Spontaneous laceration of spleen with hilar lymph node metastasis: a case of primary splenic mantle cell lymphoma in elderly

Mantle cell lymphoma (MCL) is a type of non-Hodgkin (B-cell) lymphoma (NHL) with manifestations ranging from indolent to aggressive disease. It arises from mantle zone or primary follicle lymphocytes and is associated with translocation t (11;14) which is seen in almost all cases. Most of the cases present at stage III/IV with hepatospenomegaly, generalized lymphadenopathy, bone marrow involvement or lymphoid polyposis. Rate of relapse is high occurring in 50-60% patients and 5-year survival rates are low ~27-30%. Median overall survival is 3.5 years. Age >60 years, raised serum LDH, high mitotic count, Ki67>30%, blastoid or pleomorphic variants, TP53 mutation, gains in 3q,11q and deletions of 13q as well as 17p are important prognostic factors associated with worst outcome. Treatment involves conventional chemo-immunotherapy and stem cell transplantation (SCT). In our case the elderly patient had an atraumatic splenic rupture with no past medical history of trauma. The patient presented to the emergency department with severe abdominal pain in left upper quadrant. Thus emergency splenectomy was executed successfully, and the patient was stabilized. After receiving initial cycle of R-CHOP regime, he was lost to follow up. In this case report, we will discuss the clinical presentation, as well as current treatment guidelines for atraumatic splenic rupture.

Assessment of the patient satisfaction level with outpatient department services in a tertiary care hospital of Jammu region

Background: Outpatient department (OPD) is that section of the hospital which is staffed and equipped to provide diagnostic, therapeutic and rehabilitative care to those patients who are not registered as inpatients while receiving the services during scheduled working hours. Objective of the study was to assess the patient satisfaction level with OPD services in a tertiary-care hospital of Jammu region. Methods: A cross-sectional study was conducted among patients visiting the OPD of the SMGS hospital GMC Jammu from January to March 2023. Exit interviews were conducted using a semi-structured questionnaire among patients availing the services from OPD. Results: Average percentage of total satisfaction score among sampled OPD patients has come out to be 68.13% whereas total average dissatisfaction score was 20.87% and the total average mild dissatisfaction score as 11.00%. Conclusions: This study suggests that patients were satisfied to a larger extent with OPD services except a few which are least satisfied especially with waiting time at registration counter.

De-novo Histoid Leprosy: A Series of Four Cases

Histoid leprosy, an unusual variant of lepromatous leprosy, originally thought to manifest following dapsone monotherapy, is being increasingly reported ‘de-novo’. We hereby report four de-novo cases; one mimicking lupus pernio presenting with an uncommon lesion (plaque) at an extremely rare site (nose). Of the remaining three classical cases, one exhibited a not-so-frequent development of erythema nodosum leprosum (ENL) reaction that needed modified multidrug therapy for two years, other three responded well to standard multibacillary multidrug therapy which was also given for two years.

A quasi-experimental study to compare the acquisition of basic clinical skills in novice medical students taught by George and Doto’s five-step method compared to those taught by the traditional approach (SODOTO)

Objectives: The aim of this study was to compare the acquisition of basic clinical skills by George and Doto’s five step method compared to the Traditional SODOTO approach, and to ascertain the perception of the students regarding these diverse methods. Materials and Methods: Fifty-four 2nd MBBS 1st semester students posted in the Department of Medicine at GMERS, Gotri, were enrolled for the study. After teaching the theory, both groups were taught per abdomen (P/A) examination and respiratory system (R/S) examination – one system by the five-step method and the other by the SODOTO approach. Skill acquisition was tested by pre-validated checklists. Finally, feedback was collected on the perception of students using a pre-validated questionnaire. The data were analysed using GraphPad. Results: There was an average 20% improvement (P < 0.001) in the group taught by the five-step method compared to the one taught by the traditional approach (P/A – 45.14/60 [5.64] vs. 57.86/60 [1.83] [Group B vs. Group A]) (R/S examination – 26.17/40 [6.65] vs. 34.79/40 [3.56] [Group A vs. Group B]). Conclusion: George and Doto’s five-step method has been found to be more effective than the traditional SODOTO approach.

