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   Table of Contents - Current issue
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July-December 2022
Volume 10 | Issue 2
Page Nos. 147-316

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EDITORIAL  

The metaverse: A new avatar in medical educational ecosystems? Highly accessed article p. 147
Bhaskara P Shelley
DOI:10.4103/amhs.amhs_267_22  
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INVITED EDITORIALS Top

Programmatic assessment – What are we waiting for? p. 154
Balakrishnan R Nair, Joyce M W. Moonen-van Loon
DOI:10.4103/amhs.amhs_259_22  
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Patient safety – Are we doing enough? p. 157
Naresh Shetty
DOI:10.4103/amhs.amhs_265_22  
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ORIGINAL ARTICLES Top

Addressing the need to develop critical thinking skills in the new competency-based medical education post graduate curriculum in pathology: Experience-sharing of the process of development and validation of script concordance test p. 160
Anjali J Kelkar, Shital Bhandary, Thomas V Chacko
DOI:10.4103/amhs.amhs_227_22  
Background and Aim: Ability to integrate and apply knowledge to clinical practice is recognized as a core competency under the new CBME curriculum and assessment of critical thinking skills is an essential component. Script Concordance Test (SCT) is recognised as an appropriate assessment tool for measuring critical thinking. Since in India, SCTs for testing critical thinking in the Postgraduate curriculum in Pathology, have not been developed, we worked on developing such test in the setting of a busy referral hospital attached to Medical College in Western India. The study aimed at 1. Piloting the development of script concordance test to test critical thinking ability and clinical reasoning skills in haematology. 2. Experience sharing of the process of development and validation of the test to enable others to replicate for other topics in pathology. Materials and Methods: After obtaining Ethical clearance, SCT for the topic Coagulation was constructed by following the guidelines from AMEE Guide 75. The experts' reactions and their satisfaction about the test were obtained. Pilot testing was done with post graduate students after informed consent. The students' reactions and satisfaction were obtained after taking the test. The analysis was performed using the excel workbook available from a web link maintained by the SCT creators. Item analysis and group comparison was also done. Results: Analysis performed with 22 vignettes having 66 items revealed a statistically significant difference between the scores of the experts and the students. Internal consistency reliability (Cronbach's α) was 0.86 whereas Effect size (Cohen's d) was 1.9 with 34% overlap in the items and superiority probability of 91%. Item analysis classified 23 items as “Bad”, 11 items as “Fair” and 32 items as “Good” based on the “item-total correlation” statistic. Re-analysis after removing the bad items, increased Cronbach's α to 0.91 and Cohen's d to 3.9; whereas overlap decreased to 5% and probability of superiority reached 100%. Conclusion: Development of a reliable and valid SCT for coagulation was a complex but rewarding process. The analysis of the test required inputs from the statistical experts. Using AMEE Guide 75 and our in-detail description of the process of development, optimisation and validation of script concordance test will enable faculty in many specialities to develop and include it for use in their respective fields.
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Co-expression of P53 and Ki67 in premalignant and malignant oral/oropharyngeal biopsies in Bundelkhand region, India p. 168
Swati Raj, Nidhi Vachher, Durre Aden, Amit Srivastava, Dwijendra Nath
DOI:10.4103/amhs.amhs_155_22  
Background and Aim: India is the third most common country being entitled as “The Oral Cancer Capital of the World.” Around one-third cancer deaths are due to tobacco use. In India, oral cancer ranks first among all cancers in men and second among all cancers in women. p53 over-expression has been widely demonstrated to be a reliable predictor of progression to oral squamous cell carcinoma (OSCC). Ki67 expression is strictly associated with cell proliferation and used as a proliferation marker. Oral cancer was studied in Bundelkhand region with special reference to Gutkha (a form of tobacco) chewing and relative risk. p53 and Ki 67 expression was assessed in premalignant and malignant oral and oropharyngeal lesions and their correlation was evaluated. Materials and Methods: A descriptive study including both prospective and retrospective studies carried over a period of 18 months (April 2019–September 2020) at Department of Pathology, Maharani Laxmi Bai Medical College, Jhansi, India. Immunohistochemical evaluation was done by using markers: anti p53 and anti K67 markers with positive control, i.e. p53 – colon and Ki 67 – tonsil) sections stained omitting primary antibody were taken as negative control. Results: OSCC and premalignant oral lesions are at high incidence in Bundelkhand region, India. Tobacco is found to be most identifiable risk factor with risk ratio of 0.45. Conclusion: The over/co-expression of p53 and Ki67 plays a pivotal role in labeling and predictive marker for malignant transformation as their intensity and pattern of staining increases with increasing grade (highly statistically significant; Pearson's correlation applied).
