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   Table of Contents - Current issue
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January-March 2020
Volume 7 | Issue 1
Page Nos. 1-81

Online since Friday, June 19, 2020

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REVIEW ARTICLE  

Effectiveness of physical activity in the prevention and treatment of hypertension: A mini review Highly accessed article p. 1
Chidiebere Emmanuel Okechukwu
DOI:10.4103/cjhr.cjhr_99_19  
Physical activity (PA) is associated with a clear decrease in blood pressure (BP) and cardiovascular mortality in both men and women. The aim of this review was to evaluate the effectiveness of PA as an adjunct therapy in support of the prevention and pharmacological treatment of hypertension. Studies that reported on the correlation of PA and exercise on BP control among hypertensive patients from 1994 to 2019 were evaluated. PubMed electronic database was utilized. The MeSH system was used to extract relevant research studies from PubMed using the following keywords: “Exercise,” “training,” “hypertension,” “blood pressure,” “systematic review,” and “meta-analysis,” All selected articles were published in English. Sedentariness negatively affects cardiometabolic health, body composition, and BP among hypertensive patients, whereas PA significantly improves cardiometabolic parameters and body composition and leads to an overall improvement in cardiac parasympathetic system by increasing vagal tone, causing a reduction in resting heart rate, and systolic BP in hypertensive adults. Exercise should be tailored according to patient's clinical and functional status to avoid imposing variable internal training load on the patients. Moderate intensity aerobic, isometric and dynamic resistance exercise training alone, or a combination was equally effective in lowering BP among hypertensive adults.
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ORIGINAL ARTICLES Top

Effect of exposure to formalin on peripheral and smaller airways of 1st-year medical students Highly accessed article p. 8
Dipak Kumar Dhar
DOI:10.4103/cjhr.cjhr_158_18  
Context: One of the occupational hazards experienced by a doctor is the exposure to formaldehyde during gross anatomy dissection classes. As it vaporizes at room temperature, the respiratory system is easily affected. The present study was conducted to assess the effect of formaldehyde on the smaller and peripheral airways. Aims: The study aimed to evaluate the effect of formaldehyde exposure on the smaller and peripheral airways of 1st-year medical students. Settings and Design: A longitudinal, descriptive study was conducted in the Department of Physiology, Rohilkhand Medical College and Hospital, among 1st-year MBBS students in the academic year 2015–16. Materials and Methods: The spirometric parameter, forced expiratory flow at 25%–75% (FEF25%–75%)was recorded in eighty medical students using spirometer RMS Helios 401 available in the research laboratory of the department. Percent-predicated values were used for the analysis. The baseline values were recorded at the beginning of the academic calendar and followed up at the end of the 1st, 6th, and 10th months. Statistical Analysis Used: Data were analyzed using the SPSS software. Descriptive statistics and repeated measures ANOVA were used for the analysis.P <0.05 was considered statistically significant. Results: The overall mean FEF25%–75%declined up to the 6th month following which there was a gradual correction. The overall pattern of change and the decrease in 1st month was statistically significant (P = 0.001). Conclusions: There is some detrimental effect of formaldehyde on smaller and peripheral airways which affects the ventilatory dynamics.
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Sociodemographic correlates of infant mortality in India: A review of national family health survey data p. 12
Ratan Gupta, Manas Pratim Roy
DOI:10.4103/cjhr.cjhr_6_19  
Introduction: Infant mortality rate (IMR) is interplay of several sociodemographic factors. There are several scopes for policymakers to bring IMR down by improving those factors. An ecological analysis was performed, with the aim to identify such factors. Methods: Data were taken from nationally-representative National Family Health Survey 4 (2015–2016). Correlation was used for the analysis. States were compared individually and in groups. Results: Female literacy (r = −0.639), improved sanitation (r = −0.604), and clean fuel (r = −0.463) were significantly related to IMR. States belonging to the Empowered Action Group performed poorly in terms of infant death and basic amenities provided to the citizens. Conclusion: Efforts should be made to improve household environments to reduce infant deaths in future.
