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   Table of Contents - Current issue
Coverpage
January-June 2022
Volume 10 | Issue 1
Page Nos. 1-145

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INVITED EDITORIALS  

Assessment of clinical skills – Is it time to revisit the role of the long case? Highly accessed article p. 1
Robert William Pickles
DOI:10.4103/amhs.amhs_99_22  
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Post-COVID-19: Looking back to move forward in health professions education Highly accessed article p. 3
Ajay Telang
DOI:10.4103/amhs.amhs_114_22  
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ORIGINAL ARTICLES Top

Telecollaboration: Telementorship for epilepsy surgery services in resource: Challenged lower-middle-income countries environs – A model and proof of concept p. 5
George Chandy Vilanilam, Mathew Abraham, Ashalatha Radhakrishnan, Ravish R Keni, Sunethra Senanayake, Deepal Attanayake, Jalal Uddin Muhammed Rumi, NA Sai Kiran, Ravi Gopal Varma, Forhad Hossain Chowdhury, Ramshekhar Menon, Bejoy Thomas, Easwer Hariharan Venkat
DOI:10.4103/amhs.amhs_105_22  
Background and Aim: Although 80% of people with epilepsy live in low and lower-middle-income countries (LMIC), epilepsy surgery (ES) has reached very few of its potential beneficiaries in these nations. This imbalance could be overcome by telecollaboration ES, aided by the burgeoning digital penetration in LMIC. We aimed to propose a telecollaboration-mentorship model for resource-limited LMIC environs to initiate, sustain, and expand ES centers. We also aimed to assess the model's feasibility and provide a proof of concept. Materials and Methods: Five mentee centers (level 3 epilepsy centers) across three LMIC under the mentorship of a tertiary comprehensive epilepsy care center (level 4) were part of the telecollaboration-mentorship model. This model was used for surgical candidacy selection, intraoperative surgical support, and postoperative outcome assessment at the mentee centers, using both asynchronous and synchronous telecollaboration exchanges. Results: Nineteen patients across five centers and three LMIC underwent ES as part of the telecollaboration-mentorship program from 2018 to 2021. Sixty-eight telemedicine exchanges (average 3.5/patient), 42 asynchronous (email, text message, multimedia message), and 26 synchronous (phone call, video call, video conference) were made in the preoperative, intraoperative, and postoperative period. Worthwhile seizure outcome (Engel Class I, II) was achieved in 17 patients (89.4%) at a mean duration of follow-up of 13.5 months (standard deviation 10.9). Conclusion: The telecollaboration-mentorship model is a feasible, sustainable scalable, and replicable mechanism to expand the outreach of surgical care in epilepsy, especially in resource-constrained LMIC environs. It holds the potential to overcome the “ES divide” between LMIC and high-income countries and reduce the surgical treatment gap with acceptable surgical outcomes.
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Indications and prescription pattern of electroconvulsive therapy: A 5-year retrospective medical record review of inpatients in a Tertiary Care Center p. 19
V Subbalakshmi Kota, V. V. Jagadeesh Settem, Khyati Roy
DOI:10.4103/amhs.amhs_267_21  
Background and Aim: With the advent of pharmacological agents, there were many changes in prescription patterns for modified electroconvulsive therapy (MECT) over time across the globe. This study aims to evaluate the main indications and prescription patterns of MECT in a tertiary care center. Materials and Methods: A retrospective medical record review was done in a tertiary care hospital after the institutional ethics committee approval, accessing the MECT records of 310 patients who underwent the procedure during the 5-year study period using a semi-structured pro forma. Results: In our file review, we found that the most common diagnosis, for which MECT was prescribed, was schizophrenia 146 cases (47%), and the common indication was augmentation of therapy/to speed up the rate of improvement. Depressive disorder was the primary diagnosis in 81 (26%) cases followed by mania in 46 (15%) cases. Among the major symptomatology which led to the primary use of MECT, suicidality accounted for 72 (23.2%) cases and catatonia in 34 (11%) cases. The mean number of MECTs during the course was 6.4 (2.5) in bipolar disorder, and in schizophrenia, it was 6.3 (2.3). A response rate of 85% was observed. Patient acceptability of MECT was good as only seven (2.3%) patients withdrew consent after initiation of treatment. Conclusion: Most common diagnosis, for which MECT was prescribed, was schizophrenia followed by depression. MECT was most commonly used as an augmentation strategy; however, in case of depression, it was used as first line of management. Response rate to MECT and acceptability were good in majority.