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A retrospective analysis of moderate and severe COVID-19 pneumonia with special reference to the use of Adjuvant Tocilizumab p. 176
Pratik Raval, Benny Jose Panakkal, Dinesh Joshi, Karthik Natrajan, Anand Shukla, Gajendra Dubey, Sibasis Sahoo, Subhendu Bajpai
DOI:10.4103/amhs.amhs_266_21  
Background and Aim: Coronavirus disease 2019 (COVID-19) pneumonia is associated with a hyper-inflammatory syndrome which may cause life-threatening acute respiratory distress syndrome. The aim of this study was to evaluate the safety and efficacy of an anti-inflammatory agent, tocilizumab (TCZ), a monoclonal antibody that targets the interleukin 6 receptor. Materials and Methods: We included 53 patients admitted between April and July 2020 with COVID-19 pneumonia who received TCZ. Patients received one intravenous infusion of TCZ, dosed at 8 mg/kg, up to a maximum dose of 800 mg. All patients were evaluated with clinical, laboratory, and radiological parameters. Results: Out of 53 patients 28 (52.8%) had severe disease and 25 (47.2%) had the moderate disease. The mean age was 55 years. The most common presenting symptom was fever (73%; n = 39). C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), d-dimer, and ferritin levels were elevated at baseline. After TCZ administration CRP, ferritin and NLR levels reduced significantly whereas d-dimer levels did not fall. Pulmonary fibrosis may be observed later in the course of the disease. All the mortality occurred in patients who had severe disease on presentation. There was no difference in outcomes according to gender, diabetic status, and presence of preexisting cardiac disease. Conclusion: Overall, TCZ administration is safe and effective in improving clinical and laboratory parameters with a possible reduction in the need for ventilatory care and duration of intensive care unit stay, particularly in patients with moderate severe acute respiratory syndrome coronavirus- 2 disease. However, our results should be considered preliminary and should be interpreted with caution as they stem from an uncontrolled series.
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Using qualitative research for curricular redesign of communication skills training in a dental school: From gap identification to leveraging stakeholder voices for facilitating change p. 181
Jyotsna Sriranga, Thomas V Chacko
DOI:10.4103/amhs.amhs_240_22  
Background and Aim: Poor patient-health care provider (HCP) communication skills are a major contributor for noncompliance, lack of trust and sometimes even violence against the HCPs. The students are expected to pick up communication competency through observation and self-learning. In this context, there is a need to bring in the implicit curriculum to the ambit of the explicit curriculum. Here, the focus was on “listening” to the stakeholder's voice to establish the need for explicit communication skills training and justify its importance to professional practice. Materials and Methods: A socioconstructivist world-view and qualitative research methodology was adopted. The method of data collection was interviews and focus group discussions. The dean, teaching faculty, students, and patients were interviewed until data saturation. The data were transcribed and a team of 3 coders coded the data manually using inductive methods. Results: This study identified the gaps in the existing curricular framework for teaching communication skills. Six major themes emerged from the research. The research process served as a tool to leverage on the gaps identified and build a customized communication skills training program for students. Conclusion: The process of qualitative research involves the extensive interviews and discussions with stakeholders to better understand the underlying issues. It initiates dialogs and helps to co-construct solutions to the educational problems. Such self-discovered solutions for change in curriculum that emerges from key stakeholders from within the institution, they are more likely to be accepted, adopted and “institutionalised”.
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Role of aminoglycosides in management of ventilator-associated pneumonia caused by Klebsiella pneumoniae: A report from a tertiary care hospital in Jaipur p. 187
Shaveta Kataria, Ekadashi Rajni, Priyanka Thandi, Mohit Kumar, Garima Kulhari
DOI:10.4103/amhs.amhs_202_22  
Background and Aim: Ventilator-associated pneumonia (VAP) is considered as a sub-category of healthcare-associated infections and is associated with high morbidity and mortality. Acinetobacter baumannii complex and Klebsiella pneumoniae (K. pneumoniae) are known to be the most important causes. During the last few decades, polymyxins have represented the most commonly used antimicrobial options against multidrug resistant K. pneumoniae. However, in some cases, aminoglycosides were also found to be effective. Materials and Methods: This retrospective observational study was conducted in a tertiary care hospital in Jaipur from June' 2020 to June' 2021. All endotracheal (ET) aspirate samples from the clinically suspected cases of VAP received in microbiology laboratory were processed using the standard procedures and relevant medical records were reviewed. VITEK 2 automated system was used for the bacterial identification and antimicrobial susceptibility testing. Results: Out of 705 ET aspirate samples received during the study period, 467 were found culture positive. Majority 304 (98.1%) were Gram-negative isolates, while only 6 (1.9%) were Gram-positive. 156;51.3% isolates belonged to A. baumannii complex, followed by K. pneumoniae (73;24.0%). Antimicrobial susceptibility profile of 73 K. pneumoniae isolates to aminoglycosides was noted. Out of 73 isolates, 42 were found to be resistant to both gentamicin and amikacin, 12 isolates were sensitive to both, while 19 isolates showed variable susceptibility. Conclusion: K. pneumoniae is an important causative agent of VAP. While polymyxins have an important role in the management of such cases, aminoglycosides need to be given a careful consideration. They can constitute an effective polymyxin sparing regimen, especially for carbapenem-resistant isolates.
