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   Table of Contents - Current issue
Coverpage
July-December 2021
Volume 9 | Issue 2
Page Nos. 187-370

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EDITORIAL  

Human well-being, healthy ageing, and syndemics: Inseparable lessons for a sustainable future Highly accessed article p. 187
Bhaskara P Shelley
DOI:10.4103/amhs.amhs_287_21  
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INVITED EDITORIAL Top

Interventions for Improving medical students' interpersonal communication in medical consultations; Considering the evidence in the context of the COVID-19 pandemic Highly accessed article p. 193
Conor Gilligan
DOI:10.4103/amhs.amhs_261_21  
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ORIGINAL ARTICLES Top

Olfactory and Taste Dysfunction and Its Correlation with Viral Load on Reverse Transcription-Polymerase Chain Reaction among COVID-19 Patients: A Comparative Study from Tribal India p. 196
Izhar Khan, Vikas Gupta, Abhishek Gaur, Sanjay Kumar Shukla, Shewtank Goel
DOI:10.4103/amhs.amhs_177_21  
Background and Aim: Coronavirus disease-19 (COVID-19) diagnosis is confirmed by detection of viral nucleic acid by reverse transcription-polymerase chain reaction (RT-PCR), in the upper respiratory samples through nasopharyngeal or oropharyngeal swabs or sputum. The present study compared the means of viral load on RT-PCR among COVID-19 patients with and without olfactory and taste dysfunction (OTD) admitted to dedicate COVID-19 hospital (DCH). Materials and Methods: This cross-sectional comparative study was conducted after IEC approval in DCH Shahdol for a period of 4 months, and RT-PCR positive patients were divided into two groups, Group A (with OTD) and Group B (with no OTD) using chemosensitive psychophysical test. The sample size was calculated as 160 (Group A = 80 and Group B = 80) by using sample size formula: (σ21+ σ22/K) (z1− α/2 + z1− β)22. During data analysis, an association was significant for P < 0.05. Results: Among total subjects (n = 160), 129 subjects reported the history of fever or malaise followed by cough among 55 subjects. It was observed that from Group A and Group B, 38.7% and 36.2% of subjects stayed in hospital for <5 days, respectively. The differences in the mean Ct values, of all the three genes, between Group A and Group B were found to be statistically significant (P < 0.05). Conclusion: The loss of smell and taste are important symptoms in COVID-19 patients. It need to be carefully assessed even in asymptomatic patients to reduce the further transmission of the virus in the community. This may help in further reducing the transmission of the virus in the community.
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Addressing violence against doctors: Using ADDIE framework for designing, implementation, and evaluation of the effectiveness of a therapeutic communication skills training module Highly accessed article p. 202
Aditi Chaudhuri, Thomas V Chacko
DOI:10.4103/amhs.amhs_265_21  
Background and Aim: Lack of formal training and assessment in communication skills in India combined with suboptimal doctor-patient ratio leave them with little time, and therefore, patients dissatisfied with doctor's therapeutic communication and often lead to violence against doctors. There is thus an urgent need for health-care providers and their trainers to be formally and systematically trained and assessed. Materials and Methods: Descriptive study (describing the process of training module development using ADDIE Framework) and an educational intervention study (using the Kirkpatrick model for measuring effectiveness of the training). Module's contents were identified through the literature search followed by content, context, and construct validation by communication and subject experts. Modular 8 hour training was implemented for 50 participants in two batches on two different days. Results: In the immediate postintervention feedback, all participants agreed that the training will be beneficial to them in real life and they expressed confidence in teaching communication skills to their students, particularly in breaking bad news and resolving doctor-patient conflicts in the real life. Effectiveness of intervention is reflected by gain in knowledge scores from 6.84 (at pretraining) to 10.76 (immediate posttraining) and sustained at 10.8 (at 3 months posttraining). The impact of the training on their communication skills is also demonstrated by the skill scores showing incremental increase from 12.4 (at pretraining) to 19.16 (immediate posttraining) and then 21.8 (at 3 months posttraining) which is statistically significant (P < 0.05). Conclusion: The training was effective, accepted well by trainees and has been institutionalised.
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Detection and Genotyping of Human Papillomavirus among HIV-Infected Women from Belagavi: A District Place from the Southwest Indian State of Karnataka p. 209
Vinay Pala, Chidanand Patil, Mahantesh B Nagmoti, Anita Dalal, Arati Mane
DOI:10.4103/amhs.amhs_4_21  
Background and Aim: Human papillomavirus (HPV) infection is the established cause of cervical cancer. There is sparse literature with regard to HPV infection from the southern Belagavi region of India. This study was aimed to detect the HPV genotype distribution, the associated risk factors, and relation with cervical precancerous lesions among HIV-infected women from Belagavi, India. Materials and Methods: In this prospective observational study, a total of 214 HIV-infected women aged 18–45 years were recruited. Cervical samples were subjected to the Roche Linear Array assay for HPV detection and genotyping. Cervical status was determined by composite assessment of cytology, colposcopy, and histology. Data were analyzed using Software R version 3.6.0. Results: Of the 197/214 women with the adequate cervical sample, 86 (43.6%) were HPV positive, and 111 (56.3%) were HPV negative cases. A total of 132 (69.1%) women had normal cervical status, 26 (13.6%) had CIN1 lesions, 1 (0.5%) had CIN2 lesions, and 12 (6.3%) had CIN3 lesions. Single HPV infection was detected in 47 (54.6%) women and multiple (≥2) HPV genotypes were detected in 39 (45.3%). The HPV genotypes detected in descending order of frequency were HPV 16, HPV 33, HPV 35, HPV 52, and HPV 58. Ever pregnant (parous) women were 4.47 more likely to have HPV infection. Conclusion: A high prevalence of HPV infection, with a wide diversity of HPV genotypes and a greater prevalence of HPV 16 among HIV-positive women from Belagavi, India, was observed. Parity was the independent factor associated with HPV detection.