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Contracting infection among registered nurses working in coronavirus disease units: A qualitative case series p. 24
Seema Verma, Mahalingam Venkateshan, Asha P Shetty
DOI:10.4103/amhs.amhs_237_21  
Background and Aim: Nurses are the backbone of any health system, providing quality care to the patients in the Coronavirus disease-2019 (COVID-19) pandemic. They are working as frontline warriors in this pandemic and giving their services in such challenging and difficult situations. Since nurses have high rates of exposure they are at risk of getting the SARS CoV-2 infection. The aim of the study is to explore the contributing factors for (COVID-19) infection among nurses working in COVID-2019 units. Background: Nurses are the backbone of any health system, providing quality care to the patients in this COVID pandemic. They are working as a frontline warrior in this COVID-19 pandemic and giving their services in such difficult situations. Nurses have direct patient contact which makes them at risk of getting an infection. Materials and Methods: A qualitative case series design was carried out using conventional thematic analysis through an inductive approach to explore the factors. Fourteen nurses who have turned COVID-19 positive within 7 days of their last working exposure to COVID units were interviewed using the maximum variation purposive sampling technique. Consolidated Criteria for Reporting Qualitative Research guidelines were used to report the study. Results: Nurses reported prolonged exposure to COVID-19 patients; challenges in the patient care environment, biological disequilibrium, and exposure to a non-COVID zone were the major factors contributing factors. Conclusion: It is necessary to make policies on regulating the adequate manpower (both number and gender adequacy) in various COVID units, training of every nurse, rotation of COVID duties among various teams, regular health checkups of nurses, and smart monitoring of COVID units.
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Prevalence and risk factors associated with the development of severe pelvic organ prolapse in the University of Maiduguri teaching hospital, Nigeria p. 32
Ado Danazumi Geidam, Danladi Joseph Goje
DOI:10.4103/amhs.amhs_199_21  
Background and Aim: Pelvic organ prolapse (POP) is a common gynecological disorder that negatively affects women's quality of life, especially if it is severe. Its burden has increased because of increased in life expectancy. The aim of this study is to determine the prevalence, risk factors, and the factors associated with the development of severe POP in our environment. Materials and Methods: A retrospective review of cases of POP managed at the University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria, over 10 years (January 2010–December 2019). Information including sociodemographic and risk factors were obtained from the gynecological ward register, case files, and theater records using a pro forma designed for the study. Data analysis was done using the Statistical Package for the Social Sciences. Multinomial regression analysis was used to determine factors that are independently associated with severe POP. Results: The prevalence of POP is 1.8%. The majority of the patients, 73% (54/74) were grand multipara and 64.9% (48/74) were postmenopausal. Home delivery 83.8% (62/74) and difficult labor 73.0% (54/74) were found to be the common risk factors. In 41.9% (31/74) of the cases, the POP was severe. Multivariate analysis showed postmenopausal status OR 10.7 (95% CI 1.39–82.56, P = 0.023), heavy lifting OR 13.7 (95% CI 1.73–108.75, P = 0.013), age ≥50 years OR 22.4 (95% CI 1.26–397.08, P = 0.034), and being unmarried OR 16.2 (95% CI 2.22–118.64, P = 0.006) to be independently associated with severe POP. Conclusion: POP is not uncommon in our environment with about half of the patients having severe disease. Postmenopausal status, heavy lifting, age ≥50 years, and being unmarried were independently associated with severe POP.
