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   Table of Contents - Current issue
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January-June 2021
Volume 9 | Issue 1
Page Nos. 1-185

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EDITORIAL  

Sustainable Humanity beyond the COVID-19 Crisis: ‘Vasudhaiva Kutumbakam’ for ‘One Planet, One Health, One Future’ Highly accessed article p. 1
Bhaskara P Shelley
DOI:10.4103/amhs.amhs_118_21  
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INVITED EDITORIAL Top

Digital health, learner competence, and a pandemic: The storm I had been waiting for p. 12
Lyn K Sonnenberg
DOI:10.4103/amhs.amhs_107_21  
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Blended learning in the 21st century: The need to tailor it to the changing learner self-direction levels during different phases of health professions education and beyond Highly accessed article p. 16
Thomas V Chacko
DOI:10.4103/amhs.amhs_117_21  
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ORIGINAL ARTICLES Top

Determinants of depression and its associated coping mechanisms among college students confined during COVID-19 Lockdown: A cross-sectional e-survey in India Highly accessed article p. 19
Sunny Garg, Alka Chauhan, Sanjeet Singh, Kirti Bansal
DOI:10.4103/amhs.amhs_336_20  
Background and Aim: During COVID-19 pandemic lockdown, mental health of students was highly pregnable to the loss of social connectedness, disarray of normal pattern of activities as well as academic issues. Adopted coping mechanisms may have played a significant role in surmounting the challenges related to the pandemic. The main aim of the survey is to evaluate the prevalence of depression, its determinants, and association with coping mechanisms among college students during COVID-19 lockdown. Materials and Methods: College students were invited during lockdown to participate in a nationwide cross-sectional e-survey using Snowball sampling technique (dated October 6–30, 2020). A total sample size of 920 was calculated. A self-administered questionnaire regarding sociodemographic characteristics, COVID-19-related experiences along with two scales (Patient Health Questionnaire-9 [PHQ-9] and Carver Brief-Coping Orientation to the Problem Experienced-28) for assessment of depression, and adopted coping mechanisms was applied to participants. Chi-square test, independent “t-” test, Pearson's correlation, and hierarchical multiple regression analysis were used to investigate the determinants of depression and its association with coping mechanisms in college students. Results: On analysis of 884 participants, it was revealed that 402 (45.5%) participants have depressive symptoms ranging from moderate to severe level. The mean score of PHQ-9 was 9.82 ± 6.61. Nearly 85% of the students were lagging behind in studies. Around 5%–10% of the students initiated/increased the consumption of substances. The main determinants of depression in this study were the age group of 21–24 years, thought of lagging behind in studies, and family members/friends/relatives diagnosed with COVID-19. Adaptive coping mechanisms (emotional support, religion, and humor) were significantly associated with lower depressive symptoms and maladaptive coping mechanisms (self-distraction, denial, behavioral disengagement, and venting) were significantly associated with higher depressive symptoms among students. Conclusions: This survey revealed multiple determinants of depression, mainly including academic worries among college students. The college staff should provide a well-structured pedagogical framework to encourage them and alleviate the unpleasant psychological effects of pandemic on students.
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Suicidal thoughts, suicidal attempts, and nonsuicidal self-injury among undergraduate health professionals p. 28
Vishal Kanaiyalal Patel, Renish Bhuperndrabhai Bhatt, Hitarth Himanshu Raja, Parveen Kumar, Deepak Sachidanand Tiwari, Disha Alkeshbhai Vasavada
DOI:10.4103/amhs.amhs_321_20  
Background and Aim: Nonsuicidal selfinjury (NSSI) was observed in both males and females, with higher rate among females. NSSI could increase the risk of future suicide attempts. Adolescence is considered as stressful period because of identity crisis, physical growth, coupled with set of decision regarding future profession and personality traits. The study is aimed to find suicidal thoughts, suicidal attempts, extent of the NSSI and its impact on the undergraduate health professionals. Materials and Methods: A cross-sectional study was carried out among medical, dental, and physiotherapy undergraduate college students of Jamnagar, Gujarat. A total of 1850 students were approached, out of them 1050 medical, 500 dental and 300 were physiotherapy students. Participants were requested to fill the pro forma containing following parts: (1) Demographic details, (2) Inventory of Statements about Self-injury, (3) Impact of Non-Suicidal Self-Injury Scale. Results: A total of 1408 students completed the pro forma. Overall 13.99% prevalence rate of NSSI was reported. Female participants had higher prevalence of self-harming behavior than male participants (χ2 = 24.226, P < 0.001). NSSI was related to suicidal thoughts and suicidal attempts with (χ2 = 263.050, P < 0.001) and (χ2 = 197.777, P < 0.001), respectively. A negative correlation was observed with age of onset of NSSI behaviors with and numbers of NSSI behavior (r = −0.317, P < 0.001). Conclusions: Participants engaged in different NSSI behaviors for affect regulation, interpersonal boundaries, sensation seeking, self-punishment, revenge, and self-care. High prevalence of NSSI among young health professionals needs independent clinical attention. There is a need of crisis interventions for the management of self-harming behaviors and to prevent future fetal suicidal attempts.
