Medicine

Keeping in pace with the new Biomedical Waste Management Rules: What we need to know! Publication date: Available online 15 April 2019 Source: Medical Journal Armed Forces India Author(s): Gurpreet Singh Bhalla, Kuntal Bandyopadhyay, Kavita Sahai Abstract Biomedical Waste Management Rules were first implemented in our country on 20th July 1998. Thereafter, the rules have undergone periodic updates and amendments in the years 2003 and 2011. Latest Biomedical Waste Management Rules, 2016, and (Amendment) Rules, 2018, were an update and simplification of BMW disposal as compared with the previous version, keeping in pace with the changes in the requirements of the health-care setup. Although exhaustive, numerous medical devices/products/kits did not find any mention even in the latest amendment of the rules. Thus, this article aims to bring out the key points to be known by all health-care workers and the gray areas which require clarification and inclusion in the rules for a completeness of the said rules.

Hemophagocytic lymphohistiocytosis in a child with chronic granulomatous disease: A rare complication of a rare disorder Publication date: Available online 15 April 2019 Source: Medical Journal Armed Forces India Author(s): Gitanjali Jain, Suprita Kalra, Saurabh Sharma, Gautam Kumar Vasnik, Rakesh Gupta Abstract Chronic Granulomatous Disease (CGD) is a primary immunodeficiency disorder (PID) of phagocytic cells resulting in failure to eradicate catalase positive microorganisms like Staphylococci and fungal infections; due to deficiency or malfunction of nicotinamide adenine dinucleotide phosphate (NADPH)-oxidase subunits in phagocytic leucocytes. We illustrate here one such case; a six year old girl who was admitted in our hospital with history of prolonged fever, non resolving bilateral otitis media and recurrent pneumonia. She was evaluated for an underlying PID and was found to have CGD based on Nitro blue Tetrazolium (NBT) Slide Test and flow cytometric Dihydrorhodamine (DHR) assay. The child was symptomatic despite initial treatment with first-line followed by second-line antibiotics. During the course of current systemic infection, she also developed infection-associated secondary Hemophagocytic Lympho Histiocytosis (HLH) as suggested by her clinical and laboratory parameters. Despite a thorough search, no microorganism could be isolated and so she was treated with empircal antibiotic therapy comprising of meropenem, linezolid and an antifungal. Fever resolved with gradual improvement of laboratory parameters and finally spontaneous resolution of HLH. We conclude that a high index of suspicion for PID is required in a child with recurrent infections. Identification of underlying infectious agent should be attempted to start targeted antimicrobial therapy; both to prevent as well as cure infection associated secondary HLH.

Endothelial corneal transplants: indications, clinical profile and surgical outcomes in a tertiary care hospital Publication date: Available online 15 April 2019 Source: Medical Journal Armed Forces India Author(s): Vijay Kumar Sharma, Santosh Kumar, Sagarika Patyal, Hemant S. Trehan, Arun Kumar Yadav, K. Raji, Anirudh Singh Abstract Background Endothelial keratoplasties have become the surgical procedure of choice over full thickness penetrating keratoplasty for corneal decompensation because of endothelial dysfunction. Methods A retrospective data review was performed from February 2016 to April 2017 for all the patients who underwent endothelial keratoplasty in a tertiary care center for Indian Armed Forces. Results A total of 161 corneal transplants were performed; endothelial keratoplasties accounted for 34 (21.1%) transplants. Most common indication was pseudophakic/aphakic bullous keratopathy followed by Ahmed glaucoma valve–related corneal decompensation and Fuchs' corneal dystrophy, respectively. Mean preoperative corneal thickness was 845.96 ± 106.9 microns. Mean lenticule thickness was 131.55 ± 42.47 microns with microkeratome for descemet stripping automated endothelial keratoplasty (DSAEK) and 174 ± 70.4 microns manually for descemet stripping endothelial keratoplasty (DSEK). Mean preoperative best-corrected visual acuity (BCVA) was 1.65 LogMAR (Snellen equivalent in meters 2/60 approx) which significantly improved to 0.82 LogMAR (Snellen equivalent in meters 6/36 approx) after surgery. In the DSAEK group, BCVA improved from 1.61 to 0.7 LogMAR, whereas in the DSEK group, the visual acuity improved from 1.7 to 0.94 LogMAR at one-month postoperative period. Postoperatively, two patients had graft detachment and had to undergo repeat DSAEK. Conclusion Study results suggest the similar trends in our tertiary care hospital as in other most advanced ophthalmic centers around the world for adoption of newer techniques of lamellar corneal transplants and their outcomes.