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Effect of foam rolling of quadriceps, hamstring, and IT band on knee passive range of motion and physical function in patients with patellofemoral pain syndrome - Randomized controlled trial p. 37
Shlesha Maulik Vaidya
DOI:10.4103/amhs.amhs_305_20  
Background and Aim: There are several techniques for limited and painful knee flexion, but there are very few evidences about the effect of foam rolling in patients with patellofemoral pain syndrome (PFPS). A Randomized control study was designed to determine the effect of foam rolling as well as of stretching on knee passive range of motion (ROM) and functional status in patients with patellofemoral pain and to compare the effect with that of static stretching. Materials and Methods: Thirty patients diagnosed with chronic knee pain were randomized into two groups (experimental and controlled groups) with 15 subjects in each group. The experimental group received foam rolling exercises on quadriceps, hamstring, and IT band muscles. Passive stretching of all the abovementioned muscles was given to the controlled group. The intervention was given for 3 alternate days per week for 4 weeks per patient. Strengthening exercises were given to both the groups. Outcome measures were passive ROM and knee injury and osteoarthritis outcome score scale. Results: Within-group analysis (P < 0.05) showed that both the interventions had a significant effect on passive range of motion and physical function in patients with PFPS. However, intergroup analysis (P > 0.05) showed that there is no significant difference between the two groups in terms of outcome measure. Conclusion: Both foam rolling and conventional treatment (stretching) are effective in improving knee ROM and functional status in patients with PFPS. However, the myofascial release (foam rolling) treatment showed slightly better (however, not significant) clinical improvement in terms of improving knee ROM and functional status in patients with PFPS.
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Knowledge, beliefs, barriers, acceptance, and encouragement cues associated with COVID-19 vaccination among health-care workers in India p. 42
Varchasvi Mudgal, Vijay Niranjan, Pali Rastogi, Priyash Jain
DOI:10.4103/amhs.amhs_206_21  
Background and Aim: The coronavirus disease 2019 (COVID-19) is a viral pandemic that has infected millions of people that has caused the loss of human lives on an unprecedented scale. India being the second-most populous country in the world has been severely impacted by COVID-19. India began its vaccination drive on 16th January 2021 with a huge burden of 1.3 billion people to be vaccinated. Various factors play their role to predict the success or failure of a vaccination drive. The study was aimed to assess knowledge, belief, barriers, and acceptance of the COVID-19 vaccine among healthcare workers of a tertiary care centre. Materials and Methods: This cross-sectional study was done on healthcare workers (HCW) in February 2021. 120 HCWs participated in the study after providing their consent. Data were collected using a semi-structured proforma which included basic sociodemographic details, a questionnaire about acceptance, knowledge, beliefs, and barriers against the COVID-19 vaccine. Results: The mean age of the sample was found to be 36.5 years. Average knowledge, calculated by assessing the mean responses to all the questions pertaining to knowledge, was found to be 78%, while an average of 73.5% had positive beliefs regarding the vaccine for COVID-19. Concern over side effects and doubts over vaccine efficacy turned out to be the greatest barriers contributing to vaccine hesitancy. Acceptance rates of 87.4% were obtained across all the samples. Conclusion: Physician recommendation, acceptance by peers or family, and more studies to prove vaccine efficacy was widely acceptable cues to encourage vaccination. The study with its key findings could be a helpful aid in policymaking to boost India's vaccination drive.
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Square-stepping exercises versus conventional exercises on cognition and risk of fall in postmenopausal women: A randomized control trial p. 50
Roopa R Desai, Nikita Sunil Rathi, Tushar J Palekar
DOI:10.4103/amhs.amhs_197_21  
Background and Aim: Menopause is the cessation of menstruation resulting from the loss of ovarian follicular activity. During menopause, there is a loss of estrogen which diminishes protective reflexes, increment bone resorption, thus speeding up bone loss. This has been seen as significant factor for decline in postural balance. Functional imaging shows that estrogen also regulates neural movement during the execution of intellectual assignments. Thus, women attaining menopause complain of issues with memory. The aim of this study was to compare square-stepping exercises (SSEs) and conventional physiotherapy training on cognition and risk of fall. Materials and Methods: Thirty-five postmenopausal women, attained >5 years of menopause up to 65 years of age were included in the study and were randomly allocated into SSEs Group A (n = 18) and conventional physiotherapy training Group B (n = 17). Cognition was assessed by the Montreal Cognitive Assessment and balance was assessed by the Berg's Balance Scale at pre, post-2 weeks, and post-4 weeks of intervention. Results: Paired t-test and unpaired t-test were used for within and between-group analysis for Berg's Balance Scale. Wilcoxon test was used for within-group analysis and Mann–Whitney test was used for between-group analysis for Montreal Cognitive Assessment. The level of significance was determined by P < 0.05 at 95% confidence interval. Statistically significant improvements were seen in both groups (P < 0.05), whereas between-group analysis, there was no significant difference with P > 0.05. Conclusion: Both types of exercise protocol were equally effective in improving cognition and preventing the risk of fall in postmenopausal women.