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Impact of CoronaVirus Disease-19 lockdown on physical activity and energy expenditure among middle adolescence - A cross-sectional e-survey p. 35
Vandana Jivatsinh Rathod
DOI:10.4103/amhs.amhs_257_20  
Background and Aim: Coronavirus disease-19 (COVID-19) is a pandemic disease spreading throughout the world. Lockdown declared by the Indian government to control the spread of this disease leads to change an entire lifestyle of the population. Individual's lives are greater affected due to lockdown which leads to a reduction in their physical activity (PA). It might increase the chance of infection by reducing immunity. How much PA is reduced during this lockdown period among middle adolescence is not known. This study attempts to find out PA level and energy expenditure (EE) among middle adolescence during the lockdown. Materials and Methods: One hundred and twenty-three volunteered students participated in an open e-survey. The survey was carried out by the International PA questionnaire-short form through social networking sites during the COVID-19 lockdown period through the Google Forms link. PA and EE have been measured. Results: Among identified 147 potential survey participants, 123 responded. Total PA during COVID–19 lockdown period was 6262.21 metabolic equivalent task-min/week. While EE during COVID–19 lockdown period was 6009.28 cal/week. Conclusions: A significant reduction in self-report PA and EE levels was observed among middle adolescent students during the COVID–19 lockdown period.
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A comparative study of prevalence of Chlamydia trachomatis infection among infertile and fertile women at a tertiary care center p. 39
Moushmi Balwant Parpillewar, Shweta Singh
DOI:10.4103/amhs.amhs_123_20  
Background and Aim: Chlamydia trachomatis is an obligate intracellular Gram-negative bacterium causing sexually transmitted infection leading to urogenital infections which are asymptomatic. If untreated, leads to complications such as chronic pelvic pain, inflammation, and occlusion of the fallopian tubes, resulting in infertility and ectopic pregnancy. The association is found between C. trachomatis infection and female infertility with a prevalence rate of 15%–30%. The aim was to determine the prevalence of C. trachomatis infection in women with infertility. Materials and Methods: This was a hospital-based cross-sectional study of patients presenting with or without infertility. Group A (75 cases) cases with infertility with or without symptoms of pelvic inflammatory disease. Group B (75 cases) with no infertility matching age, symptoms with Group A. After history, physical examination cervical swab for chlamydial antigen and serology sample was taken and processed. Positive cases were followed by hysterosalpingography (HSG) and laparoscopy. Results: Out of 150 patients, 14 were positive for chlamydia in cases and 4 in the control group. Chlamydial prevalence was four times more in cases as compared to the control group, which is significant. The mean age was 27.97 + 4.520 years. Out of 14 positive cases, 8 (57.14%) had symptoms, whereas 6 (42.85%) were asymptomatic; in controls, 2 were symptomatic, whereas 2 were asymptomatic. HSG and laparoscopy were positive in chlamydia positive cases. Conclusion: It can be presumed that there is a significant role of C. trachomatis in infertility and also there is an association between chlamydia antigen detection and tubal factor infertility.
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Evaluation of bite force in patients with cleft lip and palate and its comparison with normal patients p. 44
Vidya Bhat, Harikrishan Reddy, Sanha Razdan, Sanath Shetty
DOI:10.4103/amhs.amhs_235_20  
Aim and Objectives: This in vivo cross-sectional study aimed to measure and correlate the average and maximum bite forces between cleft and noncleft individuals. Materials and Methods: The study was conducted on thirty cleft and thirty noncleft lip and palate patients who were belonging to the age group of 14–30 years with unrepaired unilateral cleft lip and palate under treatment at the Craniofacial Center, Yenepoya Dental College, Mangalore, and G. S. R Craniofacial Center, Hyderabad, India. Dental Prescale® sheet was used to record the bite force of the patients and the test sheet was scanned with an Epson v330 color HD photo scanner, and the bite force was evaluated by an FDP 8010 analyzing system. The data were analyzed statistically by the Student's data t-test. Results: The control group had a statistically significantly higher mean pressed area on the left side (P = 0.034), maximum pressure on the left side (P < 0.001), mean maximum pressure on the right side (P = 0.024), and mean average pressure on the left side (P = 0.038). There was no statistically significant difference in the mean pressed area on the right side (P = 0.569) and average pressure on the right side of the control and study groups (P = 0.358). Conclusions: There was a statistically significant difference in the mean maximum pressure (P = 0.001) and average pressure (P = 0.039) among cleft lip and palate patients when compared with that of the control group. There was no significant difference between male and female subjects of both the groups.
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Can hospital doctors provide quality palliative care informed by end-of-life care legislation: An Australian perspective p. 50
Aaron K Wong, Susan E Carey, David J Kenner
DOI:10.4103/amhs.amhs_231_20  
Background and Aim: Approximately 50% of deaths in Australia occur in hospitals, and this number is growing. Studies consistently show that doctors have poor knowledge of end-of-life decision making; however, this has not been examined in specific groups of hospital doctors. We examined hospital doctors' knowledge of key elements of end-of-life care legislation. Materials and Methods: We conducted a prospective, observational, cross-sectional study of doctors from a large Australian public tertiary health network using six questions formulated on basic key elements of the legislation. Demographic data collected included years of work experience, clinical unit, and proportion of work hours spent with dying patients. Results: Of the 201 doctors censored, senior doctors (>10 years' experience) were the least knowledgeable group. Only approximately 20% of doctors correctly answered all questions. Thirty-two percent would potentially provide futile treatment if demanded by a competent patient. Fifty percent did not know how to locate an advance directive in the hospital record. There was confusion regarding the role of the substitute decision-maker. Conclusions: Approximately a quarter of hospital doctors practise with a poor understanding of the law over the various domains. The urgent call for education is further highlighted not only for students and junior doctors but also for senior doctors who scored poorly. Educational efforts could begin from addressing the simple key areas of legislation covered in the survey.