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Correlation between smartphone addiction and loneliness among healthcare students p. 192
Sneha Noronha, Renisha Fernandes, Sandra Zacharias, Sanika Jimmy, Seethu Raju, Precilla D'silva
DOI:10.4103/amhs.amhs_98_22  
Background and Aim: Smartphone has become a necessity for many individuals in the present world because they find smartphone is a suitable mode to stay connected with other people. A person is said to be dependent toward smartphone when he/she is completely with mobile phone for all works of his/her daily life and forgets about the people around them. Loneliness is a state in which a person feels complete social withdrawal or lonely. To overcome loneliness, the person will use his/her smartphone excessively for various reasons throughout the day and develops addiction to the same. This study aims at finding the level of smartphone addiction and severity of loneliness among the medical professionals. The aim of the study is to find the relationship between smartphone addiction and loneliness. Materials and Methods: A descriptive design was used for the present study. The sample consisting of 318 subjects were selected by convenient sampling. The tool used was baseline pro forma, Smartphone Addiction Scale (Short Version), and University of California Los Angeles Loneliness Scale (3rd Version). Results: Majority of the participants belonged to the age group of 18–21 years, samples were selected equally from all the programs (Nursing, MBBS, and Allied Health Sciences), and majority of the participants were females and studying in II year. There was a weak positive correlation between smartphone addiction and loneliness, r = 0.269, P = 0.001, which was statistically significant. Conclusion: The study findings reveal that majority of the participants had moderate level of smartphone addiction and loneliness, and there was weak positive correlation exists between smartphone addiction and loneliness.
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Evaluation of serum ferritin and D-Dimer levels in COVID-19 patients of an Indian tertiary care setting p. 197
Sangeetha Raja, Deepa Periasamy, Bagavathiammal Periyasamy, Dheebalakshmi Narayanasamy, Panneerselvam Periaswamy, Suganthi Vajiravelu
DOI:10.4103/amhs.amhs_125_22  
Background and Aim: Because COVID-19-affected individuals with severe disease are more susceptible to develop acute respiratory distress syndrome, metabolic acidosis, and septic shock, it is currently widely accepted that severe COVID-19 cases have a higher fatality rate than mild instances. Hence, it is very critical to identify between severe and mild disease among the COVID-19-affected individuals at the earliest to prevent the fatal sequelae. The study was done using serum ferritin and D-dimer levels as biomarkers to find a correlation between the severity of lung involvement among COVID-positive patients. Materials and Methods: A cross-sectional study has been conducted between June 2021 and November 2021 for 6 months among the patients who are positive for COVID-19 at the Government Erode Medical College. Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) was detected in all of the patients using a real-time reverse transcription–polymerase chain reaction assay. Results: One hundred and eight COVID-19-affected individuals with lung involvement and 102 COVID-19-affected individuals without lung involvement were included in the current study. Groups A and B had mean ages of 61.72 ± 10.6 years and 54.78 ± 12.4 years, respectively. COVID-19 infection was studied in patients who were both mildly unwell and severely ill, where the findings revealed a link between serum ferritin and D-dimer levels and lung involvement among COVID-positive patients. The group with lung involvement had considerably higher D-dimer levels than the group without the involvement. Conclusion: The levels of D-dimer and ferritin are linked to serious involvement of the lung as indicated by the computed tomography scan. Both these markers of inflammation are useful in determining the severity of SARS-CoV-2 infection among the infected patients.
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Prevalence and predictors of cyberchondria and depression amid COVID-19 pandemic in adult population of Uttar Pradesh, India p. 200
Saumya P Srivastava, Surya Kant Tiwari, Monika Negi
DOI:10.4103/amhs.amhs_95_22  
Background and Aim: COVID-19 pandemic and related measures of containment such as lockdown led to heavy reliance on Internet for education and leisure activities. This study aimed to assess the prevalence and predictors of cyberchondria and depression amid COVID-19 pandemic among adult population of Uttar Pradesh, India. Materials and Methods: A web-based study was conducted among 236 adult participants of Uttar Pradesh during August–November 2021. Standardized tools including Cyberchondria Severity Scale-short version (CSS-SV) and Patient Health Questionnaire-9 were used for eliciting details about cyberchondria and depression. Results: The study highlighted that the cyberchondria cluster comprised 45.3% of participants. Subscale score distribution of CSS-SV was found to be the highest (7.53 ± 2.98) for excessiveness and the lowest (6.40 ± 2.93) for compulsion subscale. Furthermore, majority (56.4%) of the participants had depression in various severities. Multivariate logistic regression analysis predicted factors such as female gender, health-care worker, and duration of watching TV and smartphone usage to be influencing cyberchondria. Strong influence of duration spent (>6 h/day) in watching TV, etc., was found on depression. Conclusion: Cyberchondria and its association with depression are indeed growing health concerns; efforts should be directed toward controlled Internet usage, which involves adhering to credible sources for authentic health-related information.