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REVIEW ARTICLES Top

Strategies for promoting treatment adherence in schizophrenia p. 55
Nagesh B Pai, Shae-Leigh C Vella
DOI:10.4103/amhs.amhs_55_21  
Promoting treatment adherence in schizophrenia remains a primary challenge, with nonadherence resulting in a range of challenges across the biological, social, and psychological spectrum. While unknown nonadherence is a central cause of failed psychopharmacological treatment resulting in the initiation of more complex treatment regimens and higher antipsychotic doses, leading to a cycle of further unknown nonadherence and illness exacerbation. This article reviews the importance of treatment adherence including a discussion that can be utilized for promoting treatment adherence in schizophrenia. The following strategies are discussed; the importance of the therapeutic alliance, the use of motivational interviewing, nonpharmacological interventions, pharmacological interventions, and long-acting injectable (LAI) antipsychotics. The article concludes by restating the importance of treatment adherence in schizophrenia and making the patient aware of the consequences of nonadherence. Further, the role of LAI antipsychotics in adherence is highlighted.
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Neuropeptides in psychiatry p. 59
Vatsal Suchak, Shashwath Sathyanath, Anil Kakunje
DOI:10.4103/amhs.amhs_91_22  
In the past few decades, the apprehension of the human brain is on the rise. There has been vast research in the past decades which have contributed not just to structural form, but even to neuroanatomical, neurophysiological, and neurochemical correlates. In terms of neurochemistry, neurotransmitters already had a principal role. However, recently, attention is drawn to neuropeptides and their role in various physiological and pathological effects on the human body. The purpose of the present article is to review data in general about the relevance of neuropeptides in psychiatry. Our article highlights the findings of previous studies concerning the role of neuropeptides in various psychiatric disorders and its implications as a target for future treatment modalities.
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Gestational diabetes mellitus and preeclampsia: An increased risk to COVID-19? p. 68
Sayuri Padayachee, Nalini Govender, Thajasvarie Naicker
DOI:10.4103/amhs.amhs_288_21  
Both gestational diabetes and preeclampsia (PE) are characterized by anti-angiogenic response, endothelial injury, and dysfunction of the maternal vasculature. The ensuing high blood pressure emanates from a renin-angiotensin-system imbalance. The angiotensin-converting enzyme 2 (ACE2) receptor has been implicated in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) entry, and emerging data are in favor of PE development in pregnant women with COVID-19 infection. This review examines the effects of SARS-CoV-2 infection in pregnant women with gestational diabetes mellitus and/or preeclampsia (PE). An online search of all published literature was done through PubMed, Google Scholar, Medline complete, The Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science, using the MeSH terms “COVID-19,” “SARS-CoV-2,” “coronavirus,” “gestational diabetes,” “hyperglycemia” and “preeclampsia.” Only articles that were directly applicable to gestational diabetes and PE in COVID-19 was reviewed. We report that up-regulation of ACE2 leads to the overexpression of angiotensin II and AT1 receptor activity (Ang II/AT1). As the damaging effects of Ang II are intensified, SARS-CoV-2 stimulates ACE2 placental activity and Ang II-mediated sFlt-1 expression may contribute to the endothelial damage in SARS-CoV-2 infection through increasing Ang II/AT1 receptor interaction and/or hypoxia-inducible factor-1. This review provides an insight into the association between SARS-CoV-2 infection, gestational diabetes, and PE. As a result of the shared pathogenic traits, we assume that the anti-angiogenic milieu in high-risk pregnancies aggravates the susceptibility of a pregnant woman to high COVID-19 morbidity and mortality. In light of the growing burden of COVID-19 on global health-care systems, we highlight the urgency for appropriate management, treatment, and educational strategies to effectively control glycemic index in pregnancy.
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CASE REPORTS Top

Cribriform hyperplasia of epididymis: A diagnostic pitfall for surgical pathologists p. 76
Savithri Ravindra, CP Manjula
DOI:10.4103/amhs.amhs_260_21  
Epididymal tubules are lined by tall columnar ciliated cells with central round lumina. Epididymis exhibits wide variations in histology, having very little clinical significance. However, they pose a diagnostic challenge for the reporting pathologists. Cribriform hyperplasia of the epididymis is reported in animals such as rats, cats, dogs, mice, and bulls, in addition to men. We report an incidental finding of cribriform hyperplasia of the epididymis in a specimen of torsion testis.