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Evaluation of normal range of maximum mouth opening for Pune Maharashtra adult population p. 216
Vaishali Vasant Koranne, Samir Achyut Joshi, Amod Pramod Patankar, Swapna Amod Patankar
DOI:10.4103/amhs.amhs_260_20  
Background and Aim: Maximal mouth opening (MMO) is used as a marker of masticatory pathology. MMO varies with age, height, gender, and race. The current study is an attempt to calculate the normal range of maximum mouth opening in an adult Pune Maharashtra population. Materials and Methods: A total of 800 individuals, 400 males and 400 females, in the age group of 18–60 years attending outpatient department in Bharati Dental College and Hospital, Pune were randomly selected and divided into four groups according to their age ranges. In addition to the basic demographic data, MMO was measured in these individuals. The subjects were asked to open their mouth maximally until no further opening was possible. The distance from the incisal edge of the upper incisor teeth to the incisal edge of the lower incisor teeth was measured using a calibrated fiber ruler. Statistical analysis was performed. Results: The mean MMO for males was 50.58 (standard deviation [SD] ± 2.16) mm (Range 37–56 mm) and for females was 48.29 (SD ± 3.12) mm (Range 36–53 mm). There was a statistically significant difference between the mouth opening of male and female in all the age groups with P < 0.05 A linear relationship was observed between the mouth opening and age in both males and females and the mouth opening decreased as the age increased. In the age group of 18–29 years, the mean MMO was 54.34 (SD ± 1.84) mm. The range was 39–56 mm for males and 51.63 (SD ± 2.33) mm. with range 38–53 mm for females. In the age group of 30–39 years, the mean MMO was 52.09 (SD ± 1.72) (range 38–53 mm) and 50.07 (SD ± 2.09) (range 38–51 mm) for males and females, respectively. For the age group 40–49 years, the mean MMO was 48.94 (SD ± 1.66) mm (range 39–54 mm) for males and 46.73 (SD ± 2.84) mm (range 38–50 mm) for females. In the age group of 50–60 years, the corresponding values for males and females were 46.98 (SD ± 2.04) (range 36–50 mm) and 44.76 (SD ± 2.59) mm (range 36–49 mm). Conclusion: The MMO range for different age groups is established for normal adult Pune Maharashtra population.
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Hematological Manifestations of COVID-19 and its correlation with outcome – A retrospective study p. 220
Bobby Abraham, Shivkumar Gopalakrishnan, Sangeetha Kandasamy
DOI:10.4103/amhs.amhs_171_21  
Background and Aim: The objective was to study the hematological manifestations of disease caused by novel coronavirus 2019 (COVID-19) and evaluate the association between absolute neutrophil count (ANC), absolute lymphocyte count (ALC), neutrophil–lymphocyte ratio (NLR), platelet–lymphocyte ratio, total count, and outcome. Materials and Methods: A hospital-based retrospective study was conducted on COVID-19 adult inpatients admitted between March and August 2020. The patients were classified into three groups based on outcome as mild COVID/uneventful recovery (Group 1), severe COVID/recovered (Group 2), and death (Group 3). Their clinical profile and hematological parameters were compared using both univariate and multivariate analyses. Binary and multinomial logistic regression analyses were used to analyze the chances of survival or death with respect to the variable studied. Results: The median age of nonsurvivors was 62.5 years. For unit increase in age, there were 1.03 times higher chances of severe disease (P = 0.013) and 1.04 times chances of death (P = 0.028). For every 1000/μl increase of ANC, the odds of developing severe disease rose by 1.85 (P = 0.270). For every 1000/μl increase in ALC, there were 94.7% lesser chances of death (P = 0.006) and 51.1% lesser chances of severe disease (P = 0.033). The odds of developing severe disease was 1.16 times per unit rise in NLR and the OR for death was 1.27 (P = 0.053). Conclusion: Advanced age, presence of lymphocytopenia, increased neutrophil count, and elevated NLR were associated with severe disease and high mortality due to COVID-19. Lymphocytopenia and age were the strongest predictors of severe disease and death.
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Association between phosphoglucomutase-1 gene y420h polymorphism and type 2 diabetes mellitus: A Case-control study p. 225
KS Praveen Kumar, Prabhakar Kamarthy, Sharath Balakrishna, MS Manu, Sureshkumar Ramaswamy
DOI:10.4103/amhs.amhs_94_21  
Background and Aim: Phosphoglucomutase 1 (PGM1) is an enzyme that catalyzes the key step that links glycogen synthesis with glucose metabolism. Single nucleotide polymorphism (SNP) (rs11208257) is a functional variant in the PGM1 gene that codes for this enzyme. Impaired glycogen synthesis is linked to type 2 diabetes mellitus (T2DM). Whether this translates into an association between SNP rs11208257 and T2DM is not known. We evaluated the association between the PGM1 gene variant (Y420H; c. 1258 T > C; rs11208257) and T2DM. Materials and Methods: We carried out a case-control study by including 225 T2DM patients and 225 age and gender-matched healthy controls. SNP rs11208257 was genotyped by a polymerase chain reaction-restriction fragment length polymorphism method. Results: Minor allele frequency was 45% in T2DM patients and 30% in healthy individuals (P = 1.4 × 10-2; Odds ratio = 1.6). The genetic model analysis showed the highest odds ratio for the additive effect of the risk allele. Conclusions: The results show that SNP rs11208257 in the PGM1 gene is associated with the risk of T2DM. This association underlines the importance of the glycogen pathway in the pathophysiology of T2DM.