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Comparing the sensitivity of palm print sign and prayer sign in prediction of difficult intubation in diabetic patients p. 207
Harjot Singh, Deepak Dwivedi, Urvashi Tandon, Vidhu Bhatnagar, Kavitha Jinjil, Swayam Tara
DOI:10.4103/amhs.amhs_175_22  
Background and Aim: Palm print and prayer signs are manifestations of “limited joint mobility” syndrome caused by long-standing Type I and Type II diabetes mellitus. This study aims at finding out, which of the two signs is more sensitive for the prediction of difficult intubation in type II diabetes mellitus patients. The secondary objective is to correlate the above two signs with the Cormack–Lehane View during direct laryngoscopy and also to determine whether the duration of Type II diabetes mellitus correlates with difficult intubation in isolation. Materials and Methods: A prospective observational study was carried out in a tertiary care hospital. One hundred and fifty patients suffering from Type II diabetes mellitus, undergoing elective general anesthesia with endotracheal intubation, were enrolled in the study. The correlation between Palm print and Prayer sign with Cormack and Lehane grades was studied using the Chi-square test, continuity correction, and Fisher's exact test. The diagnostic efficacy of intubation difficulty for both the signs was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio. Results: The palm print sign was found to be a better indicator of difficult intubation in type II diabetes mellitus patients (P < 0.01). The duration of Type II diabetes mellitus was found to be associated well with difficult intubation (P = 0.007). Conclusion: Palm print sign is the single most important test for predicting difficult intubation in Type II diabetes mellitus patients. Duration of Type II diabetes mellitus itself correlates well with difficult intubation.
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An observational study on behavioral problems among the children with epilepsy p. 213
Banothu Sudhakar, Vura U V. Naga Jyothi, V G S. N. V. Sowmya, P Anil Kumar, Suneel Kumar Bhookya, Kagithapu Surender, T Jaya Chandra
DOI:10.4103/amhs.amhs_147_22  
Background and Aim: Psychological and biochemical factors are responsible for the behavioral problems in children with epilepsy. A study was conducted to find the prevalence of behavioral problems in children with epilepsy and also to identify the relation among socioeconomic status, age of onset of seizure, and frequency of seizure attacks with the prevalence of behavioral problems. Materials and Methods: It was a prospective observational study conducted in the Department of Pediatrics, Kakatiya Medical College, Warangal. Convenient sampling was considered; the study was conducted for 2 years. Children aged 1–12 years, admitted with epilepsy to pediatric intensive care unit and pediatric wards, were included in this study. Those were having intellectual problems, cerebral palsy, developmental delay, and metabolic and neurodegenerative disorder were excluded from the study. Sociodemographic information was collected from the parents in a standard pro forma. Diagnostic and Statistical Manual of Mental Disorders-oriented scales for different ages were used for the assessment of behavior by translating into regional language. Chi-square test was used; P < 0.05 was considered statistically significant. Results: A total of 112 children were included; male: female ratio was 1.39; 41 (36.6%) children had behavioral problems; age-wise, there was significant difference; gender-wise, there was no significant difference. Attention-deficit/hyperactivity problems were identified to be the predominant. Statistically, there was no significant difference between behavioral problems either with mother education or with parent's socioeconomic status, respectively. When brain imaging was done, normal studies were revealed in 32% of children with behavior problem. Conclusion: Each and every child with epilepsy aged <5 years and frequency of seizure attack >1 time/year needs thorough screening for behavioral problems irrespective of gender and family characteristics.
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Psychological distress in pregnant women: A cross-sectional study p. 217
KP Lakshmi, Subhash Chandra, Bindu Menon, K Radhamany, P Rajana, Parvathy Suresh
DOI:10.4103/amhs.amhs_174_22  
Background and Aim: The morbidity and mortality caused by COVID-19, the economic crisis brought about by the pandemic, and the health policies laid down for the containment of the virus, have a negative effect on the mental health of the people. Pregnant women represent a high-risk group, being particularly susceptible to stress and emotional instability. This study aims to estimate the prevalence of psychological distress in pregnant women during the COVID-19 pandemic. Materials and Methods: This is a cross-sectional observational study done in a tertiary care center in Kerala between June and July 2021. All the pregnant women attending the obstetric department, after taking their informed consent were assessed with a pro forma to collect their sociodemographic details and Kessler Psychological Distress Scale was used to assess their psychological distress. The association between sociodemographic variables and distress was assessed using the Chi-square test. Results: A total of 66 pregnant women were studied. Fourteen (21.2%) were noted to have psychological distress. Three (4.5%) and 6 (9.1%) were in moderate and severe distress, respectively. None of these women were known to have any psychiatric illness. Psychological distress was more prevalent among homemakers compared to employed pregnant women (P = 0.134), more in primi, compared to second and third gravida (P = 0.825) and more in pregnant women in the second trimester compared to women in the first and third trimesters (P = 0.296). Conclusion: Psychological distress is highly prevalent in pregnant women during the COVID-19 pandemic. There is an urgent need for health policies to decrease its negative impact on the health of pregnant women, mothers, and children.
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A study on the unusual course and branching patterns of arteries in the upper limb p. 222
Senthil Ganesh P Kannappan, Havila Hasini Srivaram, Gnanagurudasan Ekambaram
DOI:10.4103/amhs.amhs_166_22  
Background and Aim: Human body consists of blood vessels, nerves, and muscles that are not always similar to each one. Anatomical study of abnormal vessels or nerve or muscle arrangements in the body interferes of clinical diagnosis, surgical procedure, and radiological findings. Comprehensive knowledge of anatomical variations present in the body is key for patient management. Arteries of upper limb variations are more common than other variations. Arterial variations may lead to vascular neuropathy. Diagnostic errors can be eliminated by understanding these variations. The aim of the present study is to correlate clinical abnormalities with arterial course variation in the upper limb and contribute some of the previously unknown new variations to medicine. Materials and Methods: A descriptive study was conducted from 2016 to 2021 in the Department of Anatomy, Apollo Medical College, Chittoor. The study was conducted with 56 upper limbs from 28 cadavers. The arterial course and relations of each region in the upper limb were noted carefully. Results: Abnormal arterial courses and variations were considered for data collection. Out of 56 limbs, 6 variations were seen from 5 limbs. Abnormal arterial courses were found in the 2 upper limbs (3%) and abnormal arterial branches were present in the 4 upper limbs (7%). In 51 upper limbs, there were no abnormal arterial courses and branches (90%). Conclusion: Study of anatomical arterial variations helps to guide the diagnosis and treatment of patients. Hence, arterial variations present in the upper limbs are more common than in other regions of the body.
