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   Table of Contents - Current issue
Coverpage
July-September 2019
Volume 6 | Issue 3
Page Nos. 131-198

Online since Tuesday, August 13, 2019

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REVIEW ARTICLES  

Oral and paraoral structures; An aid for person identification: A review on forensic stomatology Highly accessed article p. 131
Vidya Kadashetti, KM Shivakumar, Rajendra Baad, Nupura Vibhute, Uzma Belgaumi, B Sushma, K Wasim
DOI:10.4103/cjhr.cjhr_140_18  
The identification of oral tissues, including bone and teeth remains, is of primary importance when the deceased person is skeletonized, decomposed, burned, or dismembered. Primary role in the identification of remains when postmortem changes, traumatic tissue injury or lack of a fingerprint record invalidate the use of visual or fingerprint methods in Forensic Odontology. Forensic medicine and odontology has become an integral part for investigations and identification over the past decades. Forensic odontology utilizes oral and paraoral findings to serve the judicial system to investigate the truth head-and-neck findings can be used for identification as using them is cost-effective, reliable, and fast. Forensic odontology is a branch of dentistry that analyzes dental evidence to overlap the dental and legal profession. The tooth has been used as an evidence in the identification of the biter, age estimation, and gender determination of the accused. The study of forensic stomatology helps in criminal, noncriminal, and research purposes.
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Patient-centric approach through “Multi-Purpose Behavior Therapy (MPBT)” room for improving patient's satisfaction and decreasing work load in Hospitals: An analysis from available evidence Highly accessed article p. 135
Sudip Bhattacharya, Amarjeet Singh
DOI:10.4103/cjhr.cjhr_128_18  
Many studies from India have documented that patients are not satisfied with their treatment provided in the hospitals. The common reasons of patient's dissatisfaction are overcrowding, long waiting time to meet doctors, short consultation period (2 minutes), absence of a congenial environment, and communication gap. It is well known fact that there is frustration with systemic problems of government hospitals, from poor budgetary allocation to shortage of health care staff. It is evident from management studies that, if we have to give better output without changes in the input level we have to improve our existing processes. Improvement of any system is possible by proper system analysis, system design and effective implementation. In hospitals also, our aim is to design and implement a customized and comprehensive care plan, giving more emphasis on the patient's problems than on their diagnosis. Person centered care is underpinned by values of respect for persons, individuals right to self-determination, understanding, empathy, tow way communication and eye to eye contact. Newer concepts like social prescribing in patient care have been implemented in the Multi-Purpose Behavior Therapy (MPBT) room project at PGIMER, Chandigarh for urinary incontinence, dysmenorrhea, osteoarthritis and polycystic ovarian disease patients. Our results indicate that it is feasible to impart health promotion orientation in gynae OPD and orthopedic OPD through counselling of patients for de-medicalization of management of their health problems. Doctors also reported reduced workload. However, this model can be adopted in any clinical department for improving patient satisfaction and decrease workload in hospitals..
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ORIGINAL ARTICLES Top