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The lacey assessment of preterm infants: Predictive validity in early infancy p. 229
Thanooja Naushad, Meena Natarajan
DOI:10.4103/amhs.amhs_138_21  
Background and Aim: The Lacey Assessment of Preterm Infants (LAPI) is reported to have low sensitivity but high specificity to predict neurological function. The study objective was to find the predictive validity of the LAPI of preterm infants (LAPIs) to predict neuromotor outcomes of infants born preterm at the corrected age of 3–4 months. Materials and Methods: In this prospective cohort study, infants born below 35 weeks' gestation were assessed using the LAPI before their discharge from the neonatal intensive care unit. Data were collected from Latifa Hospital, Dubai. Outcome assessment was done between 3 and 4 months corrected age using Prechtl's general movement assessment (GMA) and the Test of infant motor performance (TIMP). Results: A total of 125 infants completed the tests (45.6% females); their mean gestational age was 30.28 (standard deviation 2.59) weeks. LAPI showed 87.50% sensitivity (95% confidence interval [CI] =47.35%–99.68%), 96.58% specificity (95% CI = 91.48%–99.06%), and 99.12% negative predictive value (95% CI = 94.75%–99.86%) in predicting fidgety movements in the GMA. The specificity and negative predictive value of the LAPI to predict the motor outcome in the TIMP was 98.06% (95% CI = 93.16%–99.76%) and 88.60% (95% CI = 84.57%–91.67%) respectively whereas sensitivity was 40.91% (95% CI = 20.71%–63.65%). Developmental score in the LAPI showed a weak correlation (P = 0.02, r = 0.20) with the TIMP score. Conclusion: The results suggest that the LAPI can be used to reliably predict neurological function for infants born preterm at 3–4 months corrected age. LAPI can be used as a discharge assessment tool in neonatal units to identify candidates for early intervention services.
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Antiproliferative and apoptosis-inducing properties of selected medicinal plants of Assam, India p. 236
Mritunjoy Kumar Roy, Ananta Swargiary, Akalesh Kumar Verma
DOI:10.4103/amhs.amhs_210_21  
Background and Aim: Ethnomedicine is a common practice of disease treatment among tribal communities of India. The present study investigated the antiproliferative and apoptosis-inducing activities of seven medicinal plants traditionally used by the Bodo tribe of Assam. Materials and Methods: The phytochemical and antioxidant activities of plants were investigated following standard protocols. Antiproliferative and apoptosis-inducing activities were evaluated in Dalton's lymphoma (DL) cells. Plant extract-treated cells were stained with acridine orange/ethidium bromide solutions to see the antiproliferative and apoptosis-inducing properties of plants. Results: The study showed high phenolic and flavonoid contents in all the plants. Phlogacanthus tubiflorus displayed the strongest antioxidant activity. Plant extracts showed concentration-dependent antiproliferative activity. Hydrocotyle sibthorpioides showed the strongest antiproliferative and apoptosis-inducing activities. DL cells treated with plant extracts displayed apoptotic features. Furthermore, docking study revealed 2-methyl-5-(1-adamantyl) pentan the best binding affinity with anti-apoptotic proteins. Conclusion: The present study revealed potential antiproliferative and apoptosis-inducing properties in H. sibthorpioides. However, further study needs to be carried out to investigate bioactive compounds responsible for their pharmacological properties.
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Road rage and driver anger-an Indian perspective p. 244
Varchasvi Mudgal, Vijay Niranjan, Pali Rastogi, Priyash Jain
DOI:10.4103/amhs.amhs_170_21  
Background and Aim: Road rage is a term often used to describe driving usually extreme in nature. There seems to be a multifactorial relationship between the situational characteristics of an anger-provoking road situation and the consequent feelings of anger and road behavior. We focus on the dynamics of road rage and the current study pioneers to understand road rage and its correlates in Indian drivers. Materials and Methods: An internet based cross-sectional study was done involving 282 participants in India. The 33-item Driving Anger Scale was used to measure driving anger. Data were collected between January 2019 to April 2019. Anger assessment was done using the Deffenbacher Driver Anger Scale. Results: Significant driver anger exists among Indian drivers; with males reporting higher driver anger for situations involving police presence, while females reporting higher anger for hostile gestures and discourtesy situations, two-wheeler drivers displayed higher anger in illegal and slow driving situations. Conclusion: Our study reports high anger among Indian drivers and indicate that road rage is multifactorial. Stringent checks must be placed as a prerequisite for acquiring a driving license and the devils of road rage must be curbed through intensive awareness campaigns specific to vehicle type, car-pool incentivization, and public participation.