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Assessment of quality and the utilization of the dental prosthesis and their impact on patient satisfaction p. 227
Mallika S Shetty, Hasan Sarfaraz, Kamalakanth K Shenoy
DOI:10.4103/amhs.amhs_162_22  
Background and Aim: Assessing patient satisfaction with dental prosthesis is usually difficult if the prosthesis does not fulfill the treatment need of the patient, and in most cases, the professionals' assessment of the prosthesis differs from the patients' perception of quality and treatment outcome. Patient satisfaction is important for the proper utilization of the prosthesis which helps improve the patients' overall quality of life and that remains the professionals' ultimate goal. The aim of this study was to assess the quality and utilization of dental prostheses and their impact on patient satisfaction. Materials and Methods: A cross-sectional survey was conducted on 1312 participants aged 18 years and above using a house-to-house approach among the rural population of Mangalore taluk. The study involved the completion of a predesigned and structured pro forma based on the WHO oral health assessment form. Evaluation of the prosthesis, and its quality was done by the professional. Fisher's exact test and odds ratio were conducted to find the significance of variables. P < 0.05 was considered statistically significant. Results: It was found that the retention and chewing efficiency of the complete denture had a positive comparison that was statistically significant. The retention of the partial denture wearers had a positive correlation between the patient perception and the professional assessment. In fixed partial dentures candidates, there was a statistically significant comparison between their perception and professionals' assessment with regard to hygiene and periodontal health. Conclusion: Most of the completely edentulous patients residing in the rural population of Mangalore taluk are quite satisfied with their prosthesis, whereas the professional assessment revealed that the older denture lacked retention, occlusion, and hygiene.
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A study to evaluate the impact of COVID-19 on the mental health of medical students p. 233
Shouvik Das, Arunima Chaudhuri, Biman Ray
DOI:10.4103/amhs.amhs_121_22  
Background and Aim: The COVID-19 pandemic has imposed huge challenges on medical students and medical educators as they are the frontline workers in health-care management. The present study was conducted to evaluate and compare depression, anxiety, and stress levels and the Impact of Event Scale scores among different phases of undergraduate medical students. Materials and Methods: The present study was conducted online at Burdwan Medical College after taking institutional ethical clearance and informed consent from participants. The Depression, Anxiety, and Stress Scale-21 (DASS-21) scores and the Impact of Event Scale-Revised (IES-R) scores of all phases of MBBS students were evaluated during the first and second waves of the pandemic. Jamovi software was used for statistical analysis and ANOVA was used to compare different groups. Results: There was no significant difference in the DASS-21 scores among all five groups during the first wave, but significant differences were observed in IES-R scores. On post hoc analysis, significant differences were observed in the Intrusion, Avoidance, and Hyperarousal scores between 1st- and 5th-year, 2nd- and 5th-year, and 4th- and 5th-year students. During the second wave, significant differences in DASS-21 and IES-R parameters were observed between the different phases of MBBS students. There were significant positive correlations between IES-R scores and DASS-21 scores among 1st-year students and a significant negative correlation between IES-R scores and anxiety scores among 2nd-year students during the first evaluation. There were significant positive correlations between IES-R scores and DASS-21 scores among 1st-year students and a significant positive correlation between IES-R scores and stress scores among 5th-year students during the second evaluation. Conclusion: Senior batches of MBBS students were more mentally affected by the impact of the pandemic as evaluated by DASS-21 scores and IES-R scores. Levels of depression, stress, and anxiety were also increased during the second wave as compared to the first wave of the present pandemic.
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REVIEW ARTICLES Top

Neurodevelopmental versus functional tics: The state of the art p. 239
Andrea E Cavanna, Giulia Purpura, Renata Nacinovich
DOI:10.4103/amhs.amhs_246_22  
Tic disorders of neurodevelopmental origin are the most common hyperkinetic disorder in childhood. In cases where both multiple motor tics and at least one vocal tic are present, with a chronic course, a diagnosis of Tourette syndrome can be confirmed. Functional movement disorders are a common type of functional neurological disorder, which has previously been referred to as hysteria and conversion, among other diagnostic labels. Functional tics have long been considered a rarer phenotype of functional movement disorder, compared to functional tremor or functional dystonia. However, during the COVID-19 pandemic, there have been multiple reports worldwide of an unexpected increase in the number of adolescents and young adults presenting with acute-onset functional tics. The differential diagnosis between neurodevelopmental and functional tics can be challenging, but a few demographic and clinical features have proven useful in assisting clinicians. Neurodevelopmental tics present with the gradual onset of simple motor and vocal tics in a rostrocaudal evolution, starting in early childhood, more commonly in boys. Conversely, functional tics often have an abrupt and explosive presentation of severe symptoms, with a later age of onset and a female gender predominance. Moreover, it has been reported that a proportion of patients with functional tics developed their symptoms after being exposed to social media content of influencers displaying similar manifestations. The etiology of the recent “pandemic within the pandemic” is likely to be multifactorial, with increased exposure to social media possibly playing a role alongside the psychosocial impact caused by the COVID-19 pandemic.