Clinical manifestation and images of a patient having cardiovascular involvement in myxoedema coma Publication date: Available online 15 April 2019 Source: Medical Journal Armed Forces India Author(s): Vishesh Verma, Anil S. Menon, Ajay Bahadur, Ajeet Sikarwar Abstract Myxoedema coma is an endocrine emergency characterised by diminished sensorium associated with features of severe hypothyroidism. The disease carries a high mortality of 30%–60 %. The cardiac manifestation of the disease consists of bradycardia, hypotension, pericardial effusion and certain echocardiographic changes such as heart block and features of hypothermia. Here, we report a case of myxoedema coma with characteristic cardiac manifestations. These manifestations revert promptly on starting treatment, and achieving a eumetabolic status as was demonstrated in this patient.

Comparison of electrosurgery by electrodessication versus cryotherapy by liquid nitrogen spray technique in the treatment of plantar warts Publication date: Available online 15 April 2019 Source: Medical Journal Armed Forces India Author(s): Sehdev Singh, Shekhar Neema Abstract Background Warts or verrucae are benign proliferations of the skin and mucosa resulting from infection with papilloma viruses. Warts form a small subset of patients attending skin out-patient department (OPD), out of which the plantar warts are one of the common presentation. The present study is an attempt to compare two modalities of treatment that is electrosurgery and cryotherapy in patients with plantar warts. There are no studies available where comparison of complications between two modalities has been done in plantar warts thus making it one of unique studies of its kind. Methods A prospective, comparative study was conducted over a period of 6 years. After exclusion criteria, one hundred forty-seven male patients having plantar warts were included in the study. Selection of patients suffering from warts subjected to treatment was done by simple random selection. After treatment, 39 patients were lost to follow-up, and finally 48 patients treated by electrosurgery and 60 by cryotherapy were compared and analysed statistically for response to treatment and incidence of complications. Results The overall clearance rate was 75% in electrosurgery versus 73.3% in cryotherapy patients. The pain, delayed wound healing and scarring were observed significantly in more patients treated with electrosurgery than cryotherapy. In our study, recurrence at 24 weeks was observed in 21.9% of the electrosurgery patients which was slightly higher than cryotherapy, where it was 16.6%. Conclusion This study highlighted that cryotherapy is quick, safe and comparatively painless procedure with less complications with success almost similar to electrosurgery making it more suitable for plantar warts.

Food poisoning outbreak in a religious mass gathering Publication date: Available online 5 April 2019 Source: Medical Journal Armed Forces India Author(s): Swati Bajaj, Puja Dudeja Abstract Background Food poisoning outbreaks are commonly seen in mass social events where food is prepared under temporary arrangements. This study reports a food poisoning outbreak in a city of western Maharashtra, India, where around 4000 people had consumed food during a religious community lunch and reported sick to the nearby hospital with complaints of diarrhea, abdominal cramps, fever with chills, and vomiting. Methods This was a retrospective–prospective study. Investigation of the food poisoning outbreak was conducted to identify the causes and recommend preventive measures. Interview method was used to elicit food history from the affected and non-affected persons. Inspection of the cooking area was conducted to find the likely source of contamination. Results A total of 291 patients reported sick after consumption of meal at a religious mass gathering. The range of incubation period was from 10 hours to 40 hours. Predominant features were diarrhea (100%), abdominal cramps (89%), fever with chills (81%), and vomiting (28.5%). Maximum relative risk of 14.89 was seen for green gram (moong dal) with 95% confidence interval of 2.16–102.6. Keeping the incubation period and clinical profile in view, the likely organisms are enteropathogenic Escherichia coli or Salmonella spp. Conclusion Maintaining food safety during mass gatherings is a major challenge for public health authorities. The Food Safety and Standards Act (2006) in India brings the food consumed during religious gatherings such as 'prasad' and 'langar' under its purview and comprehensively addresses this issue.