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Hematological parameters as a risk for developing metabolic syndrome in the adult population of Kashmir (India) p. 252
Sumaira Wazir, Mohammad Afzal Zargar, Muhammad Muzamil, Fouzia Rashid
DOI:10.4103/amhs.amhs_62_21  
Background and Aim: Various studies have reported an association of hematological parameters such as red blood cell (RBC), hemoglobin (Hb), hematocrit (HCT), white blood cell (WBC), and platelets with metabolic syndrome (MS) in many parts of the world. However, the association of these parameters with MS in terms of gender has not been elucidated particularly in the ethnic population of northern India. Thus, the study aimed at exploring the association of these hematological parameters with MS stratified by gender in the Kashmiri region of India. Materials and Methods: A total of 400 people were enrolled in this study consisting of 204 men and 196 women. MS was diagnosed by the International Diabetes Federation criteria. For statistical analysis, SPSS software and Pearson Partial coefficient analysis were used. Results: The prevalence of MS was (50.6% vs. 20.6%) in women and men. WBC and platelets were significantly increased in men with MS (P ≤ 0.05). RBC, Hb, HCT, and platelets were significantly increased in women with MS (P ≤ 0.05). Furthermore, in men, WBC and platelet count increased with the increasing number of MS components. Whereas, in women RBC, Hb, HCT, and platelet count increased with the increasing number of MS components (0, 1, 2, and ≥3). Conclusion: MS was more widespread in women than men than women. The association of hematological parameters differed between the genders. WBC and platelets were found to be the risk factors in men and RBC, Hb, HCT, and platelets were found to be the risk factors in women for MS. These hematological parameters could be used for assessing the risk of MS on the basis of gender.
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A comparative study of suture-less and glue-free versus sutured conjunctival autograft for the management of primary pterygium p. 260
Sachit Mahajan, Satish Kumar Gupta
DOI:10.4103/amhs.amhs_98_21  
Background and Aim: Various modalities are currently available for the management of pterygium, of which free limbal conjunctival autograft is now the most preferred method to prevent recurrence. The most common method for the fixation of autograft, at the required site, is by suturing, but it is associated with various complications. Suture-less and glue-free conjunctival autograft is a new, easy, and cheaper technique for the management of pterygium. This study was conceptualized to compare the two most commonly used techniques for conjunctival autograft fixation in pterygium surgery, either sutureless, glue-free fixation, or sutured graft. Materials and Methods: This prospective, longitudinal study included 100 eyes of 100 patients who were divided into two groups A and B, who underwent pterygium surgery with sutureless conjunctival autografting and sutured conjunctival autografting with 10'0 nylon sutures, respectively, under local anesthesia. Both the groups were compared with respect to mean operating time and postoperative complications. Data were analyzed with OpenEpi online software version 3 using t-test. Results: Mean operating time was significantly less (24.35 ± 1.22 min) in Group A as compared to Group B (28.62 ± 1.78 min) (P = 0.009). Postoperative symptoms were more in sutured conjunctival autograft group (80%) as compared to the sutureless conjunctival autograft group (10%). Two patients had graft displacement in group A. Recurrence was noted in one patient in Group A and in two patients in Group B. Conclusion: Sutureless and glue-free conjunctival autografting is less time-consuming and is associated with lesser postoperative complications as compared to sutured conjunctival autografting.
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Listening between the Lines: Introduction of a Module for Teaching Nonverbal Communication Skills to MBBS Students p. 264
Priyanka Banerjee, Niket Verma, Charu Mohan, Shaifaly M Rustagi, Bindu T Nair, Archna Rautela
DOI:10.4103/amhs.amhs_112_21  
Background and Aim: Establishing good communication with patients is an essential component of good doctor–patient relationships and has a positive impact on health outcomes. A vital component of communication is nonverbal communication (NVC). NVC may reinforce or contradict our verbal comments, thereby altering the meaning of a message and its outcomes. Hence, it is imperative that medical students are made aware of NVC. The present study was undertaken to develop and implement a module for NVC skills and assess the perception of students and faculty. Materials and Methods: The study was conducted with students of 2nd professional MBBS. Participation was voluntary and approval was taken from the institutional ethical committee. All the contents of the module were jointly developed by the core faculty members. The module was conducted across three sessions and included role plays, exposure to simulated patients, an interactive lecture, and a focused small-group discussion. Feedback was obtained from students and faculty facilitators after conclusion of the third session. Results: Fifty-two students and seven faculty facilitators participated in the study. Fifty students (96%) agreed that the module was helpful in improving their NVC skills. All 52 students (100%) agreed that they felt more confident interacting with patients after attending the sessions. Forty-four students (84.6%) strongly agreed that they would attend such sessions in future also. The suitability of the module as a whole for inclusion in the curriculum was endorsed by all participants (100%). The faculty members felt that the most encouraging aspects of the module were its implementation in a nonthreatening environment, maintaining privacy during interactions with simulated patients, and self-assessment of the interaction. Conclusion: With regard to the feasibility and acceptability of the module, 100% of the participants and faculty facilitators agreed that the module should be included in the undergraduate curriculum.