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Immunoglobulin G4-related ophthalmic disease and aortitis p. 78
Mingshu Cai, Demetrius Voutnis, Balakrishnan R Nair
DOI:10.4103/amhs.amhs_71_22  
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated inflammatory condition which is a relatively new clinical entity that can have various clinical manifestations. Our understanding of its pathogenesis is rapidly evolving and many theories have been proposed. The determinants of clinical phenotypes in various populations remain unclear. We report a case of IgG4-RD involving the extraocular muscles and aorta in an elderly male who improved with oral prednisolone. We also provided an overview of the current literature on the disease.
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Giant sacral xanthoma in familial hypercholesterolemia p. 81
Abha Singh, Neha Aggarwal, Sunayana Misra
DOI:10.4103/amhs.amhs_215_21  
A 28-year-old male patient presented with multiple large, superficial, nodular masses in his elbows, buttocks, knees, Achilles tendons, feet, shoulders, and hands along with small xanthomatous lesions on the face, inner epicanthal region; largest mass being in the sacral region measuring 15 cm × 12 cm × 8 cm. The patient also presented with an elevated level of low-density lipoprotein cholesterol and was diagnosed with familial hypercholesterolemia (FH) presenting with multiple xanthomas. Local surgical excision was performed to remove the massive xanthoma from the sacrum, histopathology of which showed sheets of foamy lipid-laden histiocytes dissecting through the dermis and subcutaneous fat. The presence of long standing and/or multiple xanthomas often indicates severe and long-term FH. A thorough systemic workup is needed for such patients, especially to rule out cardiovascular complications so that lipid-lowering agents and dietary modifications can be initiated early on. We present the case of a young male patient with FH presenting with multiple large tuberous xanthomas all over the body.
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A case of isolated wide pulp chambers in second premolars along with enamel hypoplasia - Dentinogenesis imperfecta - A diagnostic dilemma p. 84
Vela D Desai
DOI:10.4103/amhs.amhs_286_21  
Dentinogenesis Imperfecta is a rare hereditary dentin developmental disorder that affects both primary and permanent dentition. It is characterized by discolored and translucent teeth ranging from gray to brownish-blue/amber. The enamel may split readily from the dentin when subjected to occlusal stress. Radiographically, there is evidence of cervical construction, short root, and pulp chambers, whereas the root canals are smaller than normal or completely obliterated. Here, the author presents the case of a 28-year-old male with generalized enamel hypoplasia and isolated distinctly translucent second premolars in three quadrants along with root changes. Unlike the classical representation of generalized involvement of the teeth, this case differs and needs to be documented. A thorough history, careful clinical, and radiographic observation are the key to early diagnosis and management of such a rare entity.
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Primary low-grade extrauterine endometrial stromal sarcoma with sex cord elements involving the omentum: A case report with review of literature p. 87
Chikkanaganna P Manjula, V Suguna Beluru, B. K. Hanumantha Raju, Naina Mary Simon
DOI:10.4103/amhs.amhs_6_22  
Endometrial stromal sarcoma (ESS) is a rare mesenchymal neoplasm, accounting for 0.2% of all uterine malignancies. They also occur in extrauterine locations such as ovaries, rectal wall, pelvic peritoneum, and vagina, where it is associated with endometriosis. Here, we present a case of extrauterine ESS of the omentum, which resembled a urachal cyst on imaging studies. Intraoperatively, the bladder was normal, and multiple solid cystic nodules were noted in the omentum. Histopathological examination revealed features of spindle cell neoplasm. Immunohistochemistry helped in arriving at the final diagnosis of low-grade endometrial stromal sarcoma with sex cord-like elements. However, extensive sampling did not reveal endometriotic foci. Further investigations to search for a primary lesion in the female genital tract were futile, and patient remained asymptomatic 2 years after surgery. Like in uterine ESS, surgery remains the mainstay of treatment.