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Zulewski's clinical score and its validation in hypothyroid patients: Experience in a tertiary care center in Western India Highly accessed article p. 16
Prachi Srivastava, Jaideep Khare, Sandeep Rai, Jaishree Ghanekar
DOI:10.4103/cjhr.cjhr_14_19  
Introduction: Hypothyroidism is a common endocrine disorder with the prevalence of approximately 10.95% among the general population in India. Aim: The aim of this study was to evaluate the prevalence of various signs and symptoms of hypothyroidism and to correlate with the biochemical investigations and clinical Zulewski's score in hypothyroid patients. Materials and Methods: A total of 207 patients of hypothyroidism attending our endocrine and medicine outpatient department were included in the study. Clinical data including signs and symptoms of hypothyroidism were obtained by interviewing the patients and referring to records. Prevalence of various signs and symptoms was recorded along with anthropometric indices, and Zulewski's score was calculated. Thyroid function tests were performed along with other laboratory investigations according to the patient condition. Results: Patients aged between 18 and 72 years were included in the study with male-to-female ratio was 51:156. Patients had different signs and symptoms of clinical hypothyroidism, and 74.4% of patients had ≥5 components of Zulewski's score. Most and least common defining criteria of Zulewski's score were dry skin and hearing impairment, respectively. Conclusion: Zulewski's clinical scoring is an economic and effective tool for identifying clinical hypothyroidism and can be used as clinical basis for starting levothyroxine replacement therapy if due to unavoidable reasons, it is difficult to get thyroid function test.
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Clinical profile and predictors of mortality in the elderly with community-acquired pneumonia at a tertiary care hospital in South India p. 20
Pranita Harshad Vanjare, Gopinath Kangogopal, Benny Paul Wilson, Surekha Viggeswarpu
DOI:10.4103/cjhr.cjhr_15_19  
Introduction: Community-acquired pneumonia (CAP) is a common and the second-most common infectious cause of hospitalization and mortality in the elderly. There are limited data available on age-specific incidence, predictors, pattern of care, and mortality of CAP in the elderly in India. Materials and Methods: We performed a retrospective study of 108 patients over 60 years of age with CAP admitted to a tertiary care center. Death and discharge against medical advice were considered as poor outcomes. Risk factor for poor outcomes was assessed with multivariable variable logistic regression analysis. Results: The mean age of the study population was 70.4 ± 8.1 years. The overall inpatient mortality was 38%. Factors independently associated with mortality were the presence of delirium 5.4 (confidence interval 1.4–14.9;P= 0.009), mechanical ventilation (P ≤ 0.0001), and prolonged hospital stay (P ≤ 0.0001). Patients >75 years had a poor outcome as compared to <75 years (P = 0.09). Bacteremia was present only in 6.1% of patients. Conclusion: CAP in the elderly had a high risk of poor outcomes. Delirium at presentation and need for mechanical ventilation were important risk factors for mortality.
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General dentists' knowledge, attitude, and practice guidelines toward pediatric dentistry p. 24
Thabitha S Rani, E Rajendra Reddy, Kiranmayi Merum, MP Srujana, S Srikanth Raju, Manitha Pershad Seth
DOI:10.4103/cjhr.cjhr_12_19  
Introduction: Pediatric dentists play an important role in treating primary teeth and providing oral health care needs for children. The prevention for diseases of the oral cavity, namely early childhood caries (ECC), abnormal oral habits, etc., at primary level is of great need in young children. General dentists also share an equal responsibility toward early screening, educating parents, and treating and referring the patient to the pediatric dentist whenever required. Aim: The aim of this study was to determine the knowledge, attitude, and practice guidelines among general dentists in Hyderabad, Telangana, India, toward various treatment modalities in the pediatric dentistry using a questionnaire survey. Materials and Methods: A structured 25-item questionnaire was formulated in English and was distributed among 200 general dentists. The filled questionnaire survey was analyzed using the SPSS. Results: Among the respondents, the knowledge regarding treatment modalities in children was 59% said that pulpectomy is the first line of treatment for pulpal exposure, 66.5% said that crowns are necessary after pulpectomy, and 76% of general dentists said that they refer the special child to the pedodontist for the treatment. Among the respondents, 61.5% of the general dentists said that they can treat the patients with ECC with behavior management on the dental chair, and 32% had said that they can deal children with fear following tell-show-do technique. Conclusion: General dentists in Hyderabad city have got good knowledge toward various treatment modalities in preventive dentistry. The attitude is highly commendable, but in practice, patient's referral to the respectful profession is the utmost important step for the complete oral care.