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Prognostic markers in acute liver failure - Alpha feto protein p. 55
P Gayathri, Smitha Krishnamoorthy, Subhash Chandra, MG K Pillai, Raviraj Menon, Mahesh Subramania Iyer
DOI:10.4103/amhs.amhs_14_21  
Background and Aim: Acute liver failure is associated with high mortality and only about 40% patients survive without liver transplantation. The available prognostic models failed to predict the outcome correctly. Here, we aimed to determine if alpha-fetoprotein (AFP) can be used as a prognostic marker in acute liver failure. Materials and Methods: For this prospective observational study, sixty patients with the diagnosis of acute liver failure were allocated and serum AFP ratio was measured on days 1 and 3 of admission. AFP ratio was calculated as day 3 AFP/day 1 AFP value. Other laboratory parameters and various etiological factors of acute liver failure were also studied. Results: The average AFP ratio among survivors was 1.77 ± 0.94 and among patients who died, the average ratio was 0.68 ± 0.58. Hence, AFP ratio is an important prognostic tool in predicting mortality with a P < 0.001. Majority of patients (80.6%) of patients whose AFP ratio was <0.7 died while majority of patients whose AFP ratio was >0.7 survived (70.4%). Hence, we concluded that AFP values change dynamically during the course of acute liver failure and AFP ratio can be used as a prognostic marker in acute liver failure. AFP ratio showed statistically significant negative correlation with prothrombin time and international normalized ratio, serum globulin, and the levels of indirect bilirubin, especially on the third day after admission and the variables were significantly elevated in the patients who died. Conclusions: AFP ratio can be used as a predictor of mortality in acute liver failure patients. Higher the ratio more are the chances of survival.
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Dental students' perception towards feedback during clinical training p. 62
Jayashri Tamanna Nerali, Vinayak Kalyan Chakravarthy Pishipati, Lahari Ajay Telang, Ajay Telang
DOI:10.4103/amhs.amhs_212_20  
Background and Aim: Feedback is an essential element in the clinical training of dental students which paves way for the achievement of learning outcomes and also to improve their future performance. The aim of this study was to analyze dental students' perceptions of importance, process, and content of feedback received during their clinical training. Materials and Methods: A cross-sectional, questionnaire was developed and validated and distributed to dental students (n = 178) of years 3, 4, and 5. Descriptive analysis and one-way ANOVA were used to compare the mean scores between the three groups. Open-ended responses were analyzed qualitatively. Results: The majority of students agreed that feedback on clinical performance is needed to improve learning and identify areas for improvements. Most of the students prefer one-to-one feedback, in a timely and regular manner and immediately after the clinical session. Eighty-six percent believed that feedback should be given with mutual respect. Most of the students disagree (80%) that marks/grades are an important part of the feedback. Students preferred feedback with positive and negative comments about their clinical work (93%), which would help them to engage in the process of learning and to make an action plan for future learning process. Conclusions: Students are aware of the purpose and importance of feedback and preferred timely, structured, and constructive feedback on their clinical performance. The dental clinical environment is stimulating and dynamic and the role of faculty feedback is crucial for students to reflect on their learning and improve future performance.
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Prevalence of psychological morbidities and their influential variables among nurses in a designated COVID-19 tertiary care hospital in India: A cross-sectional study p. 68
Sunny Garg, Megha Yadav, Alka Chauhan, Dinesh Verma, Kirti Bansal
DOI:10.4103/amhs.amhs_302_20  
Background and Aim: Nurses are the main part of the health work force, performing their duties as frontline warriors against the novel coronavirus pandemic. Nurses involved in the care of infected (COVID-19) patients, may feel more discomfort physically, and experience greater psychological morbidities. The main aim of the study is to evaluate the prevalence of anxiety and stress among nurses in a designated COVID-19 hospital and variables that influence these psychological problems. Materials and Methods: Nurses working in the designated tertiary care hospital were invited to participate in an online cross-sectional survey (dated, 5–15 September 2020). A total sample size of 236 was calculated. A self-administered questionnaire regarding sociodemographic characteristics, COVID-19-related experiences, perceived threat regarding COVID-19 and two scales (Generalised Anxiety Disorder-7 and Perceived Stress Scale-10) for assessment of anxiety, and stress was applied to nurses. Chi-square test and multiple regression analysis were used to investigate the predictors (risk and protective) of psychological morbidities in nurses. Results: On analysis of 209 participants, it was revealed that 65 (31.1%) participants have anxiety symptoms and 35.40% have moderate-to-high level of stress. Being proud of working in this profession was the only protective factor from such psychological morbidities. The identified risk factors for greater anxiety symptoms and moderate-to-high level stress were working experience of more than 10 years (odds ratio [OR] = 3.36), direct involvement in care of suspected/diagnosed patients (OR = 3.4), feeling worried about being quarantined/isolated (OR = 1.69), and high risk of being infected at job (OR = 2.3 for anxiety and OR = 2.1 for moderate-to-high stress). Conclusions: Deteriorating psychic health of nurses is one of the major outcomes during COVID-19 pandemic in India which warrants the necessity of providing psychological support to all the nurses particularly those who are frontline workers and have working experience of more than 10 years and controlling the risk factors related to these problems.