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Ancient schwannoma: A rare case report in a 10-year-old child at an unusual site p. 91
Sarita Asotra, Gauri Nakra, Vineet Aggarwal
DOI:10.4103/amhs.amhs_39_22  
Schwannoma is a relatively uncommon, slow-growing, benign tumor that is derived apparently from the Schwann cells lining the nerve sheath. Its most common locations are the flexor surfaces of the extremities, neck, mediastinum, retroperitoneum, posterior spinal roots, and cerebellopontine angle, the occurrence on the lower limbs accounts for 1% of all cases. Ancient schwannoma is considered as a variant of schwannoma, comprising about 10% of all schwannomas. The long-standing schwannoma attributes to degenerative changes and is termed “ancient” schwannoma. We report a rare case of ancient schwannoma of the calf region in a 10-year-old child.
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True talon cusp associated with cleft lip and palate: A rare case report p. 95
Bhavana Inderchand, Bhavna Dave, Prateek Kariya, Lipsa Shah
DOI:10.4103/amhs.amhs_49_22  
Talon cusp is a rare dental anomaly in which a cusp-like structure projects from the cingulum area or cementoenamel junction of the maxillary or mandibular anterior teeth. This unusual cusp resembles the talon of an eagle. It can be found in both the primary and permanent dentitions. A comprehensive literature study reveals that only 37 examples of talon cusps in the primary dentition have been described, with only 3 cases reporting this anomaly on the primary maxillary lateral incisor. We present a male patient with cleft lip and palate having primary lateral incisor talon cusp. The clinical implications of this anomaly, as well as the dispute over its etiology, are reviewed.
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Alveolar soft part sarcoma: A rare diagnosis p. 99
Sarita Asotra, Ankita Sharma, Lexmi Vijayamohanan
DOI:10.4103/amhs.amhs_247_21  
Alveolar soft part sarcoma (ASPS) is an extremely rare sarcoma. It is a malignant soft tissue tumor that arises in the muscles, commonly seen in the age group between 15 and 35 years of age with slight increased predilection in young women. Clinically, it presents as a painless, slow-growing lesion principally around the lower limb or limb–girdle with a propensity for recurrence and metastasis. Clinically, it can be confused with a hemangioma or arteriovenous malformations. We report a case of ASPS in a 36-year-old female with pain and swelling over the anterior aspect of the right thigh without any features of metastasis, who has been treated with excision of the symptomatic lesion followed by chemotherapy.
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Gastrointestinal stromal tumor of jejunum presenting as a pelvic mass: A rare case report and review of literature p. 102
Banwari Lal Bairwa
DOI:10.4103/amhs.amhs_306_21  
Gastrointestinal stromal tumors (GISTs) are mesenchymal in origin and quite rare in the gastrointestinal system. Jejunal GISTs are extremely rare, approximately 0.1%–3% of all gastrointestinal (GI) tumors. The stomach is the most common site while small intestine (usually duodenum) is the second most common site in the GI tract. The clinical manifestations of GISTs range from asymptomatic to mild abdominal pain, mass, mechanical obstruction, and intestinal hemorrhage as well as perforation. Final diagnosis is made by combined histopathological examination (HPE) and immunohistochemistry (IHC) examination of resected specimen. Here, we present the rare case of jejunal GIST as pelvis mass in 48-year-old gentleman. The patient presented with pain abdomen and heaviness in lower abdomen. On contrast-enhanced computed tomography abdomen, diagnosis of pelvic mass was made. Exploratory laparotomy was done. A solid mass measuring 6 cm × 8 cm arising from antimesenteric border of proximal jejunum found into pelvic cavity. Jejunal segment with tumor resected and anastomosis done. HPE and IHC confirmed intermediate grade GIST of the jejunum. Imatinib mesylate was initiated due to probability of disease recurrence (24%). Carefully complete surgical excision and adjuvant therapy with imatinib is the cornerstone of intermediate to high degree GISTs.
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Effect of hand arm bimanual intensive therapy on upper limb function in young stroke p. 105
Shradha Shah, Ashwini Kale, Vibhuti Tiwari
DOI:10.4103/amhs.amhs_36_22  
Young stroke comprises of 10%–15% of all stroke patients. However, compared with stroke in older adults, stroke in the young have disproportionately large economic impact by leaving victims disabled before their most productive years. Stroke leads to chronic functional impairments of upper limb and hand. Hence, we aimed to explore the effect of hand-arm bimanual intensive training (HABIT) on the recovery of upper limb function in young stroke patient. The study is a case of a 30-year-old male patient admitted to the outpatient department with right-sided hemiplegia and sensory aphasia. The patient was engaged in HABIT for 2 h a day for a continuous duration of 3 months and the training showed remarkable improvement in Fugl-Meyer assessment-upper extremity and Motor Activity Log scores. The results suggest that HABIT appears to be efficacious in improving upper limb function in young stroke.