Assessment of the work profile of Accredited Social Health Activist workers in Kathua district of Jammu and Kashmir, India: A cross-sectional study

Background: Accredited Social Health Activist (ASHA) workers and their activity are considered as one of the key components of National Health Mission (NHM). ASHA workers serve as an important link between community and health facilities. Objectives: The objectives of the study were to assess the work profile of ASHA workers in Kathua district of Jammu and Kashmir. Materials and Methods: The present prospective cross-sectional study was conducted in Parole Block of district Kathua in Jammu and Kashmir from February 2019 to May 2019. A total of 176 rural ASHA workers were interviewed using a predesigned, pretested questionnaire after seeking informed consent. Results: About 52.2% catered to a population of 500–1000. About 34% of the workers were educated up to 10th standard and 10.7% up to 12th standard. About 64.2% of the ASHA workers are active in supporting institutional deliveries and 88% of the ASHAs made household visits for nutrition counseling. Conclusions: ASHA acts as a first link between the community and health-care services. Thus, it is necessary to strengthen the role of ASHA on promotive and preventive health care services through regular joint training of ASHAs.

A case of occult fronto temporo parietal meningoencephalocele in an infant.

We describe a case of an occult fronto temporo parietal meningoencephalocele discovered in a 45 days old infant baby. The most common cause for meningoenphalocele is trauma by any means during birth or during development. But here in our case there is lack of such significant history of trauma and so the possible cause of the lesion may be congenital defect only. Preoperative Clinical, CT and MR images are presented. Lesion was removed surgically with satisfactory post operative recovery.

Sex determination from hand dimensions for forensic identification.

Background: Sex determination is an important and foremost criteria in establishing the identity of an individual. The issue of Sex discrimination can be very complicated in cases of intersex, bodies in advanced state of putrefaction, mutilated & fragmentary remains in which it is common to recover dismembered & peripheral parts of the body. It was realized that anthropometric measurements of the hand has been very useful tool in sexual identification. Objectives: This paper attempts to discriminate between male and female on the basis of hand dimensions, to investigate among the variables which can better predict sex, to derive sectioning point for discriminating sex and to reflect frequent hand index category among the sexes. Methods: The research study was based on 182 subjects (91 males & 91 females) within age 18-60 years, devoid of any deformity, fracture or surgical proceedings of either hand were randomly selected from Udaipur district of Rajasthan. Hand Length and Hand Breadth was obtained from each subject and results were analyzed using IBM SPSS computer software. Results: Hand length and hand breadth show statistically significant male – female differences at p<0.001. Hand Breadth was found as best predictor of sex in comparison with hand length. Frequency of hand index categories reveals that females have highest dolichocheir morphology of hand. Sectioning point analysis confirms that cut-off point of 43 and below is suggestive of male hand whereas above 43 were considered as female hand. Conclusions: This study has implications in mass disasters and in criminal cases where an isolated hand is recovered and needs forensic identification.

A Comparative Evaluation of Losartan/ Hydrochlorothiazide (Fixed Combination) versus Amlodipine Monotherapy on Left Ventricular Hypertrophy, Biochemical Parameters and Adverse Effects in Patients of Hypertension.

Background: Long-term administration of antihypertensives require better efficacy and tolerability. Moreover, the agent should regress left ventricular hypertrophy (LVH), which is an important predictor of cardiovascular events. Aims: To comparatively evaluate the effects of losartan/hydrochlorothiazide (LST/HCTZ) and amlodipine (AMLO) on LVH, biochemical parameters and adverse effects in hypertension. Material and methods: Two hundred fifty newly diagnosed hypertensive patients were randomly divided into two groups. LST 50 mg/HCTZ 12.5 mg and AMLO 5 mg once-daily, were administered. Biochemical parameters, adverse effects and ECG were recorded initially and after 6 months of therapy. Statistical analysis was done. Results: Both regimens significantly reduced mean SBP and DBP in each of the six follow ups (p < 0.001). LST/HCTZ caused regression of LVH in greater number of cases (26) than AMLO (20) and also showed a significant increase in mean values of serum creatinine, serum uric acid and high-density lipoprotein (HDL) levels and a significant decrease in Serum cholesterol. In AMLO group only serum creatinine was raised. The most common adverse effects in LST/HCTZ was dizziness (4.5%) and in AMLO group pedal edema (22%). Conclusion: Comparatively LST/HCTZ therapy causes regression of LVH in larger number of cases, increases HDL and is better tolerated.