Correlation between high-resolution computed tomography temporal bone findings and surgical findings in patients with inflammatory diseases of the middle ear p. 140
Jeslean Jose, Uttam B George, Ashish Varghese, Shubhra Rathore
DOI:10.4103/cjhr.cjhr_161_18  
Background: With the advent of high-resolution computed tomography (HRCT), more information can be obtained about the anatomy of the middle ear, soft tissue pathologies, and the complications of middle ear disease process as compared to the conventional diagnostic methods. Aims: This study aims to study the spectrum of HRCT temporal bone findings in inflammatory middle ear diseases as well as correlate computed tomography (CT) with intraoperative findings. Settings and Design: This is a cross-sectional study including all consecutive patients presenting to the ear, nose, and throat department with a provisional diagnosis of inflammatory middle ear disease requiring surgical management and referred to department of radiodiagnosis for HRCT temporal bone. Materials and Methods: The HRCT findings of 58 such patients were compared with the intraoperative findings. Statistical Analysis Used: Interrater agreement Kappa was used to find agreement between CT and surgical findings. Diagnostic test was used to find out sensitivity, specificity, negative predictive value, and positive predictive value of CT taking surgery as gold standard. P < 0.05 was considered as statistically significant. Results: HRCT had high sensitivity for delineating the disease at most of the sites except for the facial canal and integrity of stapes. Correlative accuracy was highest in the region of the incus, labyrinth, scutum, sinus plate, inner ear, and jugular bulb. Conclusions: Our study showed moderate to very good correlation between HRCT temporal bone and operative findings. It also allowed early identification of complications enabling a better surgical approach and treatment plan.
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Analysis, comparison, and significance of nested polymerase chain reaction with conventional methods for the diagnosis of pulmonary and extrapulmonary tuberculosis among the rural population of North India p. 146
Amit Singh, Seema Dayal
DOI:10.4103/cjhr.cjhr_87_18  
Introduction: Tuberculosis (TB) is one of the most common infectious diseases among the Indian population, especially in rural scenario. It affects young people in majority. Living at slum areas and poverty are predisposing etiological factors. The diagnosis of TB is based on microbiology, cytology, and histopathology. Materials and Methods: The present study was carried out in the Department of Microbiology in collaboration with the Department of Pathology, UPUMS, Saifai, Etawah, UP, India, from January 2015 to June 2016. Samples were collected from suspected tubercular patients. A total of 101 samples were collected including tissue, ascitic fluid, pleural fluid, cerebral fluids, bronchoalveolar lavage, tracheal aspirates, urine, sputum, and pus from clinically suspected cases. Ziehl–Neelsen (ZN) staining, fluorescent staining with auramine phenol, culture on Löwenstein–Jensen (LJ) media, mycobacterial growth indicator tube (MGIT), and Middlebrook media were done. Subsequently, biochemical tests such as niacin detection, catalase test, and nitrate reduction test were done for identification of mycobacteria. Nested polymerase chain reaction (PCR) was performed for the detection of Mycobacteria in clinical samples. Results: Of the 101 suspected tubercular patients, males were more, and the maximum age group involved was 21–40 years. ZN staining was found positive in 16 cases which included ten extrapulmonary and six pulmonary, whereas auramine phenol was found positive in 22 cases which included 14 extrapulmonary and 8 pulmonary. Of 101 patients, 35 (34.6%) were found to be LJ culture positive, whereas 49 (48.5%) were found positive with MGIT culture. PCR for TB was found maximum, which was 76 (75.2%). Conclusion: TB is common among the young group with more predilection among males. Smear- and culture-negative specimens could not rule out TB. Nested PCR proved to be highly sensitive in detecting Mycobacterium tuberculosis DNA. Hence, when TB is suspected, a combination of conventional test and newer rapid techniques such as PCR is always required for the early diagnosis and treatment of TB.
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Level of stress among schoolteachers of a school in South Delhi, India p. 150
Mamta Parashar, Deeksha Ellawadi, Mitasha Singh, Ram Chander Jiloha
DOI:10.4103/cjhr.cjhr_85_18  