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Androgen receptor in breast cancer: A tissue microarray-based study p. 76
Sneha Chavan, Savithri Ravindra
DOI:10.4103/amhs.amhs_5_21  
Background and Aim: Breast carcinoma is the most common malignant tumor and the leading cause of cancer deaths in women. The incidence of breast cancer in India has been gradually raising accounting for 25%–33% of all cancers in women. Breast carcinomas are a heterogeneous group of tumors which show varied behavior and response to therapeutic agents. Androgen receptors (ARs) have been studied in great detail in prostate cancers, now being studied in breast cancers, but its role in breast cancer has not been elucidated completely. The aim of our study was to evaluate the expression of AR in invasive carcinoma of the breast and to evaluate its relation to estrogen receptor (ER), progesterone receptor (PR), and Human Epidermal growth factor Receptor2 (HER2) expression on tissue microarray (TMA) sections. Materials and Methods: This was a descriptive study which included 53 cases of breast carcinoma. The specimens were fixed in 10% formalin, routinely processed. A master block for TMA was made by taking 2 mm cores from paraffin blocks containing tumor. Sections were taken and stained for ER, PR, AR, and HER2. Results: A total of 53 cases were studied. Around 63% of breast carcinomas were positive for AR. Conclusion: AR expression can be used as an additional biomarker in breast carcinomas, and a large number of cases can be studied by TMA sections.
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Antimicrobial Stewardship – Implementation and Improvements in Antibiotic-Prescribing Practices in a Dental School p. 80
Lahari Ajay Telang, Jayashri Tamanna Nerali, Pishipati Vinayak Kalyan Chakravarthy, Fawaz Shamim Siddiqui, Ajay Telang
DOI:10.4103/amhs.amhs_20_21  
Background and Aim: Antimicrobial stewardship (AMS) is a coordinated systematic approach aimed at educating prescribers to follow evidence-based prescription practice to reduce misuse of antimicrobials and thus antimicrobial resistance (AMR). We aimed to improve the standards of antimicrobial prescribing in a dental school by implementing AMS. Materials and Methods: A retrospective (first) clinical audit of antibiotic prescriptions (n = 200) over a 6 months' period was analyzed for the following parameters: type of antibiotic, clinical condition, compliance to national guidelines, and errors in prescriptions. In response to the results of this audit, an educational intervention workshop was conducted for clinical faculty. A validated self-administered questionnaire on perception and practice of antimicrobial prescribing was given to participants (n = 31) before and after the workshop and t-test was used to compare the mean scores of responses. Prospective clinical audits were conducted 6 months (second) and 1 year (third) after the workshop assessing the same parameters. A Strengths, Weaknesses, Opportunities, and Threats analysis of the AMS program was also done. Results: The total number of prescriptions issued was 943 in the first audit, which reduced to 552 in the second audit and further to 435 in the third audit. The most commonly prescribed antibiotic was a combination of amoxicillin and metronidazole. The percentage of prescriptions in accordance with national guidelines improved from 19% during the first audit to 54% and 79% in the subsequent audits. The percentage of erroneous prescriptions was 23% in the first audit, which reduced to 12% in the second audit and 9% in the third audit. The pre- and posttest mean values of the questionnaire when compared suggested that there is a need for uniformity in prescribing antimicrobials. Conclusions: Clinical audits with educational workshops on appropriate use of antibiotics have a positive impact on conforming with prescription guidelines. This will encourage the rational prescription of antibiotics based on clinical needs of patients, thus contributing to the fight against AMR.
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A study on depression, anxiety, stress, and life quality among medical aspirants and medical students of Aligarh City in North India p. 87
Manal Khursheed, Sufia Naseem
DOI:10.4103/amhs.amhs_32_21  
Background and Aim: Rapid intellectual and psychosocial development occurs mainly during young adulthood. Coincidently, decisions regarding collegiate and professions are taken during this period. Thus, adulthood is vulnerable to psychological disorders. Contrary to most other professions, medical education is more likely to affect mental health. The present explicates the prevalence of depression, anxiety, and stress among premedical and medical students of Aligarh city, and various coping mechanisms they adopt to mitigate above symptoms. Assessment on students' quality of life (QOL) has also been made. Materials and Methods: The study sample (220) consisted of 11th and 12th pursuing and 12th passed students preparing for medical entrance examinations and those pursuing the medical course. The study protocol was approved by the Institutional Ethics Committee. The method of online survey was questionnaire through Google forms. Study lasted for 3 months. We used Depression Anxiety Stress Scale and World Health Organization QOL (WHOQOL)-BREF (QOL assessment scale developed by WHO) questionnaires. Results: Our study suggests that levels of extremely severe anxiety (37.7%) and depression (20%) were relatively higher than stress (10.9%) in the respondents. The Pearson's Chi-square alpha and the P value indicated that depression, stress and anxiety were quite gender centric. We also found significantly higher levels of depression, stress, and anxiety in 11th, 12th pursuing, 12th passed students preparing for medical entrance, final professional (Part 2) students, and interns. Furthermore, physical domain of QOL score showed strong negative correlation with depression, stress, and anxiety. Conclusion: The present study found that depression, stress, and anxiety are present among medical as well as premedical students. It is a matter of concern, as the conditions may severely affect the health as well as the performance of students.