Five year retrospective survival analysis of triple negative breast cancer in North-West India.

Background: In our institute, about 10% of total cancer is female breast cancer. This analysis was performed to check triple negativity among these patients with their survival strength up to 5 years in relation to different age groups, stage and chemotherapy protocols. Materials and Methods: 208 immunohistochemistry proved triple negative breast cancer patients registered and treated until 2008 were retrospectively selected for the study. Overall survival up to 5 years was observed on the basis of stage, different age groups and chemotherapy regimens. All patients had undergone surgery, conventional external beam radiation therapy and adjuvant chemotherapy. The survival analyses were performed using the Kaplan-Meier method. Results: The majority of patients (41%) were in the age group 21-30 years. Stage IV was seen in 18% of the patients at diagnosis and mainly in 21-40 years age group. Only 3% of females were >70 years age and were of Stage I and II. Overall 5 year survival in Stage I in Cyclophosphamide, Adriamycin/Epirubicin, 5-Flurouracil group was 37.5% as compared with Docetaxel/Paclitaxel, Epirubicin group 93% (P < 0.0001). Conclusion: Triple negativity in North-West India is about 11.8%. We observed it in younger patients mainly with highly aggressive behaviors. Taxane based chemotherapy gives better result as compared with anthracycline based regimens in all stages.

Arteriovenous Malformation in Crouzon Syndrome: A Case Report.

Crouzon syndrome, a hereditary syndrome of craniofacial dysostosis, is a triad of skull deformities, facial anomalies and exophthalmos . It accounts for approximately 4.8% of all cases of craniosynostosis with the prevalence of approximately 1 per 25,000 live births worldwide. This is a case of Crouzon syndrome with arteriovenous malformation over vertex which has not been reported so for in the literature.

Predictors of Hypertension among Adult Tribal Males of India.

Background: Cardiovascular diseases (CVD) have increased worldwide equally burdening people from different ethnic and socio-economic groups. Hypertension is an eminent modifiable risk factor for CVD and relates to body adiposity, which can be evaluated by various anthropometric measurements. Objective: The present study reports prevalence of under nutrition and hypertension, potential predictors of hypertension and new cutoff values for various disease associated adiposity markers in six tribal populations inhabiting different states in India. Methods: Cross sectional sample of 910 adult males aged 46.98 ±17.17 years was studied. Anthropometric measurement (height, body weight, body circumferences, skinfold thicknesses), blood pressure and socio-demographic characteristics were ascertained. General and regional adiposity indices, muscle diameter and fat % were derived. Descriptive, multivariate regression analyses were performed. Receiver operating characteristics (ROC) was used to determine optimal cutoffs values. Results: Underweight (45.3%) and hypertension [Systolic blood pressure (SBP) - 15.2%, Diastolic blood pressure (DBP)-25.5%] co-exist increasing the morbidity in the tribal population under study. General adiposity measures were better predictors of hypertension. Body mass index (BMI), fat% (negatively associated), age and mid upper arm circumference (positively associated) were independent risk factor for hypertension. Out of all reported cut offs, the new BMI cutoff values (20.12 kg/m2 and 18.98 kg/m2) and for mid upper arm circumference (MUAC) (21.44cm and 21.95cm) for predicting SBP and DBP respectively corresponding nearly to earlier reported standards by World health Organization (WHO). Conclusion: The inverse association of general adiposity markers with blood pressure among the present subjects indicates that CVD is not only prevalent among the affluents but is also affecting the socio-economically and nutritionally deprived groups. Population specific cutoffs for the anthropometric markers are needed to identify individuals with different body compositions at risk. Long term treatment expenses and health burden further depletes the limited economic resources of these vulnerable groups creating a vicious cycle of CVD and under nutrition.

An analysis of prescription patterns in cases of uncomplicated hypertension in a tertiary care hospital.