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REVIEW ARTICLE Top

Amniotic fluid embolism: A narrative review of current concepts and future perspectives p. 270
Divyanu Jain
DOI:10.4103/amhs.amhs_261_20  
Amniotic fluid embolism (AFE) is a rare yet devastating complication of pregnancy. The outcomes are often poor, proving fatal for both mother and neonate. The incidence and mortality rate due to AFE is quite high even in developed countries and may be much higher in developing countries. Data from developing countries are unavailable. There is no uniform internationally accepted diagnostic criterion for AFE. No single diagnostic test has been found sufficient to suspect AFE in the early stages. Recently, complement system activation and an anaphylactoid reaction in the uterine tissue have been proposed in relation to its pathophysiology. In few cases, the use of complement C1 inhibitor with tranexamic acid, atropine, ondansetron, ketorolac therapy, and extracorporeal membrane oxygenation was observed to be very effective for early management. The studies on the pathophysiology of AFE are still limited. Further research is required to know the mechanism of this disease. Reliable rapid diagnostic tests are much needed at this stage. It is important to investigate the histopathology of tissues affected by AFE and find the origin of the disease in the maternal system. This review intends to highlight the best known and the unknown aspects of AFE relevant for future research purposes to minimize the fatality/mortality rate due to AFE, which remains an undiagnosed cause.
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CASE REPORTS Top

Dual Invasive fungal infection by aspergillus and mucor in COVID-19 patient: A rare case report with literature review p. 278
Deependra Kumar Rai, Subhash Kumar
DOI:10.4103/amhs.amhs_218_21  
Patients with COVID-19, especially those with severe disease, in intensive care units, are particularly vulnerable to bacterial and fungal infections. The most common fungal infections reported include aspergillosis, candidiasis, and mucormycois. Mucormycosis, a potentially life-threatening fungal infection, has contributed to India's COVID-19-related deaths, especially during the second wave of pandemic. Several cases of COVID-19-associated pulmonary aspergillosis (CAPA) have been reported from many countries in Europe, Asia, Australia, and South America. Recently, several cases of rhino-orbito-cerebral mucormycosis in patients with COVID-19 (ROCM) have been reported from India. However, case of COVID-19-associated pulmonary mucormycosis (CAPM) is rarely described in the literature. It has been hypothesized to affect patients recovering from COVID-19 who are immunocompromised due to COVID-19 disease or due to the usage of steroids and/or concomitant diabetes. The authors hereby report a combination of CAPM and CAPA in the same patient and perform a systemic review of the published cases highlighting the differences between these two-life-threatening pulmonary fungal infections.
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“They're not my children” – A case series of capgras syndrome in depression, a rare occurrence, and a missed diagnosis p. 283
Akansha Bhardwaj, Jagriti Yadav, Priti Singh, Rajiv Gupta
DOI:10.4103/amhs.amhs_121_21  
Capgras syndrome is a psychopathological phenomenon which is defined under the broad category of “Delusional misidentification syndromes.” It is seen in a wide range of psychiatric and neurological disorders. In the psychiatric literature, Capgras syndrome is most commonly seen in association with schizophreniform psychosis. Here, we report the two cases of severe depressive disorder with psychotic symptoms presenting as Capgras syndrome, leading to significant socio-occupational and biological dysfunction. The case series highlights the need for the early identification of depressive symptoms and timely intervention in patients presenting with Capgras syndrome as it carries high risk of harm to self and others.
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A case report of amyand hernia and its management p. 287
Jayabal Pandiaraja, Arumugam Shalini
DOI:10.4103/amhs.amhs_28_21  
Amyand hernia is a variant of inguinal hernia with appendix as the content of the sac. Most of the Amyand hernia is undetectable in the preoperative period and mostly diagnosed during the intraoperative period. The management of Amyand hernia varies depends on the condition of the patient, and there are no standard guidelines for it. This case is reported for a few important educational points that pertain to Amyand hernia. Amyand hernia is one of the differential diagnoses for acute onset of pain in reducible inguinal hernia. Appendicectomy with hernioplasty can be done without complication in an inflamed appendix without much contamination.
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Primary Malignant Melanoma of the Stomach: A Rare Entity p. 290
Sarita Asotra, Akshita Mehta, Brij Sharma
DOI:10.4103/amhs.amhs_88_21  
Primary gastrointestinal malignant melanoma is an unusual clinical entity. With primary gastric melanoma being very rare, Primary gastric melanoma is underdiagnosed as clinical manifestations are not specific and usually similar with other common malignancies at this site such as gastric cancer and lymphoma. Most melanomas found in the stomach are metastases from cutaneous source. Cutaneous source with nonspecific signs and symptoms. We report a case of a 65-year-old women with pain abdomen and vomiting. We submit this report as primary gastric melanoma is a rare entity with aggressive behavior and poor prognosis
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Expectant management of an asymptomatic complete uterine rupture presenting as a herniated amniotic sac p. 293
Benjamin Howe Nongo, Obande Samuel Ojah, Teddy Eyaofun Agida, Anthony Dennis Isah
DOI:10.4103/amhs.amhs_77_21  
When there is a defect in the uterine wall, it serves as a weakness through which the fetal membrane may herniate into abdominal cavity during pregnancy. This may manifest as either a silent (partial) or complete uterine rupture. Any silent (partial) uterine rupture has a potential of becoming complete. When a uterine rupture becomes complete, it may lead to acute life-threatening complications to both the mother and her fetus. As of today, there seems to be no consensus as to whether to manage silent or complete uterine rupture expectantly or surgically, including repair of the uterine wall or termination of the pregnancy, especially when this happens in the early second trimester, especially in Nigeria where the age of viability is still 28 weeks of gestation.