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Assessment and comparison of the mental health status of patients seeking psychiatry facilities in prelockdown and postlockdown period of the COVID-19 Pandemic: An ambispective study in a tertiary care center in a Hilly Region of North India p. 95
Devesh Sharma, Sunny Garg, Anchal Sharma, Dinesh Dutt Sharma, Nidhi Sharma, Simran Gupta, Shivam Sharma
DOI:10.4103/amhs.amhs_64_21  
Background and Aim: The servicing and framework for mental health care accessible to population have been affected during the unprecedented times of the coronavirus disease (COVID-19) pandemic. The new and almost exclusive method to maintain a therapeutic alliance with these patients has been the recently evolving telepsychiatry services. The main aim of the study is to assess and compare the mental health status of patients seeking psychiatry facilities in prelockdown and postlockdown period during the COVID-19 pandemic. Materials and Methods: This was a ambirespective study which was conducted in a tertiary care hospital in a hilly region of North India in which the registered data were analyzed between January 1, 2020 and March 21, 2020 (prelockdown phase) and from May 3, 2020 to September 30, 2020 (postlockdown phase, after the resumption of outpatient department services in the institute), to gather the information of patients about sociodemographic profile and clinical diagnosis on the basis of International Classification of Diseases-10. A total sample size of 1000 patients was included. Chi-square test and Student's t-test were used to compare the patient presentation before and after the lockdown periods. Results: Majority of the patients were male (66%) and within 19–60 years of age (85%–90%). The average age of the patients (39.17 years, standard deviation = 14.37) was significantly higher in postlockdown phase. As compared to prelockdown period (499 patients), a significantly (P < 0.001) lower number of patients diagnosed with substance use disorders and a significantly (P < 0.001) higher number of patients diagnosed with psychotic disorders along with anxiety disorders, availed the available psychiatry services in the period of COVID-19 pandemic (501 patients). Conclusions: Sudden cessation of the psychiatry services further precipitated the deterioration of mental health of the patients. There is an urgent demand for services to adapt to changing scenarios with emphasis on practical approaches to help the mentally ill people, especially in geographically difficult hilly areas.
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REVIEW ARTICLES Top

Multisystem inflammatory syndrome in children associated with Coronavirus Disease-2019: An overview p. 101
Subhranshu Sekhar Kar, Rajani Dube
DOI:10.4103/amhs.amhs_273_20  
Coronavirus disease-2019 has been ravaging the world since the past several months with devastating consequences. Although it is seen that specific categories of patients with comorbidities are especially vulnerable, the risks from the acute disease in pediatric population have been consistently lower. However, the alarming rise in pediatric admissions in intensive care units with varied clinical presentation during this pandemic gave an insight to a new hyperinflammatory response called as multisystem inflammatory syndrome in children. Although overlapping symptoms may mimic toxic shock syndrome, macrophage activation syndrome, secondary hemophagocytic lymphohistiocytosis, myocarditis, or Kawasaki-like illness, clinical findings are relatively consistent across geographically distinct regions. Diagnosis is essentially clinical, and laboratory investigations are suggestive of increased inflammatory markers. Early recognition and appropriate institution of inotropes, intravenous immunoglobulins, corticosteroids, and antibiotics apart from general supportive treatment are required for a favorable outcome.
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COVID-19 and pregnancy: Challenges for an anesthesiologist p. 107
Shalendra Singh, Subhasish Patnaik, Rabi Narayan Hota, George Cherian Ambooken, Venigalla Sri Krishna
DOI:10.4103/amhs.amhs_38_21  
The anesthetic management of a pregnant patient with coronavirus disease 2019 (COVID-19) presents various unique challenges in terms of patient preparation, intraoperative management, and postoperative concerns, all while taking concurrent measures to prevent the spread of the virus from the patient to the healthcare workers. Anesthetic management of parturient in the era of the COVID-19 pandemic is further complicated by the fact that intubation and extubation are highly aerosol-generating procedures, and are generally advised to be avoided. While various organizations have come up with guidelines on the management of pregnant patients with COVID-19, definitive evidence-based guidelines for the same are lacking. This article aims to consolidate the available literature on the management of pregnant patients with COVID-19, with special impetus on the anesthetic management of these patients.
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CASE REPORTS Top

Odontogenic keratocyst with horizontal impaction of third molar p. 113
Hannah Maryam, Harshita Bejai Ratnakar, P Rithul, Bhargabi Paul Majumder, Anita M Varghese, Preethi A Poonja, Prasanna Kumar Rao, Raghavendra Kini, Nithin Gonsalves
DOI:10.4103/amhs.amhs_12_21  
Odontogenic keratocyst (OKC), previously known as keratocystic odontogenic tumor, are benign cystic lesions involving the mandible or maxilla and are believed to arise from dental lamina. What makes this cyst special is its aggressive behavior and high recurrence rate. This cyst is predominantly seen in younger patients (2nd–3rd decade) and may be seen in either the body or ramus of the mandible or maxilla. The distribution between sexes varies from equality to a male-to-female ratio of 1.6:1, except in children. There may be male predilection. Radiographically, it appears as unilocular or multilocular lesions with scalloped contour. This cyst is commonly detected incidentally. When symptomatic, jaw swelling and pain are common symptoms associated with this tumor. Less commonly, trismus and paresthesia may occur. Here, we present a case of OKC in a young male patient associated with an impacted right mandibular third molar.