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Endometrial clear cell carcinoma with leiomyoma and adenomyosis in a postmenopausal lady - A case report with review p. 109
Pranita Mohanty, Anima Hota, Ajit S Mohapatra, T Govardhan
DOI:10.4103/amhs.amhs_224_21  
Endometrial cancer (EC) is the 6th most common cancer in women and endometrial clear cell carcinoma (CCC) comprised 2% of it. The association of uterine leiomyoma (UL) and adenomyosis (AM) with endometrioid variant of EC is well established, especially in postmenopausal women. Although the pathogenesis is still debatable, their presence with CCC is extremely uncommon. Moreover, the relation between CCC, AM, and UL is not yet validated because of limited data. Here, we report such a case of CCA associated with leiomyoma and AM in a 58-year-old postmenopausal Indian woman who presented with complaints of vaginal bleeding and watery discharge. She underwent hysterectomy and histopathology revealed CCC with multiple ULs and foci of AM, but there was no evidence of tumor transitioning from adenomyotic foci. This case study was aimed to evaluate if there really exists any clinicopathological correlation, tumor progression, and prognostic significance or simply this was a coexistence of all three entities.
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SPECIAL ARTICLES Top

Big data in clinical sciences-value, impact, and fallacies p. 112
Liya Abraham, George C Vilanilam
DOI:10.4103/amhs.amhs_296_21  
The ever-burgeoning healthcare enigmata may find their answers in Big Data. When data cannot be collected, curated, managed, and processed by commonly used software tools within a requisite time frame, they are referred to as Big Data. We put forth a narrative review on the evolution and spectrum of the clinical applications of Big Data across medical and surgical sciences, evaluating their impact and cautioning about their potential fallibilities. There is an explosion of health care data generated as a byproduct of clinical care and research in the digital information era. The challenge lies in converting these unstructured datasets into clinical wisdom and practice-defining insights. Big data provides information on the quality of health care, resource utilization, public health deficiencies, research hypothesis creation, and overall holds the potential to revolutionize clinical sciences. Several fallacies of big data like data inaccuracies, privacy, confidentiality, proprietary concerns, and caveats in data analysis algorithms may misdirect the lessons from big data.
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Problematic internet use among adolescents and the impact of COVID-19 pandemic on mental health: An overview p. 118
Avinash Joe, A. T Safeekh, S Malarmathi
DOI:10.4103/amhs.amhs_118_22  
Adolescents are a vulnerable population to problematic Internet use. Although it is considered a behavioral addiction, there is a lack of unified definition and criteria, and the current models are derived from substance dependence and their validity is yet to be established. At present, the Internet has become an integral part of everyday life and further explication is needed on what constitutes problematic Internet use. Unrealistic expectations, the need for excitement, risky behaviors, addictive temptations, and late bedtime in adolescents can lead to addiction. The Internet provides anonymity and at the same time a sense of belongingness and social acceptability to them. The prevalence of Internet addiction (IA) varies across cultures and countries. More than 90% of students stayed at home due to coronavirus disease 2019 pandemic and the technology became necessary to access education and gather information. Flexible daily routine, unlimited Internet access, less parental interference, boredom, and the natural tendency of this age group to use the Internet have led to an increase in IA. Unsupervised screen time and Internet access, lack of identification of at-risk individuals, lack of appropriate interventional strategies, and lack of awareness of mental health have made the scenario more complex, which is often overlooked. Treatment of problematic Internet use is an evolving field and the traditional model of abstinence is not feasible for the management of IA. Cognitive behavioral approaches are promising when combined with other treatments. Psychotropic drugs are found to be effective on comorbid conditions, which, in turn, can help in mitigating the symptoms of IA.