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Intercostal chest tube drain-related bleeding in a severe COVID-19 pneumonia patient with pneumothorax and its management p. 299
Nikahat Jahan, Kaminder Bir Kaur, Prabhav Chapperwal, Prashant Tiwari
DOI:10.4103/amhs.amhs_205_21  
Pneumothorax and pneumomediastinum have both been noted to complicate cases of coronavirus disease-19 (COVID-19) requiring hospital admission; however, the incidence is very low with only few cases reported in the literature. Spontaneous pneumothorax was also reported as a complication of the severe acute respiratory syndrome (SARS) with an incidence of 1.7% in hospitalized patients during the SARS pandemic of 2004. COVID-19 is also associated with a hypercoagulable state leading to pulmonary microvasculature thrombosis and systemic thromboembolic manifestations. Therefore, it is standard practice to start low molecular weight heparin (LMWH) for all moderate and severe COVID-19 pneumonia patients. We report a case of spontaneous pneumothorax in a severe COVID-19 pneumonia patient after three weeks of admission, where placing an intercostal drain (ICD) led to persistent bleeding into the ICD. He was managed with an innovative technique of instillation of Adrenaline saline solution three times into the pleural cavity through the ICD tube. Following the instillation of Adrenaline saline solution, the bleeding from the ICD stopped, however, the patient succumbed to his illness.
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Basal cell nevus syndrome p. 302
Anjali Ravi, Hannah Maryam Mohiddin, Bhargabi Paul Majumder, Vishal S Nair, YR Girish, Prasanna Kumar Rao, Deepak Pai, Raghavendra Kini, Nitin Gonsalves
DOI:10.4103/amhs.amhs_182_21  
Gorlin-Goltz syndrome (GGS) is a hereditary condition; it is transmitted as an autosomal dominant trait and characterized by a wide range of developmental abnormalities and a tendency to neoplasm. This article includes a case report and an extensive review of the GGS with regard to its history, incidence, etiology, features, investigations, diagnostic criteria, and treatment modalities.
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COVID-19 associated pulmonary aspergillosis- A case report p. 306
Ankit Kumar, Satish Kumar, Vishal Mangal, Anil Shankar Menon
DOI:10.4103/amhs.amhs_226_21  
Coronavirus disease-19 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2. Viral illnesses such as influenza and COVID-19 are known to coexist with fungal infections, including Aspergillosis. The cases of COVID-19-associated pulmonary Aspergillosis (CAPA) have been reported in the recent past; however, there is a paucity of literature from India. Hence, we report a case of CAPA in a 55-year-old diabetic male from India who was successfully managed with anti-fungals and had a favorable outcome. This case highlights the importance of the high index of suspicion for CAPA in patients with severe COVID-19 pneumonia and acute respiratory distress syndrome who fail to improve or deteriorate clinically and radiologically despite standard therapy. The diagnosis must be confirmed with galactomannan assay from serum or bronchoalveolar lavage samples – early diagnosis and prompt management with anti-fungal results in a favorable outcome.
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Dual nerve transfer for facial reanimation p. 310
Deekshith Rajmohan, Deviprasad Sulli, MK Mohammed Jasim, Arjun Suresh
DOI:10.4103/amhs.amhs_145_21  
The facial nerve is the 7th cranial nerve and carries nerve fibers which control facial movement and expression. This nerve also carries fibers that are involved for the production of taste from the anterior 2/3rd of the tongue and tears from the lacrimal gland. Facial asymmetry is a debilitating condition to treat, and over the years, different techniques have been devised for improving facial asymmetry and function. Dual nerve transfer is the combination of hypoglossal nerve transfer and massetric nerve transfer. This technique is proven to correct facial asymmetry and helps restore facial tone without affecting much of tongue functionality. This case report helps understand the effectiveness of facial reanimation that was conducted on a patient with Grade VI facial nerve paralysis and follow-up after 6 months postsurgery shows drastic change in the outcome.
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Primary carnitine deficiency in a neonate p. 314
Manish Rasania, Naveed Majid Ahmed, Bhatt Vivek Prafulchandra, Shashank Jain
DOI:10.4103/amhs.amhs_174_21  
Carnitine deficiency in paediatrics can present in infants with episodes of irritability, lethargy and hepatomegaly. The main treatment for primary carnitine deficiency is to take L-carnitine supplements. Here we report a case of a female neonate with carnitine deficiency. A female child of 1.5 kg of 34 weeks of gestation was admitted for low birth weight .Baby was discharged on 18th day of life. On 25thday of life, parents brought the patient back with complains of lethargy, where hypoglycemia was detected. After recovery, baby was shifted to full feed. Metabolic disorder was suspected. Extended neonatal screening test was sent and was suggestive of decreased levels of free carnitine in blood. For treatment, syrup L-carnitine was started. Signs and symptoms of primary carnitine deficiency typically appear during infancy or early childhood. Infants mostly present with hypoglycaemia. For treatment, carnitine supplements are provided
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Trichilemmal carcinoma of the scalp: Demystifying anecdote of a rare entity p. 317
Archana Shetty, Aparna Muralidhar, Nidha Gaffoor
DOI:10.4103/amhs.amhs_99_21  
Trichilemmal carcinoma (TC) is a rare malignant adnexal neoplasm, falling under the umbrella of tumors with follicular differentiation generally presenting as papulonodular growth with surface ulceration over sun-exposed skin. Histologically, it mimics tumors such as basal cell carcinoma, sebaceous carcinoma, squamous cell carcinoma, and malignant proliferating trichilemmal tumors. As there is a difference of opinion regarding the histopathological criteria for TC, a definitive diagnosis should be confined to cases having the majority of histomorphological findings with immunohistochemical corroboration to help define the clinicopathological behavior of this disease. Rarity, indolent clinical course in spite of local aggressiveness and a good survival rate postexcision further undermine the importance of this unique entity.