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Acinetobacter infections: Overview and treatment dilemma p. 30
Sana Ali
DOI:10.4103/cjhr.cjhr_30_19  
Introduction: Acinetobacter species are known to cause serious hospital-acquired infections (HAIs), especially in the intensive care unit (ICU). The aim of this study is to estimate the burden of such infections and also to determine their sensitivity to currently available antimicrobials. Materials and Methods: The study was conducted at a tertiary care hospital in New Delhi from June 2017 to December 2018 to estimate the number of Acinetobacter isolates from clinical samples. Organisms were identified, and their susceptibility to antimicrobials was tested using VITEK-2 automated system. Results: Of the total 701 isolates recovered from clinical samples during the study, 28 (4%) were Acinetobacter species. Among them, majority (57%) of the isolates were isolated from ICU patients. Respiratory specimen yielded maximum number of isolates (46.4%). About 71.4% of isolated strains were extremely drug resistant, 10.7% were multidrug resistant, whereas 3.5% were pandrug resistant (PDR). PDR strains were found to be resistant to even the last resort antibiotics such as tigecycline and colistin. Acinetobacter baumannii was also the most common cause for HAIs (57.1%), resulting in overall mortality of 42.8% due to HAI. Conclusion: Acinetobacter has gained great importance in health-care setting by posing serious threat to patients, which is compounded by its tendency of antibiotic resistance. HAIs are usually difficult to treat, resulting in therapeutic failure and increased mortality. It signifies the need to implement strict preventive measures in hospitals and to use higher antimicrobials or combination therapy judiciously.
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Assessment of job satisfaction among nursing officers working at a tertiary care hospital in Northern India p. 35
Ajay Sharma, Vipin Kaushal, Navin Pandey, Pankaj Arora, Arulmani Thiyagarajan, Sudip Bhattacharya
DOI:10.4103/cjhr.cjhr_11_19  
Introduction: Job satisfaction among nurses is an indicator of excellent working environment and management of the institution. The study of job satisfaction has relevance to nursing from economic, humanitarian, and professional perspectives. Aim and Objective: This study aimed to understand the job satisfaction among nursing officers (NOs) at a tertiary care hospital. Methodology: A cross-sectional questionnaire-based study was conducted using the Minnesota Satisfaction Questionnaire short form. Results: The study was conducted in the different areas of tertiary care hospital. The study population comprised NOs employed in tertiary care hospital. Nearly half of the participants were in the age group of 21–30 years. Among the nursing professionals, more than two-third of them were NOs 620 (73.4%), followed by senior NOs, assistant nursing superintendent (NS), deputy NS, and NS with least in count comprising 0.1%. It was found that mostly all of the nursing professionals were either moderately satisfied or highly satisfied with their profession. Discussion: Chi-square test was performed to find the relationship between the job satisfaction and age group factor, which indicated that there was a significant association between the variables (P < 0.01). There was no significant difference was observed in the satisfaction level of intrinsic factors among the nurses. Age, area of posting, and the educational qualification had a significant influence on satisfaction level of nurses. It was also observed that length of service did not have any significant influence on the satisfaction level among the nursing staffs. Conclusion: The study found that most of the nurses were satisfied but some factors were commonly related with dis-satisfaction.
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The tansen technique – A new, easy, reliable, safe and cost effective, technique in closed reduction and percutaneous fixation of type 3 supracondylar fracture of the humerus in children p. 42
Bhim Bahadur Shreemal, Tul Bahadur Pun, Dipak Maharjan
DOI:10.4103/cjhr.cjhr_85_19  
Introduction: Closed reduction and internal fixation with K wires is the standard of care for Gartland type III supracondylar fractures of children since they are too unstable for nonoperative treatment. Occasionally closed reduction of these fractures could be difficult using standard technique warranting open reduction which is associated with additional complications. We report a new intrafocal reduction technique and its results which can be used to reduce difficult supracondylar fractures reliably thus avoiding open reduction and its complications in most instances. Materials and Methods: Consecutive series of twenty-one patients who were treated successfully using intrafocal reduction (Tansen) technique from January 2014 to December 2015 were followed up for minimum of 6 months. Duration of operation, any intraoperative technique-related complication, and number of intraoperative image intensifier images were reviewed. Children were followed up at 3 weeks, 6 weeks, 3 months, and 6 months for the adequacy of reduction, for loss of reduction of fixation and fracture healing as well as a range of motion, complications, and functional outcome using Flynn's criteria. Results: The average operation time was 30.5 ± 10.5 min. The average number of intraoperative images was 15 ± 5. The average time and number of intraoperative images were not affected by the experience of the surgeon. Average healing was 6.1 ± 2 weeks. All patients achieved a satisfactory cosmetic and functional result. There was no significant loss of initial reduction on follow up. The minor complication rate was 16%. There was no technique-specific complication. Conclusion: Our simple intrafocal technique using artery forceps – “Tansen Technique” – gives an acceptable reduction in difficult supracondylar fractures which would otherwise require open reduction. It is cost-effective, consistent, has a short learning curve, and is a safe technique with potential use in day-to-day practice.
