was subsequently discharged. Although the prevalence of TB has been declining in recent times, it still remains a major public health problem in our country. Abdominal TB is known to mimic multiple other conditions, and a high index of suspicion is needed to initiate appropriate therapy, thereby preventing morbidity and mortality. It is therefore crucial that young surgeons familiarize themselves with all the different manifestations of abdominal TB.
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PRACTICE STORY Top

Extracapsular parotidectomy – How we do it? p. 148
Pranay Gaikwad, Cecilt T Thomas
DOI:10.4103/cmi.cmi_51_19  
Benign tumors of the parotid gland are the most common salivary tumors. Pleomorphic adenoma is the most common benign neoplasm of the parotid gland. Benign salivary gland tumors can undergo a malignant transformation, the reason for which the salivary tumors need to be excised. Pleomorphic adenomas extend their microscopic pseudopods into the surrounding capsule mainly composed of compressed normal tissue. The facial nerve traverses through the substance of the gland. Although the nerve injury could be avoided, the earlier treatment of pleomorphic adenoma with enucleation was fraught with an unacceptably high incidence of multicentric tumor recurrences. Superficial parotidectomy or excision of the portion superficial to the facial nerve evolved as the procedure of choice for benign parotid lesions. Formal identification of its trunk at the stylomastoid foramen and tracing its branches peripherally up to the facial muscles was an essential component of the procedure. With further understanding, it became evident thatsuperficial parotidectomy (SP) was overkill for small benign lesions in the superficial lobe of the gland with an unnecessary risk to the facial nerve. Extracapsular excision (ECE) of a benign parotid tumor is a procedure that has evolved in the last two decades with the recurrence rates comparable to those following SP with reduced facial nerve dissection-related morbidity. The senior author (PG) has adopted the technique for nearly a decade and has also been involved in conducting a randomized controlled trial comparing the outcomes after SP and ECE. Through this article, the authors would like to share their technique and experience with ECE.
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CME QUIZ Top

Status epilepticus secondary to meningioma p. 152
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
DOI:10.4103/cmi.cmi_2_19  
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Mimicking amyotrophic lateral sclerosis: Cervical spondylotic myelopathy p. 155
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
DOI:10.4103/cmi.cmi_36_19  
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Anterior scalloping of lumbar vertebrae p. 157
Ganesh Singh Dharmshaktu, Tanuja Pangtey
DOI:10.4103/cmi.cmi_38_18  
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