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MEDICAL EDUCATION Top

Quality assurance of medical education in India: The concerns, available guiding frameworks, and the way forward to improve quality and patient safety p. 320
Thomas V Chacko
DOI:10.4103/amhs.amhs_284_21  
With India having the largest number of medical schools (619) globally and these numbers are increasing every year, quality assurance (QA) in medical education is a matter of shared concern and responsibility for all stakeholders in India and the interconnected world. Hence, an attempt is made through key literature review on good practices by accreditation agencies that have put in place comprehensive QA systems in their respective countries. Looking through the lens of the “Systems Approach” (inputs–process–outcomes) to investigate and intervene in educational systems and the quality improvement framework followed by the UK, the focus of the system followed in India has been identified as predominantly “Inputs-based Minimum Requirements Standards” and essential elements of processes influencing the educational outcomes and quality control (QC) through monitoring of progression toward graduate outcome competencies among students and the workplace where they get employed as part of the scrutiny by accreditation system are found missing. The way forward to address the concerns of all stakeholders and ensure patient safety through well-known systems and processes of QA at the national level and QC through quality management within institutions is suggested. Further, the working models for quality improvement in medical education such as the World Federation for Medical Education Standards and the National Assessment and Accreditation Council Standards for Higher Educational Institutions are taken as exemplars for preparing a way forward that can be useful to the National Accreditation Agency and medical schools in India including its expeditious implementation by applying for international recognition as an accreditation agency is presented.
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Crossing the final hurdle: How is scholarship practically conceptualized in the lives of busy clinicians? p. 328
Elizabeth M Wooster, Douglas L Wooster, Jerry M Maniate
DOI:10.4103/amhs.amhs_285_21  
Clinicians juggle many roles in addition to their clinical responsibilities. These roles include teaching and academic responsibilities. When academic responsibilities and productivity is discussed, the question of what is recognized and valued often surfaces. While large “R” research areas may have high barriers preventing entry by many clinicians, scholarly activity and scholarship may be enacted and realized through engagement with daily activities. In this paper, Wooster, Wooster and Maniate explore the role of scholarly activities, discuss practical tips, and reflect on a culture that may be enacted to support scholarly activities and scholarship in the future.
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Problem-based learning curriculum and process assessment system for the undergraduate competency-based medical education: Experiences from Nepal p. 331
Shital Bhandary
DOI:10.4103/amhs.amhs_282_21  
This article aims to provide an overview of problem-based learning (PBL) curriculum for integrating basic sciences subjects and clinical sciences with early clinical exposure. This approach provides the opportunity to teach the basic science subjects in context to medical students. PBL promotes self-directed learning skills among the medical students and facilitation skills among the faculty. PBL can also be used to observe, assess, and foster the noncognitive competencies among the medical students for which process assessment system must be established. The use of process assessment to observe, assess, and improve the preparation, participation, self-directed learning, critical thinking, leadership, communication, group skills and reflective competencies among medical students in Nepal for the last 10 years reveals that it can be implemented with the proper planning and training of faculty for this new system. PBL and process assessment system can serve to complement the competency-based medical education in the basic sciences phase of the undergraduate medical education curriculum.
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SPECIAL ARTICLE Top

Storytelling in medical education, clinical care, and clinician well-being p. 337
Cory Ingram
DOI:10.4103/amhs.amhs_289_21  
We all share our lived experiences with others through stories. Sometimes we may share a story in conversation over a cup of coffee or simply share a photograph with a friend to illustrate an event in our life. During our health care training we can learn concepts through reading textbooks, medical articles, and informational lectures. However, it is often the real-life stories that teach the lessons, so it is best understood, remembered, and applied. This actionable knowledge is created through patients, family members, and/or clinicians sharing their stories. When learners are able to acknowledge, absorb, interpret, and act on the stories of others they are practicing narrative medicine. Storytelling bridges the worlds of patients, families, clinicians, health systems, policy makers, communities, cultures, and traditions to help us find common understanding to create experiences that match our expectations and improve the lived experience of giving and getting patient centered healthcare. This paper reviews the literature on storytelling as a methodology that lends a rich opportunity for meaningful academic productivity in research, community engagement, and quality and safety improvement. I close the paper with a sincere invitation to explore a specially crafted storytelling workshop to train patients to craft their stories of receiving health care to share with intentionality, confidence, and emotional wellness with medical audiences to improve the delivery of patient centered care; to improve the delivery of narrative medicine.
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MEDICAL HISTORY Top

Psychogenic nonepileptic seizures: A historical perspective p. 345
Andrea E Cavanna
DOI:10.4103/amhs.amhs_278_21  
Psychogenic nonepileptic seizures have been documented, if not recognized, for over 2000 years. Conventionally, the term hysteria has been used successfully used to describe patients with nonorganic or medically unexplained convulsions. Therefore, the history of psychogenic nonepileptic seizures is closely woven within the texture of hysteria. It is possible to identify a progressive shift from the ancient concept of a female malady caused by an allegedly wandering womb to a neurological disorder that dominated the clinical practice of Victorian physicians in England and, most importantly, Charcot's school in France. Freud's contribution was essential to the development of individualized etiological models within the psychological framework. Over time, causation shifted away from the uterus to the brain, and then to the mind, but was never fully elucidated. The paradigm shift that led from psychodynamic psychiatry to biological psychiatry was accompanied by the operationalization of diagnostic criteria. Historical developments were also mirrored by changes in the terminology, which have led to the recent dismissal of the term hysteria, among a few other medical labels. Psychogenic nonepileptic seizures are currently categorized as functional neurological symptoms, and remain a mysterious, although relatively common, neuropsychiatric condition at the borderlands between epileptology and psychiatry.