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Bony outgrowths on the base of skull near foramen spinosum p. 47
Neeru Goyal, Anjali Jain
DOI:10.4103/cjhr.cjhr_28_19  
Objectives: Ossification of the various ligaments at the base of the skull is quite common. Ossified pterygospinous and pterygoalar ligaments have been extensively described in the literature. We observed some bony outgrowths extending from the bar of bone between foramen spinosum (FS) and foramen ovale (FO). The objective of the present study was to report the incidence of these bony outgrowths near the FS. Materials and Methods: Fifty-five dried adult skulls and 20 sphenoid bones were examined for the bony outgrowths (if present) near the FS. Results: Bony outgrowths extended posteriorly from the bar of bone between FO and FS in 60% of cases. These bony outgrowths when long were seen meeting the spine extending from the spine of the sphenoid, forming a complete or incomplete bar of the bone. At times, a thick bony plate joined the bar of bone between FO and FS to the spine of the sphenoid. Conclusions: The bony outgrowths near FS become clinically important in surgeries involving middle meningeal artery. In spite of such implications, these bony outgrowths are neither named nor have they received the due attention in the literature. Detailed studies of these bony outgrowths could be of interest to radiologists, anesthetists, and neurosurgeons.
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Single institution experience with esophageal atresia over 9 years with a review of literature: Where do we stand? p. 51
Nandini Kaul Bedi, Alka Gupta Grewal, William Bhatti
DOI:10.4103/cjhr.cjhr_16_19  
Aim: We have conducted a study of the clinical profile of esophageal atresia (OA) at our institution over a period of 9 years with an aim toward improving our results. We have attempted to find the significant indicators of mortality to be able to focus on improving the survival of these patients in future. To achieve this end, we applied the Waterston's prognostic classification and the Spitz' prognostic criteria to our patients and studied the effects of each variable independently as a cause of mortality. We have also compared the two prognostic criteria to see, which has more significance for us at our institution. Materials and Methods: Over a period of 9 years, from 2006 to 2014, 73 neonates were treated for OA at our institute. There were 27 mortalities. We analyzed our results using the Waterston and the Spitz criteria and studied each independent variable within the two prognostic classifications for the more highly significant cause of mortality. The variables considered as significant indicators of mortality were low birth weight (LBW), pneumonia, associated congenital heart disease (CHD), other associated anomalies, and very LBW. Results: The Waterston prognostic classification was very highly significant (P < 0.0005) as an indicator of prognosis in this study. The two most significant variables affecting survival were LBW, as described by Waterston (P = 0.005) and the association of major CHD (P = 0.006). We had 63% survival and none below the birth weight of 1.8 kg. Conclusion: The study clearly points out that LBW is a highly significant indicator of prognosis followed by the association of major CHD. Waterston's risk classification continues to be a highly significant indicator of prognosis. Further studies are required to assess the combined effects of more than one variable on babies with OA.
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Antimicrobial resistance pattern of bacterial isolates and genetic resistance determinants of carbapenemase producers in bloodstream infections p. 56
Lipika Jena, Bichitrananda Swain, Swati Jain
DOI:10.4103/cjhr.cjhr_22_19  
Introduction: Bloodstream infection (BSI) continues to be a significant cause of disease and death in hospitalized patients worldwide. These are among the most common healthcare-associated infections with a mortality rate of 20%–50%. The emergence of multidrug resistance among the organisms causing BSI is of great concern. Objectives: The study was undertaken in a medical intensive care unit of a tertiary care hospital in Eastern India to evaluate the spectrum of pathogens causing BSI, their antimicrobial resistance patterns and carbapenemase enzyme production using polymerase chain reaction (PCR). Materials and Methods: A total of 550 blood samples from clinically suspected cases of BSIs were studied from July 2016 to June 2018. Blood samples were inoculated and incubated in BacT/ALERT (BioMerieux) system. Identification and antibiotic susceptibility testing was conducted in Vitek-2 (BioMerieux) as per the Clinical Laboratory Standards Institute guidelines. Methicillin-resistant Staphylococcus aureus (MRSA) and β-lactamase production were also noted in the Vitek-2 method. All Gram-negative isolates were studied for carbapenemase production by the genotypic method using PCR. Results: Of 550 samples, 116 samples yielded the growth of various bacterial isolates. Of these, 54 (47%) were Gram-positive organisms and 62 (53%) were Gram-negative organisms. S. aureus was the most common organism isolated followed by Klebsiella pneumoniae. MRSA was observed in 66.7% of S. aureus isolates. Among Gram-negative isolates, 43.5% were found to be β-lactamase producers and 66.1% were carbapenemase producers. Most of the carbapenemase producers were encoded by the OXA gene (58%). Conclusion: This study emphasizes the importance of antibiotic policy and its stringent application, which will eventually help us to control the menacing rise in antimicrobial resistance.