Background & objectives- Prescribing pattern in hypertension patients were found to be different from the recommended guidelines in the past. The objectives of the present study were to analyze prescribing trends in uncomplicated hypertension and to compare with those of current international guidelines with the objective to note any deviation. Methods- A prescription based analysis in 1400 hundred uncomplicated hypertensives in the age group 30 to 60 years was carried out. Results- Monotherapy was prescribed to 893 cases (M 407; F 486) and combination therapy to 507 cases (M 342; F 165). Overall, Calcium Channel Blockers (CCBs) were the most common agents used 787 (56.21%) cases, 350 monotherapy and 437 as combination therapy. Angiotensin Converting Enzyme Inhibitors (ACE I) 452 (32.28%) and Angiotensin II Receptor Blockers (ARBs) 231 (16.5%) cases were the next preferred groups. In double drug combination CCB+ Beta Blockers (BB) and for triple drug combination CCB+ARB+ Diuretics (D) were more preferred. A significant effect of age (p<0.01) on prescription of CCBs was noted. Prescription of ARBs and D were significantly (p<0.05 and <0.01 respectively) influenced by gender. Gender had no significant effect on the prescribing trend of antihypertensive agents in combination therapy, while a significant effect (p<0.05) of age and combined drug classes CCB+ACE I and CCB+BB+D was noted. The overall prescription rate for diuretics was 40.24% and that for monotherapy was meagre 5.15% (M 1.23%±; F 3.92%). Diuretics were always prescribed in triple drug combinations. Interpretation & Conclusions- CCBs were the most commonly prescribed agents. A deviation existed between antihypertensives prescribed and current international guidelines thus calling upon greater awareness.

Utility of carotid intimal medial thickness as a screening tool for evaluation of coronary artery disease in pre-transplant end stage renal disease.

BACKGROUND: Coronary artery disease (CAD) is associated with a higher incidence of allograft failure and mortality in patients with end-stage renal disease (ESRD) following renal transplant. AIM: To evaluate the efficacy of using carotid intimal medial thickness (CIMT) to predict the presence of CAD in patients with ESRD, using coronary angiography (CAG) as the gold standard. MATERIALS AND METHODS: This prospective study enrolled consecutive patients with ESRD who underwent CAG as a part of pretransplant evaluation to rule out the presence of atherosclerotic CAD. An operator who was blinded with respect to the results of the CAG, measured carotid IMT in all patients prior to CAG and recorded it on videotape. Two independent observers blinded to the results of CAG measured carotid IMT offline to validate its predictive accuracy as a noninvasive test in predicting the presence or absence of CAD. Measurement of carotid IMT was done on USG B mode 7.5 MHZ probe [HP 5500 andover, Massachusetts]. Student's t-test was used for inter-group comparisons. Pearson correlation coefficient test was used to assess the relation between CAD and various risk factors and carotid IMT. Linear regression analysis was applied to identify independent factors determining presence of CAD. A P value < 0.05 was considered statistically significant. RESULTS: Mean CIMT was significantly higher in those with CAD as compared to those without [0.80+/- 0.06 vs.0.70+/-0.06 mm, P< 0.0001). Patients with CIMT> 0.75 mm were older and had more incidence of diabetes(78% vs. 47%; P=0.001). Only 4/53 (7%) of patients with CIMT< 0.75 mm had CAD, vs. 38/52 (73%) in those with CIMT >0.75 mm. The sensitivity and specificity of using CIMT > 0.75 as a predictor of CAD was 90.47%and 73% and its positive and negative predictive values were 0.73 and 0.92. On multivariate analysis, only CIMT was a significant predictor of CAD. CONCLUSION: Carotid IMT can be used to predict CAD in patients with ESRD. In the absence of other risk factors,patients with IMT< 0.75 mm may not need a pretransplant CAG.

Prevalence of anaemia in pregnant & lactating women in India.