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Spinal intramedullary tumors p. 247
Girish Menon, Siddharth Srinivasan, Rajesh Nair, Ajay Hegde, Suresh Nair
DOI:10.4103/amhs.amhs_263_22  
Intramedullary spinal cord tumors constitute an uncommon group of central nervous system neoplasms which pose considerable diagnostic and management challenges. Often low grade, these tumors have an insidious onset and slow progression, which makes early diagnosis a challenge. Advances in magnetic resonance imaging technology have greatly aided the diagnosis and preoperative planning of intramedullary tumors. Yet, radiological diagnosis can be difficult in the presence of several tumor mimics. The introduction and advancement of microsurgical techniques have made surgery the preferred treatment modality. Timing of intervention, however, is contentious. Eloquence of the surrounding tissue and the unforgiving nature of the spinal cord adds to the surgical challenge. Their treatment and prognosis is largely dependent on tumor histology and patient functionality. Well-demarcated tumors like ependymomas and hemangioblastomas can be resected completely with good outcome. Infiltrative tumors such as high-grade astrocytomas are best managed with biopsies or limited resections. Postoperative deficits can be crippling and the use of intraoperative neurophysiologic monitoring and other adjuncts is mandatory. Subtotal resection carry a high risk of recurrence and gross total resection carries a high risk of operative morbidity. With the availability of newer imaging modalities and intraoperative adjuncts, the earlier pessimistic conservative approach has been replaced by an aggressive surgical approach. This review provides an overview on the entire spectra of spinal intramedullary tumors with particular focus on management strategies.
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Artificial intelligence in health professions education p. 256
P Ravi Shankar
DOI:10.4103/amhs.amhs_234_22  
Artificial intelligence (AI) is widely used in medicine. AI may provide low-cost solutions to health problems and is especially important for developing countries. Health-care professionals will play an important role in providing data for educating AI systems and validating these through clinical trials. AI may necessitate changes in the different roles of a physician and possibly other professionals. Intelligent tutoring systems can support student learning by providing individualized feedback and creating personalized learning pathways. Role-plays with an intelligent active agent can enhance students' interaction with computers and activate their sense of responsibility. AI can support personalized learning by intelligent agents, autonomous scoring, and chatbots. AI has an important role to play in supporting simulations, serious games, and the gamification of learning. Learning analytics and educational data mining are two other important applications. Personalized prediction is also an important benefit. AI will supplement the work of educators and can reduce curricular overload by migrating some knowledge to AI algorithms. Routine tasks and responses to routine queries of learners can be provided by AI. AI can support continuing professional education by incorporating longitudinal and innovative formative assessment methods that can help identify knowledge and skill gaps and support learning. The use of AI in curriculum review and assessment has been limited. Data integrity and privacy are important issues to consider. Unconscious bias in the data used to educate AI systems is also possible. Most of the literature is from developed countries and among medical students and residents.
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Role of mirror therapy in management of stroke – Current and future perspectives p. 262
Deepa Ramaswamy, S Parimala
DOI:10.4103/amhs.amhs_182_22  
Mirror therapy (MT) is a sort of therapy that makes use of vision for managing pain in persons with amputated limbs or weakness in stroke patients. Mirror treatment works by deceiving the brain by making it appear as though the missing limb or weaker limb is moving while the patient looks at the actual, functional limb in a mirror. By doing this, the brain conceals the fact that the amputated limb itself does not provide any signals of movement. Although very encouraging, MT has notable drawbacks that researchers are desiring and working hard to resolve so that it could be applied in treating more composite movements or pain of several types. Stroke has been the third biggest cause worldwide for the years of life lost (YLL); the age-standardized YLL grew by 12.9% (10.6–15.2) between 1990 and 2007 and by 12.1% (9.9–14.1) between 2007 and 2017. MT is a kind of rehabilitation method where the movement of an unaffected limb creates the illusion that the affected limb is also moving, for which a mirror is positioned amidst the legs or arms.
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A narrative review of global perspective on illicit drug utilization and substance use disorders p. 266
Paila Bhanujirao, Saman Salari, Paeizi Behzad, Tayebeh Salari
DOI:10.4103/amhs.amhs_258_22  
Drug addiction and abuse are major public health issues across the globe that impact millions of people. Substance abuse and dependence seem to have been relatively high among university students and laborers and comparatively low among school students. Drugs used by the person for nonintended reasons, mainly for their psychoactive effects termed as drug abuse. Continued use of alcohol, illegal drugs, or prescription or over-the-counter medications harms health, employment, family, and law. When it comes to illicit substance usage, possession, and trafficking, every nation has its unique set of laws. The frequency of lifetime drug usage in 2015 was 5%, according to the most current World Drug Report. There is reason to be concerned about the high rates of drug and alcohol addiction among youths because of the substantial problems that have been linked to such use, including higher rates of aggression, suicidal attempts, etc., In this narrative review, we have focused on illicit drugs, substance use, its negative impacts among youths and its prevalence among youths nationally and internationally, and also some prevention strategies to control substance use.