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MEDICAL EDUCATION Top

Developing a framework for the integration of E-learning with the existing medical curriculum p. 61
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cjhr.cjhr_13_19  
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Introduction of early clinical exposure to 1st year MBBS students in physiology p. 63
Suchitra Deolalikar, Jayshree Nandi, John Pramod
DOI:10.4103/cjhr.cjhr_71_19  
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CASE REPORTS Top

Hydrocortisone and ulinastatin for miliary tuberculosis-induced septic shock and adult respiratory distress syndrome in the intensive care unit p. 68
Niraj Kumar Keyal, Manish Nakarmi
DOI:10.4103/cjhr.cjhr_45_19  
Hydrocortisone and ulinastatin are anti-inflammatory agent. We hereby report the case of a patient of sputum-positive miliary pulmonary tuberculosis that developed adult respiratory distress syndrome with septic shock. The patient was treated with anti-tubercular drugs, antibiotics, inotropes, vasopressors, hydrocortisone, and ulinastatin. From this, we want to emphasize that hydrocortisone and ulinastatin can be one of the treatment options in refractory shock patient not responding to conventional treatment but requires randomized controlled trial to confirm the effectiveness of this combination.
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Fine-needle aspiration cytology-induced infarction of thyroid nodule hampers diagnosis p. 71
Khushboo Dewan, Poonam Rani, Arti Khatri, Kusum Gupta, Ashish K Mandal
DOI:10.4103/cjhr.cjhr_25_19  
Fine-needle aspiration cytology (FNAC) is a useful procedure for the investigation of thyroid swellings. It is a safe and minimally invasive procedure but is accompanied by its own set of complications. Infarction of the parent tissue post-FNAC has been reported in the lymph node, salivary gland, and breast but is a rare phenomenon in the thyroid. We present a case of a 34-year-old female with a solitary thyroid nodule. FNAC smears were hypercellular and showed numerous Hurthle cells suggesting a possibility of Hurthle cell neoplasm. Hemithyroidectomy performed 1 month thereafter showed extensive necrosis and hemorrhage with only few atypical follicular epithelial cells and Hurthle cells at the periphery. The near-total infarction and paucity of viable cells made it extremely difficult to make a histopathological diagnosis. The case highlights the need for extensive sampling and thorough examination of the periphery for any viable foci on histopathology along with cytologic-histologic correlation in such cases.
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Ocular scedosporiosis in an immunocompetent host p. 74
Ashish Bajaj, Bibhabati Mishra, Archana Thakur, Poonam Sood Loomba, Abha Sharma
DOI:10.4103/cjhr.cjhr_86_19  
Scedosporium apiospermum infection in humans is rare. Fungal keratitis is the most common manifestation of S. apiospermum infection in immunocompetent individuals. S. apiospermum is a filamentous fungus found in soil and polluted water. Strong suspicion of fungal keratitis should be made in all corneal ulcers with a history of trauma with vegetative matter or soil. Here, we present a case of fungal keratitis caused by S. apiospermum in an immunocompetent host.
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LETTERS TO EDITOR Top

The role of health-care professionals in controlling the spread of zika virus in India p. 78
Akshay Parihar, Brian Heng, Isha Patel
DOI:10.4103/cjhr.cjhr_67_19  
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Cytomorphological diagnosis of fibromatosis colli in a 2-week-old neonate p. 80
Prita Pradhan, Ranjita Panigrahi, Soumya Sucharita, Kanakalata Dash
DOI:10.4103/cjhr.cjhr_164_18  
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