Rapid in-situ hybridization and immunohistochemistry: a pilot comparative study of two rapid diagnostic techniques for establishing monoclonality in plasma cell dyscrasias Publication date: Available online 5 April 2019 Source: Medical Journal Armed Forces India Author(s): Arijit Sen, Divya Gupta, Rajat Jagani Abstract Background Light chain restriction needs to be established on the paraffin embedded tissue in certain types of plasma cell dyscrasias when serum levels of monoclonal immunoglobulins and light chain assays in the urine and serum may be normal. Rapid-in-situ-hybridisation (RISH) is thought to be a superior to immunohistochemistry (IHC) for kappa and lambda staining due to brighter and crisp staining without any background. Methods Fifty cases were included in this pilot study. Serum light chain restriction status of the case was taken as gold standard. The results of standard IHC for kappa and lambda immunoglobulins on the bone marrow biopsy of these cases was compared with RISH performed by the two commercially available kits. The results of the two methods were compared for sensitivity, need to repeat the test and background staining. Results The study found that in IHC first run sensitivity was 58% which improved to 88% after the second run. For RISH the sensitivity was 100%. Conclusion Rapid-in-situ-hybridisation (RISH) is a superior technique to IHC for detecting kappa and lambda light chain in plasma cells. The test is as labour intensive and time consuming as the routine IHC but has no background staining with more bright and crisp staining quality.

Bilateral ptosis: An unusual presentation of mid brain tuberculoma Publication date: Available online 2 April 2019 Source: Medical Journal Armed Forces India Author(s): J. Sankar, S.S. Majumdar, Manish Unniyal, Harmanpreet Singh, Atul Khullar, Kishore Kumar Abstract Central nervous system tuberculoma can have different clinical manifestations like headache, seizures, papilledema or other signs of raised intracranial pressure depending up on the site and number of tuberculoma. We report a case of 56 year old female reported with history of bilateral asymmetric ptosis of one month duration,with no other neurological defecit. Magnetic resonance imaging (MRI) brain revealed well defined ring enhancing lesion in the medial aspect of left hemi midbrain with diffuse disproportionate perilessional edema. Contrast Enhanced Computed Tomogram (CECT) of chest and abdomen revealed features of disseminated tuberculosis. She was diagnosed as a case of disseminated tuberculosis and started on antitubercular therapy with steroids and the ptosis almost resolved after 01 month of antitubercular therapy. Our case report is unique in the sense that only few cases of midbrain tuberculoma causing occulomotor abnormalities are reported in literature.

Primary pulmonary Hodgkin's lymphoma with pulmonary histoplasmosis Publication date: Available online 2 April 2019 Source: Medical Journal Armed Forces India Author(s): G.S. Chowdhary, Ritu Mehta, Rahul Tyagi Abstract Primary pulmonary Hodgkins lymphoma is a rare and enigmatic neoplasm commonly seen in females. The aim of this case report is to emphasize that pulmonary lymphoma should be considered as a differential diagnosis in a young patient presenting with a lung mass and B symptoms. Extensive clinical details, imaging should be done to rule out the secondary involvement of lung by other lymphomas.

Correlation between cerebral co-oximetry (rSO2) and outcomes in traumatic brain injury cases: A prospective, observational study Publication date: April 2019 Source: Medical Journal Armed Forces India, Volume 75, Issue 2 Author(s): Mathews Jacob, M.N. Kale, Shahabaz Hasnain Abstract Background Traumatic brain injury (TBI) is known to be an important reason for the increase in disabilities and deaths worldwide. Studies have demonstrated that brain tissue oxygen (PO2) monitoring reduces mortality significantly but is a invasive method of monitoring. Therefore, there is a need to monitor cerebral ischemia in TBI by noninvasive methods. The study aims to correlate cerebral co-oximetry and possible outcomes in patients with TBI. Methods The study included 78 patients with TBI admitted in intensive care unit (ICU) with glascow coma scale (GCS) of 8 or less than 8. Near-infrared spectroscopy monitor is applied to the patients immediately after admission to ICU; readings are noted every 4 hours up to first 48 hours, and outcomes studied as survival or neurological deficit are noted at 28 days. Results A total of 12 (15.4%) deaths were seen in this study. Survived patients were further divided into good recovery 33 (42.3%), moderate disability 21(26.9%), major disability 8 (10.3%), and persistent vegetative state 4 (5.1%). The rSO2 values in surviving patients were ranging from mean of 60.74% (standard deviation [SD] 4.38) to a mean of 64.98% (SD 5.01), and the mean rSO2 values in patients who died were ranging from a mean of 52.17% (SD 4.11) to a mean of 37.17% (SD 12.48). Lower rSO2 values were correlating significantly with worse neurological outcome or death by using two independent sample t-test (p < 0.001). Conclusion Cerebral co-oximetry is a simple noninvasive method for predicting the outcomes in TBI and can be used to guide the management of these patients.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com