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MEDICAL HISTORY Top

History of trepanation and the Indian connection p. 126
Ashwin Pai, Girish Menon
DOI:10.4103/amhs.amhs_96_22  
Trepanation refers to scraping, cutting, or drilling of an opening (or openings) into the cranium and is believed to be one of the earliest surgeries performed on and by man. Fossil evidence of trephined skulls has been found in separate continents throughout ancient history and such discoveries continue to be made even from geographic areas or time periods from which the practice was not previously known. Equally interesting is the evolution of this practice from ancient times to the modern neurosurgical era. This review seeks to define a framework around the history of cranial trepanation and tries to understand the various different interpretations of the origin and etiology of the art of cranial trepanation, starting in the prehistoric era. The contribution of ancient Indian medicine toward the progress of this branch of surgical expertise is also discussed.
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TEACHING IMAGES Top

Fordyce spots of buccal mucosa p. 132
Soumyajit Das, Satvinder Singh Bakshi
DOI:10.4103/amhs.amhs_276_21  
Fordyce spots, also known as Fordyce glands, are enlarged ectopic sebaceous glands. The diagnosis is mainly clinical. These lesions appear as asymptomatic, isolated or scattered, grouped minute (pinhead-sized, “dust-like”), creamy yellow, discrete papules. The clinical significance Fordyce spots over the oral mucosa are reported rarely and is known to have an array of clinical mimics such as malignancies of oral mucosa. They are also often mistaken for a fungal infection or lichen planus papules. Fordyce spots should be differentiated from milia and sebaceous hyperplasia. These pseudo lesions of the oral mucosa do not require any intervention apart from reassurance in view of the benign nature of the condition.
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LETTER TO THE EDITOR Top

Envisaging the planning and implementation of diversity education as an integral component of medical curriculum p. 134
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/amhs.amhs_300_20  
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SHORT COMMUNICATIONS Top

Career intentions, choices, and motivation of undergraduate dental students toward dentistry p. 136
Maryam Siddiqui, Amina Sultan, Abhishek Mehta, Akanksha Juneja
DOI:10.4103/amhs.amhs_61_22  
Students studying healthcare related professional courses like dentistry are future role models and leaders of our society. It is imperative that only interested and motivated candidates join dental profession because of amount of time and resources involved. The aims of this survey were to study the intentions, motivation, and selection of dentistry as a profession by the dental students. Data was collected through a self-administered questionnaire survey was conducted among 500 undergraduate dental students and interns of two government (n = 250) and one private dental college (n = 250) located in National Capital Region (NCR) of Delhi, India. Majority of respondents were females and were residing in urban area. Students of government dental college were significantly more inclined to continue with their profession. Oral and maxillofacial surgery was the most sought after branch of dentistry to pursue post-graduation by the study participants. This study highlighted some important factors for selecting and continuing dentistry as a profession. Majority of students indicated that dentistry was not their first choice of career. There is a need to educate students about their preferred career choices and its future aspects before joining the course.
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The effectiveness of mind mapping as a learning strategy in promoting information retrieval among II MBBS students p. 141
Tejeswini Vaddatti, B Chaitra, Pretesh Kiran, Inuganti V Renuka, Kasula Laxmi, Ramya Potti
DOI:10.4103/amhs.amhs_120_21  
In medical curriculum, shift to self-directed student-centered learning is required. The mind maps are multisensory tools that help students organize, integrate, and retain information. This study was conducted to evaluate the effectiveness of mind mapping in information retrieval and assess the perceptions of II MBBS students. An interventional crossover study conducted on II MBBS students who were divided into two equal groups. One group learned by conventional reading and the other group by mind mapping. The groups were swapped for the second topic. Knowledge gained assessed before the study, immediately after the session and after 1 month. The scores analyzed by independent t-test with P < 0.05 considered significant. Effect size was calculated and Cohen's d scores equal to 0.2 considered small effect, while 0.5 as moderate and 0.8 as large effect. A validated questionnaire used to assess perceptions of students. This study showed that the knowledge gained in immediate posttest and the information retrieved after 1 month for both topics were higher with mind mapping than traditional learning. Effect size also showed that mind mapping as more effective learning strategy over conventional reading. The majority of the students were positive toward mind mapping. It was evident from this study that the gain in knowledge and information retrieval is better by mind mapping. Students perceived mind mapping as a useful and effective learning strategy, which can be implemented as a routine method.
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