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TEACHING IMAGES Top

Posterior quadrantic dysplasia: An unusual cause of focal seizures p. 353
Krishnan Balagopal, Jeyaseelan Nadarajah, Jasica Joy Thottiyil
DOI:10.4103/amhs.amhs_156_21  
Hemimegalencephaly (HME) is one of the rare malformations of cortical development that can present in children and in adults with refractory seizures. One of the localized forms of HME is posterior quadrantic dysplasia (PQD). This entity commonly involves hypertrophy of the parieto-temporo-occipital lobes with periventricular signal changes on imaging. Presentation is with focal seizures in children and in adults. We present here a 24-year-old man presenting with recurrent left focal seizures who was found to have PQD on imaging. He was started on anticonvulsants with improvement in his symptoms. This report aims to highlight the characteristic imaging findings and clinical features of PQD.
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V sign in dermatomyositis p. 355
Sumantro Mondal, Rashmi Roongta, Debanjali Sinha
DOI:10.4103/amhs.amhs_207_21  
V sign is a patchy or discrete macular erythema over the sun-exposed parts of the anterior neck and upper chest in patients with dermatomyositis (DM). It is one of the clinical hallmarks of DM and aids in diagnosis. It can be associated with telangiectasias and a shawl sign, which is a similar rash in the upper back, posterior neck, and shoulders.
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Abdominal ultrasound depicting vaginal evisceration of bowel p. 357
Vinayak Jain, Akhila Vasudeva
DOI:10.4103/amhs.amhs_248_20  
Vaginal evisceration represents the extreme outcome of intestinal prolapse following iatrogenic uterine perforation. It is a rare occurrence and considered a surgical emergency with a mortality rate of 6%. The whole track is rarely seen in abdominal ultrasound. Ultrasound is the least expensive, easily available imaging tool, which may clearly show the track of perforation. Timely detection prevents deadly sequelae.
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Choroid plexus xanthogranuloma: Radiological features p. 359
S Sheetal, S Amith Kumar
DOI:10.4103/amhs.amhs_119_21  
Choroid plexus xanthogranulomas are rare tumors of the central nervous system. They are usually asymptomatic and are often reported as incidental autopsy findings. Although they are mostly asymptomatic, rarely, these tumors can result in obstructive hydrocephalus. The etiology of these tumors is often uncertain. They are also known as cholesterol granuloma and are typically composed of large foam-filled cells with clusters of lymphocytes and macrophages and multinucleated giant cells. The radiological features vary, owing to the heterogeneity of content. We hereby report the neuroimaging findings of choroid plexus xanthogranuloma, located in bilateral lateral ventricles, which was detected incidentally in a patient.
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SHORT COMMUNICATIONS Top

Peer-assisted learning: Our experience with undergraduate medical students p. 361
Ashok Vanagamudi, PJ Padmini
DOI:10.4103/amhs.amhs_162_21  
Peer-assisted learning (PAL) is an innovative approach of learning where people from similar social groupings who are not professional teachers help each other to learn. This study was an experimental interventional comparative analysis conducted in the Department of Biochemistry and Department of Pediatrics, Karpagam faculty of medical sciences and research, Coimbatore. One hundred students were recruited in the study after getting informed consent. This study compared the effects of two educational methods: PAL and teaching by regular faculty members on 1st-year undergraduate medical students. Students' posttest marks in the PAL group were higher than the lecture group (12 ± 2.9 vs. 9.8 ± 3.5, P < 0.02). The majority (70%) of the students agreed that PAL is a better method of learning and develops teaching attitude. Most of the students strongly agreed that PAL provides friendly environment for learning (80%). PAL provides a relaxed environment for students to study and learn skills including leadership, presentation, and communication, all of which are very essential to practice modern medicine.
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Delivering telemedicine services in otolaryngology through “Mohalla” clinics in remote areas and in resource-constrained settings: A viewpoint p. 364
Soumyajit Das, Satvinder Singh Bakshi, Seepana Ramesh
DOI:10.4103/amhs.amhs_142_21  
Telemedicine services in India are underutilized. Otolaryngology provides a unique opportunity to adopt telemedicine services. Otolaryngology has seen a drastic surge in teleconsultation due to the COVID-19 pandemic. However, the challenge lies in sustaining the services and making them affordable and acceptable in the remote corners of the country. The concept of “Mohalla clinics” offers a scope to integrate and adopt telemedicine in otolaryngology and expand its outreach effectively and with minimal resources. It is high time we start training ourselves and investing in telemedicine and develop the modality across our specialties.
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Clinical significance of horizontal high-frequency headshake test Highly accessed article p. 368
Prateek Porwal, VR Ananthu, Srinivas Dorasala, Ravi Nayar, Vijayalakshmi Subramaniam
DOI:10.4103/amhs.amhs_124_21  
The method of performing the horizontal high-frequency headshake test with its interpretation and clinical significance is described. The videonystagmographic recordings of headshaking nystagmus using BalanceEye videonystagmography system are explained.
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