BACKGROUND & OBJECTIVES: The prevalence of anaemia during pregnancy and lactation was significantly lower in the National Family Health Survey 1998-1999 (NFHS-2), using the hemocue method for haemoglobin estimation compared to earlier surveys. The present study selected seven States and used the same districts and villages studied in the NFHS-2, to see if the reported reduction in prevalence of anaemia was due to health and nutrition inputs and/or due to a different method for haemoglobin estimation. METHODS: A total of 1,751 women (1,148 pregnant and 603 lactating- exclusively breastfeeding up to 3 months of age), from seven States- Himachal Pradesh and Haryana in north; Assam and Orissa in east; Kerala and Tamil Nadu in south and Madhya Pradesh in central India, were selected. Haemoglobin was estimated by the cyanmethaemoglobin method, so that comparison was possible with earlier studies. Data on socio-demographic characteristics, pregnancy, nutritional status and dietary intakes were collected. RESULTS: Prevalence as well as severity of anaemia was significantly higher in the present study as compared to the NFHS-2 study data. The difference could be due to haemocue method, which gives higher haemoglobin values. The contributing factors found on multiple regression analysis for anaemia in pregnancy and lactation were: literacy, occupation and standard living index of the study women; their awareness about anaemia, its prevention by regular consumption of ironfolate tablets and increase in food intake. Maternal height, age of marriage, parity and foetal loss also contributed to haemoglobin level. There were interstate differences; lower fertility, higher literacy and better diet was observed in Himachal Pradesh as compared to Haryana. The literacy and nutritional status of women in Tamil Nadu was lower than Kerala. The remaining 3 states had poor fertility, lower social living index and nutritional status with >90 per cent women being anaemic in pregnancy and lactation. Low prevalence of severe anaemia in Orissa as compared to Assam was due to availability and consumption of iron folate tablets. The antenatal services in the first trimester and checkup by a doctor, along with availability and consumption of iron folate tablets over 3 months in all the States influenced haemoglobin levels. INTERPRETATION & CONCLUSION: Despite the measures taken to control anaemia in pregnancy and lactation in the last two decades, the severity of nutritional anaemia continues to remain a public health issue of great magnitude, suggesting that these measures have been largely ineffective. The present findings also showed interstate differences particularly in fertility, women education, nutrition status and occupation; availability of antenatal services and iron folate tablets as possible factors responsible for differences in prevalence of anaemia.

Histopathological changes in cases of aluminium phosphide poisoning.

Of a total of 205 poisoning deaths in our hospital in 2003, 83 cases were due to Aluminium phosphide poisoning and were further analyzed. Most vulnerable age group was 21-40 years and M:F ratio was 2:1. On naked eye examination, almost all the vital organs were found to be congested. On microscopic study, the liver showed central venous congestion, degeneration, haemorrhage, sinusoidal dilation, bile stasis, centrilobular necrosis, Kupffer cell hyperplasia, infiltration by mononuclear cells and fatty change. Microscopy of the lungs revealed alveolar thickening, oedema, dilated capillaries, collapsed alveoli and haemorrhage. In the kidney, changes were degeneration, infiltration, tubular dilation and cloudy swelling. Changes in the brain included congestion and coagulative necrosis and in the stomach, congestion and haemorrhage. Easy availability of this cheap and highly toxic substance was responsible for the sudden spurt of poisoning with aluminium phosphide.

Fatal road traffic accidents, study of distribution, nature and type of injury.

During one year study period medico legal autopsies were conducted on 950 cases of fatal road traffic accidents at the mortuary of SRN Hospital, MLN Medical College, Allahabad. M/F ratio 3:1. 33.68% of cases were in the age group of 25-44 years. Pedestrians were most vulnerable accounting for 35.79% of total fatalities followed by motorized two wheelers 30.53%. Heavy Vehicles were found to be mostly involved 58.52% of cases and most accidents 83.05% occurred on highways. Majority of cases sustained multiple injuries. Primary impact injuries were recorded in 455 cases and pedestrians 36.26% were mostly affected followed by pedal cyclists 20.88%. 505 cases sustained secondary impact injuries and pedestrians and motor cyclists were primarily involved. Of 697 secondary injuries, 29.99% were sustained by motorcyclists followed by pediastrians 22.67%. Mostly lower extremities 27.39% and pelvis 25.99% received the primary impacts; the head and neck 55.62% the secondary impacts, while secondary injuries were mostly located in the lower extremities 28.38%. Largest number of injuries were recorded in lower extremities 804 number, followed by head & neck 748 number. Vehicle occupants mostly sustained thoracic injuries. In majority of cases, the site of initial impact of the responsible vehicle was frontal (45.14%) followed by rear (25.83%) and side (7.01%). In 179 cases (22.02%) site of responsible vehicle were not known.