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Dermatopathic lymphadenitis: Cytological diagnosis p. 117
Neeti Nagar, Sheetal Arora, Sunil Ranga
DOI:10.4103/amhs.amhs_306_20  
Dermatopathic lymphadenopathy usually presents with multiple enlarged lymph nodes. It is often seen in patients with skin diseases with either exfoliative or eczematoid inflammatory erythrodermas. Multiple enlarged lymph nodes usually point to the diagnosis of lymphoma. Fine-needle aspiration cytology helps in reaching the correct diagnosis at the preliminary stage. There are very few case reports on cytological features of this disease in literature. Here, we describe a case of dermatopathic lymphadenopathy in a 15-year-old female with subtle skin disease.
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Long standing paraparesis: A rare presentation of distal renal tubular acidosis p. 120
Pankaj Kumar, Prabhjot Dhillon, Geetanjali Jindal, Shivani Randev, Vishal Guglani
DOI:10.4103/amhs.amhs_121_20  
Neurologic manifestations can accompany systemic diseases, and primary disease can be identified with a careful history, physical examination, and laboratory investigations. Renal tubular acidosis (RTA) is an important differential diagnosis in any child presenting with failure to thrive. Hypokalemic distal RTA, also known as classic RTA or type 1 RTA, may present, though not so frequently , with weakness consequent upon hypokalemic paralysis, compounded by rickets.
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Successful postoperative pain management by a surgeon-assisted interfascial plane block under vision in patients undergoing modified radical mastectomy: A case series p. 123
Richa Joshi, Deepak Dwivedi, Kaminder Bir Kaur, Debashish Paul
DOI:10.4103/amhs.amhs_297_20  
As anatomical structures get exposed intraoperatively, we present a case series of 18 patients of the surgeon-assisted interfascial plane block with local anesthetic infiltration between pectoralis minor and serratus anterior (SA) and between SA and latissimus dorsi for postoperative analgesia in patients undergoing modified radical mastectomy. Surgeons infiltrated 25 ml of 0.25% bupivacaine with dexmedetomidine (0.5 μg/kg) in the above-mentioned plane after the completion of axillary dissection and the removal of axillary content en bloc with the breast. The median pain score was assessed by numeric rating scale for pain. This score was <3 with no requirement of rescue analgesia in the first 24 h postoperatively. Intraoperative hemodynamic parameters were stable, and there was no adverse event. Hence, surgeon-assisted interfascial plane block under vision can be a feasible option for providing adequate postoperative analgesia.
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Oropharyngeal muscle strengthening exercises in obstructive sleep apnea p. 127
Nistara Singh Chawla, Anujot Kaur, Thiagarajan Subramanian
DOI:10.4103/amhs.amhs_318_20  
Obstructive sleep apnea (OSA) is a common pattern of sleep-disordered breathing in the adult population. It is characterized by episodes of partial or complete cessation of breathing during sleep due to the collapse of the pharyngeal airway. OSA is involved in the pathogenesis of numerous cardiovascular and metabolic disorders. This study brings forth the case of a 54-year-old male who was experiencing breathing difficulty during sleep with recent episodes of sudden loss of consciousness followed by labored breathing and excessive sweating. He was diagnosed and treated for a bifascicular block. This was followed by the additional diagnosis of OSA. The treatment plan comprised a set of Oropharyngeal Muscle-Strengthening Exercises (OMSE). The daytime sleepiness was quantified using the Epworth Sleepiness Scale (ESS). Over the span of 6 weeks, an improvement of −2 points on the score was documented, which is considered to be statistically significant according to the ESS scale. From this case report, the authors concluded that OMSE can be used as an alternative treatment option for mild OSA. OMSE is a noninvasive, cost-effective intervention for mild OSA that provides long-term benefits to the patient. Timely diagnosis and intervention can help in improving the quality of life of the patient.
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MEDICAL EDUCATION Top

Defining medical education scholarship: Its evolution and its importance p. 132
Elizabeth M Wooster, Douglas L Wooster, Jerry M Maniate
DOI:10.4103/amhs.amhs_111_21  
Understanding the definition of medical education scholarship and its underlying theoretical constructs is essential to constructing medical education and supporting learning across the continuum. There continues to exist uncertainty surrounding defining and enacting medical education scholarship. This uncertainty results in an inability for educators to conduct medical education and scholarship and may result in missed opportunities for educators and learners across the continuum. For this paper, the authors define medical education scholarship as endeavours that are purposefully undertaken and may surpass the borders of those traditionally defined as research or innovation. Medical education may take place in areas of discovery, integration, application, teaching, and engagement. This definition is based on works by Boyer, Glassick and Shulman. This paper describes the contribution that each of these seminal works has made to advance the definition of medical education scholarship. The differences between medical education scholarship and creative professional activities as well as daily work are explored throughout the paper. The paper concludes with a call to develop, demonstrate, promote and support medical education scholarship and the faculty who are focused on undertaking related activities.