Background: Modernization and increasing level of competition in day to day life has increased the expectations from teachers. Objective: To describe the level of stress and its associated factors among teachers using Teacher's stress inventory in a government school of urban area of South Delhi. Methods: A cross sectional study among teachers of a senior secondary school located in south Delhi. This was part of mental health literacy workshop conducted March 2017. 124 teachers attended the same and 94 participated in the study. Teachers' stress inventory scale was used as a tool to assess the level of stress along with demographic factors of the study participants. Only 82 completed questionnaires were included in analysis. Results: The mean score among discipline and motivation sub category was a significantly higher source of stress among young age teachers (P <0.001). The mean scores among females were higher as compared to males among the sources of stress however the difference was not statistically significant. Joint family was a significant stressor source especially under professional distress in bivariate analysis (P: 0.04). As the experience duration increased the mean stress score also increased (correlation coefficient: 0.10, P: 0.36). All the variables were subjected to multiple linear regression models and it was found that gender, education and family income are significant predictors with stress as dependent variable. Conclusion: The social and economic instability cut across all ages and increase the risk of stress and burnout.
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Is combined spinal-epidural more effective compared to epidural for labor analgesia? p. 156
Jerry Joseph Joel, Narjeet K Osahan, Ekta Rai, Priyanka Daniel, Sunimal Bhaggien
DOI:10.4103/cjhr.cjhr_99_18  
Aims and Objectives: This study aims to compare the effectiveness of combined spinal-epidural (CSE) analgesia and low-dose epidural analgesia in labor and study their effects on maternal and fetal well-being. Material and Methods: Sixty parturients classified as the American Society of Anesthesiologists I, in established labor and requesting epidural, were alternately divided into two groups (30 each). Group I received 0.125% bupivacaine with fentanyl 2 ug/ml epidural analgesia. Group II received CSE analgesia comprising of 25 μg fentanyl in the intrathecal space and 0.125% bupivacaine with fentanyl 2 ug/ml for epidural analgesia. Onset of analgesia, maternal hemodynamics, fetal heart rate, duration of labor, ambulation, incidence of cesarean section, instrumental delivery, side effects, and total dose of bupivacaine and fentanyl used were recorded. Results: Onset of analgesia in CSE group (1.48 ± 0.46 min) was significantly faster compared to the epidural group (3.87 ± 0.83 min). Duration of the first stage of labor was shorter in the CSE group (218.93 ± 78.15 min) compared to epidural group (308.03 ± 147). No significant difference between the groups was found in hemodynamic effects, duration of the second stage of labor, or in maternal and neonatal outcomes. Pruritus was seen in 50% of CSE patients. Mean total bupivacaine used in CSE group was significantly lesser than that used in Group I (56.750 ± 22.33 mg vs. 79.325 ± 28.81 mg). Conclusion: Both CSE and epidural analgesia provide comparable pain relief and maternal and fetal outcomes. CSE can be beneficial for parturients coming in advanced labor as its onset of action is faster.
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Assessment of hepatitis B virus genotype D and interleukin-10, interferon gamma, and tumor necrosis factor-α in fulminant hepatic failure p. 162
Meher Rizvi, Hiba Sami, Mohd Azam, Indu Shukla, Haris M Khan, MR Ajmal
DOI:10.4103/cjhr.cjhr_131_18  
Background: Genotypically, hepatitis B virus (HBV) is divided into 8 groups, A–H. The interaction between HBV replication and immune responses against HBV infection plays an important role in the pathogenesis of virus infection. Aims and Objectives: In an attempt to elucidate the role of immunomodulatory, pro-inflammatory, and anti-inflammatory mediators in the pathogenesis of HBV genotype D fulminant hepatitis (FH), we assessed the role of interferon gamma (IFN-γ), tumor necrosis factor-α (TNF-α), and interleukin-10 (IL-10) in such patients. Subjects and Methods: Two hundred and seventy-six cases of acute hepatitis among which 37 cases of fulminant hepatic failure were screened. A genotyping system based on polymerase chain reaction using type-specific primers was used in this study (Sami et al. 2013). TNF-α, IL-10 levels, and IFN-γ serum level were measured by ELISA. Results: Genotype D was detected in 10 cases (27.02%) out of 37 FH patients. Mean IL-10, IFN-γ, and TNF-α levels in FH patients were significantly higher than the healthy controls at 127.6 ± 73.45 pg/ml (P < 0.001), 10.6778 ± 5.23 pg/ml (P < 0.0001), and 62.9000 ± 21.67 pg/ml (P < 0.001), respectively. IFN-γ and IL-10 levels were much higher in cases of hepatitis B e-antigen (HBeAg) seronegative individuals, mean levels being 20.77 pg/ml and 36.53 pg/ml, respectively. Using multiple linear regression analysis, the presence of HBeAg was inversely associated with TNF-α. Conclusion: This study clearly highlights the excessive dysregulated response of the three cytokines, more so of IL-10 which appears pivotal in the pathogenesis of FH. Interventions leading to suppression of IL-10 levels may be beneficial in improving the patient outcome.