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CASE REPORTS Top

Fluvoxamine-induced tics: A rare phenomenon p. 274
Dimple Gupta, Akansha Bhardwaj, Rashmi Prakash, Nimmi Jose
DOI:10.4103/amhs.amhs_207_22  
Fluvoxamine is a commonly used drug in obsessive-compulsive disorder (OCD) and has shown remarkable results in the recovery of such patients. Fluvoxamine is generally well tolerated. However, this drug comes with its own series of adverse effects such as nausea, headaches, diarrhea, sleep disturbance, agitation, anorexia, tremulousness, and decreased libido. It has also been less commonly associated with convulsion, dyskinesia, dystonia, extrapyramidal syndrome, and twitching. In this case report, we wish to highlight a case of OCD, who was prescribed tablet fluvoxamine as a treatment and subsequently developed tics. On reducing the dose of fluvoxamine, her tics gradually resolved with no deterioration of OC symptoms. By reporting this case, we wish to emphasize the potential side effect of fluvoxamine which should be kept in mind while choosing this antidepressant agent. The rising number of cases of movement disorder along with their varied clinical features undermines the importance of considering drugs as a possible cause of tics.
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Pneumomediastinum is a poor prognostic factor in COVID-19 patients – case series and review p. 277
Ashish Ranjan, Saroj K Meena, Jitendra Kumar Saini, Rajnish Gupta, Amit Sharma
DOI:10.4103/amhs.amhs_34_22  
During the second wave of COVID-19, a number of patients requiring invasive or noninvasive pressure support ventilation rose significantly. The cases of pneumomediastinum (PM), pneumothorax (PTX), and subcutaneous emphysema (SCE) were also reported, largely attributed to barotrauma with observation of some spontaneous cases. Here, we present seven moderate-to-severe COVID-19 cases with variable severity developing PM with or without PTX and SCE during the course of hospitalization. Five received noninvasive ventilation, of whom two required invasive mechanical ventilation. The remaining two patients received oxygen therapy alone. Two patients required insertion of intercostal chest drainage tubes for pneumothoraces. Appropriate medical management was given to all patients. Three patients improved and were discharged from the hospital, while four expired. The case series highlights need of early diagnosis, constant monitoring, and judicious use of pressure support ventilation to prevent air leak complications in COVID-19 patients in order to improve their prognostic outcomes.
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First-use hypersensitivity reactions during hemodialysis p. 282
Mafdy N Basta
DOI:10.4103/amhs.amhs_236_22  
Hypersensitivity reactions during hemodialysis result from the interaction between blood constituents and the hemodialysis membrane. Different types of membrane materials, including cellulose, substituted cellulose, or synthetic noncellulose, are used in dialyzers' manufacture which can affect the frequency and type of reaction seen. Two types of reactions, classified as Type A and Type B, have been described. Type A reaction is far less common but more severe than Type B. The following is a case of Type A reaction in a 63-year-old Caucasian male who had his first hemodialysis prescribed with a synthetic noncellulose membrane. His hemodialysis session was aborted and the reaction was successfully managed. Subsequent dialysis sessions were performed, uneventfully, with a substituted cellulose membrane. This case illustrates the importance of remaining vigilant and cognizant of the possibility of hypersensitivity reactions to hemodialysis membranes, as some of the reactions could be potentially life-threatening.
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Angiomyomatous hamartoma of the inguinal lymph node p. 285
Supriya Verma, Gauri Nakra, Anchana Gulati
DOI:10.4103/amhs.amhs_245_21  
Angiomyomatous hamartoma is a rare disease of the lymph nodes, particularly inguinal and femoral lymph nodes. It was first identified as a distinct entity by Chan et al. in 1992. Histologically, it is characterized by the replacement of lymph nodal parenchyma with irregularly distributed thick-walled variable-sized blood vessels, haphazardly arranged smooth muscle cells, and variable amounts of fat and fibrous tissue in a sclerotic lymphatic stroma. Only a few atrophic lymphatic follicles are seen in the subcapsular area. The exact pathogenesis is still controversial. Although this entity is very rare, its recognition is important in discriminating it from other benign and malignant vascular lesions of lymph nodes.
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Autoimmune hemolytic anemia complicating a non-severe SARS-COV2 pneumonia p. 288
Youssef Motiaa, Youssef Dwassy
DOI:10.4103/amhs.amhs_199_22  
COVID-19 has been associated with a spectrum of hematological complications secondary to excessive activation of the immune system. In this article, we report the case of a 64-year-old patient who developed delayed autoimmune hemolytic anemia following a mild severe acute respiratory syndrome-coronavirus-2 infection. We will discuss its pathophysiological, clinical, and biological aspects as well as the clinical management of this complication.