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The unexplored value of “Normal”: A commentary on the lack of normal cases in high-stakes assessment p. 136
Andrew Logiudice, Matthew Sibbald, Sandra Monteiro
DOI:10.4103/amhs.amhs_106_21  
In this article, we highlight how standard assessments in the health professions pay little attention to “normal” cases – i.e. those without pathology – and as a result may be overlooking a skill that lies at the heart of efficient health care. The issue is explored with two overarching questions in mind: What specifically might be missed by excluding these normal cases from high-stakes assessment? And what broader implications does this have for medical practice? Drawing upon a large body of research on diagnostic expertise and clinical reasoning, we argue that accurate categorization of a case as either abnormal or normal represents a key diagnostic skill, and that this skill may be neglected in many standardized assessments because they consist almost entirely of abnormal cases. Unforeseen consequences of this structure are then discussed in terms of curriculum design and trainee perceptions. If discerning “abnormal versus normal” is as critical as the literature suggests, then perhaps our typical assessment strategies need to be re-evaluated. This under explored topic warrants further research.
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SPECIAL ARTICLES Top

Role of biofilms in otorhinolaryngological Diseases p. 140
Harsh Suri, Neha Vijay Haswani, Gangadhara Somayaji
DOI:10.4103/amhs.amhs_291_20  
Biofilms over the years have been implicated to play a major role in the development of various diseases particularly Otorhinolaryngology. It is one of the topics with great interest within the field of medicine. A thorough review of the literature reveals the association of various infectious conditions of ENT practice is associated with biofilm-producing bacteria. Infections associated with biofilms are usually chronic due to the resilience of bacteria, to the innate and acquired immune system of the host and antibiotic therapy. This review article is written to evaluate and understand various aspects of biofilm-related infections in ENT.
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Artificial intelligence in medicine and health sciences p. 145
Parameshwar R Hegde, Manjunath Mala Shenoy
DOI:10.4103/amhs.amhs_315_20  
Artificial intelligence (AI) is being used in almost all aspects of life. The AI can assist medical consultants, primary health workers, and hospital administrators to understand analyze and interpret the medical data. The concepts such as data mining, image and signal processing, computer graphics, and machine learning are being utilized or being tried to implement in different health science areas such as dermatology, radiology, anesthesiology, psychiatry, surgery, and medical records . This article throws lights on some of the AI-related works that were carried out, especially in dermatology and radiology. This review has discussed its utility in other fields and the advantages such as faster execution, reliable results, and advantage over the manual process in certain aspects of healthcare. There are challenges, but further research and advances in technology in AI are likely to enormously benefit mankind.
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MEDICAL HISTORY Top

Journey of hearing health care in India: Historical perspectives p. 151
S Hemaraja Nayaka, Vijayalakshmi Subramaniam
DOI:10.4103/amhs.amhs_125_21  
The article presents a brief history on the evolution of Hearing Health Care in India. March 3rd, 2021 witnessed the launch of the world report on hearing by the World Health Organization as part of the observation of world hearing day with a special theme for 2021- “Hearing Care for all.” With the estimated prevalence rates of 5.67%–16.5% among all disabilities in India, hearing impairment impacts the country's overall development with a significant economic burden. Hearing health care received more attention during the 1960s with the establishment of specialized nodal centers in 1964 in India. India witnessed a spurt in the growth of hearing health care sector during the 1980s with the development and application of technology. There was an official launch of the trial of indigenous Cochlear Implants designed by the Defence Research and Development Organization of India in 2020. Currently, in India, there are both private and public domains in hearing care services with more than 6000 registered professionals in Audiology and Speech-Language Pathology. With the vast diversity of population and culture, limitation of centers to the urban area, and lack of trained professionals in hearing health care in rural areas, there is a need to reach to the unreached population with hearing problems.
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History of brain tumor surgery – A global and Indian perspective p. 156
P Shah Shreykumar, K Patel Biren, R Hirisave Darshan, C Vilanilam George, V Harihara Easwer
DOI:10.4103/amhs.amhs_129_21  
Brain tumor surgery has grown exponentially in the last century, aided by sophistication, globalization, and training initiatives. With progress in cerebral localization, antisepsis, anesthesia, and hemostasis, brain surgery took off in a cautious manner and soon gained momentum. The earliest brain tumor surgery based on cerebral localization dates back to the 19th century and is older than imaging techniques such as X-rays, computed tomography, or magnetic resonance imaging scans. In India, formal neurosurgery started in the post independence era in 1949 at CMC, Vellore and Chennai. With over 2000 practicing neurosurgeons today, India has contributed immensely to global advancements in brain tumor care. The advent of microneurosurgery in the late 60s has been a landmark in the history of brain tumor surgery, advancing safety profiles and elevating outcomes. Further on, advances in brain tumor imaging, surgical gadgetry (neuronavigation and intraoperative imaging), adjuvant therapy, and molecular tumor profiling have improved prognosis and survival. We examine the rich legacy of brain tumor surgery from a global and Indian perspective with five epochs of historical development – premodern (before 1879), incubational (1879–1919), modern (1919–1967), microsurgical (1967–1999), and new millennial (2000 onward). Several path-breaking advancements and an exciting future await brain tumor surgery, translating into superior surgical outcomes and quality of life.