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Risk factors for active tuberculosis in human immunodeficiency virus-infected individuals p. 167
Vijay Prakash Turaka, Roshini G Nair, Tunny Sebastian, Rajesh Kannangai, Joy Sarojini Michael, George M Varghese
DOI:10.4103/cjhr.cjhr_91_18  
Context: Tuberculosis (TB) has become the most common opportunistic infection among individuals with human immunodeficiency virus (HIV) infection worldwide and continues to be a major killer resulting in 0.4 million deaths every year. While some of the risk factors for developing TB in HIV-infected individuals are known, identifying other risk factors will help in screening strategies to pick out those at higher risk for closer follow-up. Aims: The aim of this study was to identify the risk factors related to the development of active TB in HIV-infected individuals. Settings and Design: This case–control study among the HIV-infected individuals was carried out at a HIV clinic in a large tertiary care hospital in South India. Methods: HIV-infected individuals >18 years of age with confirmed TB were chosen as cases. For each case, two age- and sex-matched controls, diagnosed to have HIV infection without active TB or history of TB, were included. The potential risk factors for the development of active TB were evaluated using the odds ratios (ORs) and logistic regression analysis. Results: A total of 150 patients, 50 cases (mean age: 39.3 ± 7.2 years) and 100 controls (mean age: 40.2 ± 7.1 years) were included. On univariate analysis, smoking (OR 8.14, 95% confidence interval [CI]: 3.13–21.21; P < 0.001), low body mass index (OR 6.31, 95% CI: 2.75–14.48; P < 0.001), chronic obstructive pulmonary disease (P = 0.013), ethanol consumption (OR 8.61, 95% CI: 3.57–20.81; P < 0.001), CD4 cell count < 200 cells/μL (OR 13.12, 95% CI: 5.64–30.50; P < 0.001), and not on antiretroviral treatment (ART) (13.34, 95% CI: 5.85–30.41; P < 0.001) were associated with active TB. The risk factors found to be independently associated were CD4 counts < 200 cells/μL (OR 5.75, 95% CI: 1.81–18.20; P = 0003), smoking (OR 7.40, 95% CI: 1.47–37.15; P = 0.015), and not being on ART (OR 13.94, 95% CI: 3.84–50.61; P < 0.001). Conclusion: Initiating ART as soon as possible and patient education on modifiable risk factors including counseling for smoking cessation for HIV-infected individuals are warranted.
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Sonographic assessment of normal fetal cerebral lateral ventricular diameter at different gestational ages among fetuses in Southern Nigeria p. 172
Benjamin Effiong Udoh, Anthony Chukwuka Ugwu, Alhaji Modu Ali, Hyacinth Uche Chiegwu, Joseph Chukwuma Eze, Ulu Okoro Ulu
DOI:10.4103/cjhr.cjhr_98_18  
Aim: The study was to determine the normal fetal lateral ventricular diameter using ultrasound at different gestational ages (GAs). Materials and Methods: This is a prospective cross-sectional descriptive study of the fetal cerebral lateral ventricular diameter of 685 singleton fetuses. Measurement of the fetal lateral ventricular diameter was obtained from fetuses of pregnant mothers that met the inclusion criteria during the routine ultrasound scan in Calabar metropolis. A sufficient ultrasound gel was applied on the abdomen of the subject and scanning was done at different planes until a good ovoid shape of the fetal skull was achieved. Axial images at the level of the lateral ventricles were obtained. The widest part of the posterior lateral ventricle far from the transducer was measured more than once and the average value computed for each subject. Results: About 85.4% of the patients were multiparous while 14.6 were primipara. The ages of the pregnant mothers ranged from 20 to 35 years with a mean age of 28 ± 3 years. The male fetuses were 311 while the female was 374. The lateral ventricular diameter did not show any significant correlation with fetal characteristics such as gender, estimated fetal weight, and fetal head circumference throughout gestation. However, the fetal ventricular diameter had a weak but not statistically significant correlation with GA of the fetus (r, P = 0.13, 0.06). Conclusion: Our studies show that 10 mm is the acceptable upper limits of normal for fetal lateral ventricular diameter (FLVD) of fetuses in Southern Nigeria. Ventricular diameter out of this normal range in this region could be considered abnormal and may demand further investigations.
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MEDICAL EDUCATION Top