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Conservative approach for managing complicated crown-root fracture in a 4-year-old child: A case with 12-month follow-up p. 292
Pratik B Kariya, Sweta Singh, Anshula Neeraj Deshpande, Arohi Desai
DOI:10.4103/amhs.amhs_109_22  
Traumatic dental injuries (TDIs) are of great concern when it comes to a child. Crown-root fracture is the most complicated type as both crown and root are affected by trauma. Complicated crown-root fracture seldom occurs in deciduous dentition. It is a tragic experience and requires immediate attention and quick functional and esthetic repair. Appropriate and early diagnosis leads to successful treatment, for which knowledge on types of TDIs, classification, and management is necessary. Complete restoration of teeth affected with trauma will restore function and esthetics and preserve occlusal harmony. The objective of the present case report is to discuss the appropriate diagnosis and conservative treatment of this unusual and rare case of complicated crown-root fracture in a 4-year-old child using tooth fragment reattachment. This case will focus on the options to restore the uncommon trauma and normalize the function and esthetics of the patient, which will lead to improvement of speech, increase in self-confidence and protection of successors, and describe the treatment and aspects concerning follow-up of the patient.
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The triad of denial, neglect, behavioral disorder causing to habitual multiple foreign-body ingestion – A surgeon's nightmare p. 297
Roshan K Verma
DOI:10.4103/amhs.amhs_113_22  
Behavioral disorders in children can sometimes lead to habitual and deliberate ingestion of multiple foreign bodies that may be neglected for long periods and require a multidisciplinary team approach to remove them successfully.
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MEDICAL EDUCATION Top

Academic leadership in the era of curricular and quality transition toward excellence: Frameworks that guide actions needed for facilitating and sustaining change p. 300
Thomas Vengail Chacko
DOI:10.4103/amhs.amhs_272_22  
Leadership literature indicates that focus has shifted from “top-down hierarchical” to “leadership everywhere” approach within organizations and this also applies to academic leadership. The context in which the new eco-leadership discourse has emerged, is presented as it is important for academic leaders to be aware that they need to tailor their leadership style and approach to be ready for the 21st century challenges arising from “triple disruptions due to digital and technology revolution, environmental emergency, and rising societal iniquity.” The framework of “leading from within” that has emerged from research on leadership in higher education has been found to be relevant and resonates well with academic leaders in India and so is presented in greater detail. Understanding of different academic leadership frameworks has been used to generate guidelines for academic leaders to use for implementing the changes that they would be expected to make to improve quality and make faculty future-ready.
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Medical students' perspective on working in a health-care team - Revealed by thematic analysis p. 307
Archana Shetty
DOI:10.4103/amhs.amhs_223_22  
Implementation of Competency-Based Medical Education in 2019 has brought significant changes in the delivery of medical education in India. Attitude, ethics, and communication module has been introduced in to focus on the much-overlooked soft skill aspects and real-life scenarios that will be encountered during future medical practice. The present study has used thematic analysis to understand the effect of this newly implemented module on undergraduates. Qualitative data analysis of thematic type was performed for gaining in-depth perceptions. Analysis revealed that students observed the importance of various roles and their hard work involved in hospital functioning. Students felt they would practice attributes of collaborative work, enhanced communication, and respect for all support systems in future practice. Students perceived the module positively and got to know the facets of under-recognized roles of health-care workers other than medical professions, whose role is crucial for delivering quality health-care services.
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TEACHING IMAGES Top

Is it a diaphragmatic hernia? p. 310
Amine Naggar, Soufiane Rostoum, Hamza Retal, Jamal El Fenni, Rachida Saouab
DOI:10.4103/amhs.amhs_245_22  
Chilaiditi's syndrome is a symptomatic hepato-diaphragmatic interposition of a colon and/or small intestine. When it is asymptomatic, it is called Chilaiditi's sign. It is a benign condition that may mimic other concerning diagnoses on radiography, such as diaphragmatic hernia or pneumoperitoneum. Computed tomography (CT) is the best imaging tool to assess the diagnosis. We report a rare case of Chilaiditi's syndrome with intermittent dyspnea, suspected on radiography and diagnosed on CT. Nasogastric decompression relieved the patient's symptoms.
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SHORT COMMUNICATION Top

Tourette syndrome with functional overlay: A case series p. 312
Andrea E Cavanna, Laavanya Damodaran, Giulia Purpura, Renata Nacinovich
DOI:10.4103/amhs.amhs_247_22  
Functional tics have long been described as part of the much wider spectrum of functional neurological disorders with motor manifestations. Reports of functional tics have been relatively rare, until their recent increase on a global scale during the COVID-19 pandemic. Such reports have often been characterized by an acute or subacute onset of complex motor and vocal manifestations. Moreover, functional tics have predominantly been reported in adolescent females, whereas neurodevelopmental tics, such as those reported by patients with Tourette syndrome (TS), typically begin in younger boys. In addition to their marked severity and complexity, functional tics can merge into other types of functional neurological disorders. However, functional tics can also coexist with neurodevelopmental tics, as patients diagnosed with TS can present with a functional overlay (dual diagnosis). In the present study, we report the clinical characteristics of a case series of 10 patients diagnosed with both TS and functional tics during the COVID-19 pandemic. We also provide the first within-subject comparison between neurodevelopmental tics and functional tics, to assist clinicians in the differential diagnosis of patients with TS who developed a functional overlay during challenging times.
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