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History of psychiatric rehabilitation in India Highly accessed article p. 163
Anil Kakunje, Rajesh Mithur, Sowmya Puthran, Anjana Joy, Shwetha Shetty
DOI:10.4103/amhs.amhs_127_21  
Psychiatric rehabilitation is a therapeutic approach in the management of mental illness which encourages people to recover from the illness and achieve their fullest potential through learning and environmental support. The method involves adapting the patient to his environment or modifies the environment to meet the patient's needs. The concept of psychiatric rehabilitation has a long history in India. In its difficult journey from colonial ages to post independence it has come across many hurdles. With the hard work of few pioneers, institutes and government reforms we have reached a significant stage today. We will discuss psychiatric rehabilitation from the Vedic period, ancient India, British rule, post-independence to the current status. Also covering the laws related to the field, achievements, people and Institutions involved. People say past is where we learn lesson and future is where we apply them. After this long fascinating journey through development of psychiatric rehabilitation in India, we can find that the development in this field is still inadequate. With multiple deficiencies in funding, infrastructure and work force this unique multidisciplinary field has a long way to go in this country..
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TEACHING IMAGES Top

“Deck chair sign” presenting in type 1 lepra reaction p. 171
Amina Asfiya, Manjunath Mala Shenoy, Vishal B Amin, Malcolm Pinto, Spandana Prakash Hegde, Ashmiya Abdul Razak
DOI:10.4103/amhs.amhs_100_21  
Deck chair sign (DCS) was first described in papuloerythroderma of Ofuji as the characteristic pattern of sparing of the skin folds which resembles the narrow strips of a deck chair. The sparing of skin folds includes areas such as the inguinal, axillary, sub-mammary, and flexural regions. Although first described in papuloerythroderma of Ofuji, it is also seen in other inflammatory dermatoses. We report a case of borderline leprosy in type 1 reaction who presented with the DCS involving the abdominal folds which to the best of our knowledge is the first of its kind.
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Rhino-Orbito-Cerebral Mucormycosis in COVID-19 p. 173
Harsh Suri, Deekshith Rajmohan, Vijayalakshmi Subramaniam
DOI:10.4103/amhs.amhs_126_21  
COVID-19 is associated with a wide range of opportunistic bacterial and fungal infections Mucormycosis is a fatal fungal infection mainly involving the nose, paranasal sinuses, orbit and brain with a high mortality rate.
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LETTER TO THE EDITOR Top

Telemental health – Is it “Virtually” perfect p. 175
Harpreet Singh Dhillon, Shibu Sasidharan
DOI:10.4103/amhs.amhs_97_21  
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SHORT COMMUNICATIONS Top

Exclusive outlook of a community health professional: A changed perspective p. 178
Divya Sethi, Manish Taywade
DOI:10.4103/amhs.amhs_35_21  
Community health nursing (CHN) is a vast area to learn. This article focuses on experiences during my master's in CHN and mostly about the understanding and depth of the subject. This field not only deals with the intellectual part but also lays equal importance to the relationship we share with the people in the community. This is the career where your collaborative skills for individuals, families, groups, and communities will help to make things happen. My perspective to look into this stream changed which all are sharing in this article. A sharing experience in words to encourage all those upcoming youths in health care professional who do not have interest in this field. The most important boon felt is the least mental exhaustion. This profession needs passionate health care providers who can be smart and innovative enough to bring a small change at a huge level. It will provide you satisfaction for your service to humanity. Surely, this story of the journey of learning will motivate you to opt for this beautiful stream.
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Evaluation of anti-microbial usage using world health organization-anatomical therapeutic chemical methodology in tertiary care teaching hospital of Central India: A cross-sectional study p. 181
Alok Singh, Ajaya Kumar Sahoo, Suryaprakash Dhaneria, Pugazhenthan Thangraju, Dhyuti Gupta
DOI:10.4103/amhs.amhs_299_20  
Antimicrobial agents are the most common group of drugs prescribed, especially in inpatients, as well as contribute highest in the drug-related expenses. To gather an overview regarding the utilization pattern of antimicrobials among hospitalized patients, this retrospective study was conducted for the patients admitted in 2019. The present study was conducted at All India Institute of Medical Sciences Raipur, wherein the 600 medical records (50*12) of different departments for the year 2019 were chosen randomly for evaluation. Information regarding the number of beds, occupancy, demography, strength, route, and amount of drug that prescribed was noted for each month. Antimicrobial utilization was performed using the World Health Organization Anatomical Therapeutic Chemical/Defined Daily Dose (DDD) methodology. Antimicrobial drugs which were prescribed at least 5% of patients were evaluated in detail, and their prescribed daily dose (PDD) and anti-microbial consumption index was calculated and compared with their defined-daily dose. Monthly consumption of antimicrobials was noted and summed to get consumption for the whole year. Most of the records encountered while collecting data were of female patients, with an overall mean age of 42.4 years. Moreover, the records were largely from the patients who were admitted in either of the surgical departments. For the in-patients with an average duration of hospitalization of 6.56 days, the mean number of antimicrobials prescribed per prescription was observed to be 1.41. Highest consumption units were of ceftriaxone in 2019. The PDD of azithromycin and piperacillin + tazobactam was different from their DDD. For majority of antimicrobials, the calculated PDD was close to their DDD. The consumption was noted to be disproportionately higher in the 4 months of 2019 (September–December). Moreover, ceftriaxone was found to be prescribed routinely in the clinical practice.
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