Employing a systematic approach to conduct program evaluation in medical education p. 176
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cjhr.cjhr_31_19  
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MEDICAL HISTORY Top

Did job in the bible have flatbush diabetes mellitus? p. 178
Sanjay Kalra, Andrew Uloko, Jubbin Jagan Jacob
DOI:10.4103/cjhr.cjhr_151_18  
The Book of Job, a poetic book in the Old Testament narrates the story of Job, the “richest man in the East.” Job was afflicted by a severe illness, which tested his coping abilities and his resolve. Job's illness, and the way he coped with it has many lessons for health-care providers. In this brief communication, we hypothesize that Job suffered from diabetes, with various acute and vascular complications. We further suggest that he had type 1.5 diabetes or flat bush diabetes which is a subtype of type 2 diabetes with an explosive presentation like type 1 diabetes initially followed by sustained course like regular type 2 diabetes mellitus. This explanation accounts for the severity of his symptoms, as well as his eventual recovery. Job's words retain their relevance for modern readers: We take this opportunity to remind ourselves of the importance of patient-centered care.
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CASE REPORTS Top

Spontaneous expanding internal oblique hematoma induced by vigorous cough in an elderly patient under antiplatelet therapy: Case report and review of literature p. 181
Reddy Ravikanth
DOI:10.4103/cjhr.cjhr_108_18  
Oblique muscle hematomas are an uncommon cause of acute abdominal pain and are more common in elderly individuals, particularly in those under anticoagulant therapy. They are often misdiagnosed from other causes of abdominal pain. We report a case of a cough-induced internal oblique hematoma in an elderly 62-year-old male patient under antiplatelet therapy. He had no history of trauma and presented with acute worsening pain in the left flank. Ultrasonography revealed a hypoechoic mass in the right lateral abdominal wall. Nonenhanced computed tomography of the abdomen showed a 6 cm × 4 cm × 7 cm hematoma in the left internal oblique muscle. The patient was managed conservatively without blood transfusion. Differential diagnosis of an acute-onset flank mass should include oblique muscle hematoma even in the absence of anticoagulant therapy or trauma.
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A report of cerebellopontine angle epidermoid presenting with trigeminal neuralgia p. 184
Paramdeep Singh, Rupinderjeet Kaur, Rashmeet Kaur
DOI:10.4103/cjhr.cjhr_150_18  
Trigeminal neuralgia is typified by recurrent attacks of unilateral facial pain that is often severe and starts with cutaneous stimulation. These paroxysms usually last for few seconds, and the etiology comprises compression of the trigeminal nerve by vessels and space-occupying lesions of the brain and involvement by inflammatory plaques. It is rare for intracranial epidermoids to present as trigeminal neuralgia which is usually seen at the cerebellopontine angle, third ventricle, and suprasellar area and comprise about 1% of all intracranial tumors. We present the case of a 35-year-old male who had episodes of left-sided facial pain for the last few months. Magnetic resonance imaging revealed left cerebellopontine epidermoid which showed restriction on diffusion-weighted imaging and was operated upon. The symptoms completely resolved after the surgery.
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Acute psychoses: An unusual presentation of empty sella syndrome p. 187
Abhishek Singhai, Karan Kapur, Sagar Khadanga, Aparna Paramanandam
DOI:10.4103/cjhr.cjhr_139_18  
We report a case of a 54-year-old female admitted to our hospital with altered behavior. We found that severe hyponatremia (116 mEq/L) was the cause of the patient's status. In turn, hyponatremia was due to panhypopituitarism. Mild-to-moderate hyponatremia had been previously detected in this patient; however, it was overlooked. The clinical onset of panhypopituitarism is often characterized by mild nonspecific symptoms, especially in the older people, and it is often overlooked. Although hyponatremia is a common electrolyte disorder in the elderly, physicians should not forget that it could be the leading manifestation of panhypopituitarism. Panhypopituitarism may be easily diagnosed; however, clinical suspicion is needed. Due to the high mortality associated with panhypopituitarism, hormone assays should be included in the initial diagnostic workup of hyponatremia.
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Penetrating injury to the maxilla and skull base resulting in the mount fuji sign of tension pneumocephalus and ipsilateral vision loss p. 191
Reddy Ravikanth, Ashwin Chandrasekhar, Anegh Pavithran, Sivakumar Kandasamy, John Joshy
DOI:10.4103/cjhr.cjhr_106_18  
Pneumocephalus is defined as the presence of intracranial air seen most commonly secondary to a traumatic head injury. Tension pneumocephalus is often termed in radiology as the Mount Fuji sign due to a perceived similarity with the iconic mountain peak in Japan. We present the case of a 62-year-old gentleman who presented to the emergency department following a penetrating injury to the right maxilla and skull base which resulted in acute-onset ipsilateral vision loss due to direct traumatic injury to the optic nerve by the fractured bone fragments encountered in the optic canal.
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IMAGE Top

Unusual presentation of intraventricular metastases from small-cell carcinoma of the lung p. 194
Reddy Ravikanth, Kanagasabai Kamalasekar
DOI:10.4103/cjhr.cjhr_137_18  
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LETTERS TO EDITORS Top

Reconsidering the axioms of medical education researches – What we need first? p. 196
V Dinesh Kumar
DOI:10.4103/cjhr.cjhr_159_18  
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Relationship between body mass index and blood pressure in school students p. 198
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/cjhr.cjhr_114_18  
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