Assessment of left ventricular systolic and diastolic function in juvenile rheumatoid arthritis.

BACKGROUND AND AIMS: Recognizing the paucity of data regarding echocardiographic studies of Left ventricular (LV) systolic and diastolic function in patients with juvenile rheumatoid arthritis (JRA), a study was carried out to study these parameters in these subjects. SETTINGS, DESIGN AND METHODS: Thirty-five patients with JRA and an equal number of age- and sex-matched controls were studied by two-dimensional and Doppler echocardiography. RESULTS: Patients with JRA had higher systolic and diastolic blood pressures, resting heart rates, LV systolic (26.9+/-4.3 vs. 22.4 +/- 4.1 mm, p=0.001) and diastolic size (42.3+/-4.6 vs. 35.4+/-3.8 mm, p< 0.001) and volumes. Though ejection fraction (EF) and fractional shortening (FS) were normal, they were lower in those with JRA as compared to controls (EF: 62.9+/-4.47 vs. 67.5+/-3.63 %, p< 0.001; FS: 36.4+/-4.5 vs. 38.5 +/- 6.87, p=0.2). On Doppler analysis the JRA group had lower peak E velocity, higher peak A velocity, higher A VTI and more prolonged IVRT. Male patients had higher A VTI and IVRT as compared to females. Those with longer duration of disease had larger LV systolic (r=0.517, p=0.01) and diastolic dimension (r=0.40, p=0.05) and lower FS (r=-0.506, p=0.01). Patients with polyarticular JRA had higher E and A VTI as compared to those with systemic or oligoarticular types. CONCLUSION: Despite an asymptomatic cardiac status, significant systolic and diastolic functional abnormalities exist in patients with JRA. The duration of the disease, mode of presentation, patient's age and gender have a significant impact on the left ventricular systolic and diastolic functions in patients with JRA.

Neoadjuvant chemotherapy in squamous cell carcinoma of the esophagus using low dose continuous infusion 5-fluorouracil and cisplatin: results of a prospective study.

BACKGROUND: Surgery is the treatment of choice for localized esophageal squamous cell carcinoma (ESCC). Despite curative surgical resection, the majority of patients develop local and systemic recurrence with poor 5-year survival. AIMS: To study the role of low dose continuous infusion (CI) 5-fluorouracil (5-FU) and cisplatin as neoadjuvant chemotherapy in ESCC. SETTINGS AND DESIGN: A non-randomized prospective study conducted over a period of two years (1996-1998) in the Department of Surgery, All India Institute of Medical Sciences, India. MATERIAL AND METHODS: Twenty-two patients with ESCC were included in the study. Chemotherapy consisted of a continuous 30-day infusion of 5-FU (350 mg/m2/day) and cisplatin (7.5 mg/m2/day), 5 days/week for 4 weeks. All patients had surgery following chemotherapy. RESULTS: A full course of chemotherapy was completed in 18 patients (82%). Chemotherapy was not completed due to non-compliance (n=2), thrombophlebitis (n=1), and vomiting (n=1). Grade-1 haematological and hepato-toxicity was observed in four patients. Thirteen patients developed thrombophlebitis. After chemotherapy, improvement in dysphagia was observed in 13 of 22 (59%) patients. Radiological partial response was observed in 8 patients (36.4%). 19 patients underwent surgical resection (86.4%) with zero mortality. Post-operative morbidity was observed in six patients (27%). Complete and partial pathological response was observed in two (11%) and one patient (5.5%) respectively. The overall median survival was 18 months and 4-year survival was 42%. CONCLUSIONS: Low dose CI 5-FU and cisplatin is well tolerated with minimal toxicity. Histopathological response rates and survival figures are comparable with the more toxic neoadjuvant chemotherapeutic regimens.