Unusually complicated course of a common disease: challenges in managing pediatric HIV Publication date: Available online 15 July 2019 Source: Medical Journal Armed Forces India Author(s): Punam Bajracharya, Suprita Kalra, Gitanjali Jain, Amit Sood

Does pre-procedure ultrasound increase the success and safety of right internal jugular venous catheterization? An intervention study Publication date: Available online 12 July 2019 Source: Medical Journal Armed Forces India Author(s): Vikrant Ghode, Naresh Dhawan, R.M. Sharma Abstract Background Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, ensuring real-time US into routine practice is impeded by its perceived expense and difficulty. This expertise requires hand–eye coordination and learning curve. Moreover, availability of multiple US machines and probes for multiple operation theatres may not be possible even at the tertiary level care set-up. Currently, pre-procedure US and landmark methods are most widely used. We investigated both the techniques with application of skin markings in the pre-procedure group to ascertain efficacy and safety with a view to incorporate pre-procedure US in our practice. Methods In this randomized study, we investigated 66 patients. Thirty-three patients in the pre-procedure ultrasound group and 33 patients in the landmark group were included for right internal jugular vein (RIJV) cannulation. We recorded the first needle pass success rate, cannulation time and complications. Results Pre-procedure US was associated with more successful attempts, shorter cannulation times and less complications. Under pre-procedure US, 75.76% of first attempts were successful with a cannulation time of 50 (25–180) seconds. Under landmark technique, 27.27% of first attempts were successful with a cannulation time of 85 (20–200) seconds. First puncture success rates were higher in pre-procedure US than landmark technique, 66.67% vs 27.27%, respectively. Conclusion Pre-procedure US for RIJV catheterization is safer, quicker and superior to landmark technique.

Klippel Feil syndrome with crossed fused renal ectopia with pelviureteric junction obstruction: A rare association Publication date: Available online 12 July 2019 Source: Medical Journal Armed Forces India Author(s): Pratyush Chandra Madhur, V. Shankar Raman, Santosh Dey Abstract An 11-year-old female patient presented with congenital spinal deformity with a history of occasional pain in the right flank for a duration of six months. On evaluation, she was diagnosed to be a case of type III Klippel Feil syndrome (KFS) with crossed fused renal ectopia (left to right) and pelviureteric junction obstruction (PUJO) of the right moiety. The patient underwent successful pyeloplasty of the right moeity. To the best of our knowledge, this is the first reported case in the literature with a combination of KFS, crossed fused renal ectopia, and PUJO.

Correction of hypernatremic dehydration in neonates with supervised breast-feeding: A cross-sectional observational study Publication date: Available online 11 July 2019 Source: Medical Journal Armed Forces India Author(s): Apoorv Saxena, Suprita Kalra, Subhash Chandra Shaw, K. Venkatnarayan, Amit Sood, V.V. Tewari, Rakesh Gupta Abstract Background Hypernatremic dehydration is an uncommon but a serious cause of readmission in neonates especially in the ones on exclusive breast-feeding. The management of such neonates is challenging as serious complications can occur both because of hypernatremic dehydration and its rapid correction. The aim was to study the clinical profile of neonates with hypernatremic dehydration and determine the outcome of these neonates after appropriate management. Methods This is a prospective cross-sectional observational study of neonates readmitted with hypernatremic dehydration in a tertiary care hospital in a 12-month period from March 2017 to February 2018. The inclusion criterion was as follows: all neonates with serum sodium >145 mEq/l. The exclusion criteria were as follows: neonates with hypoglycemia, positive sepsis screen and any other congenital diseases. Neonates with serum sodium between 145 and 160 mEq/l were treated with supervised quantified oral feeds at 150 ml/kg/day, unless they had features of shock. Neonates who had serum sodium ≥160 mEq/l were given intravenous (IV) fluids initially. Results A total of 2412 deliveries took place during the study period. Hypernatremic dehydration was reported in 46 (1.9%) of them, which required admission. We found that all these neonates were exclusively breast-fed, with 81.3% neonates born to primigravidae. One neonate presented with seizures, and one, with metabolic acidosis. More than 50% neonates had acute kidney injury (AKI) on admission. No neonates in our study developed central nervous system (CNS) complications such as cerebral venous thrombosis, convulsions or intracranial haemorrhage, and complete recovery from AKI was documented in all neonates. Conclusion Hypernatremic dehydration can be a serious problem even in term healthy neonates especially in exclusively breast-fed neonates born to primiparous women. Our study shows that quantified oral feeding is effective in successful management of hypernatremic dehydration and not associated with the dreaded CNS complications due to rapid correction.

First trimester obstetric outcome of frozen thawed embryo transfer: does the stage of embryo make any difference? Publication date: Available online 11 July 2019 Source: Medical Journal Armed Forces India Author(s): Debkalyan Maji, Raju Agarwal, P.R. Lele, H.C. Bandhu, Manash Biswas Abstract Background The direction of management and outcome of frozen thawed embryo transfer (FET) is becoming different day by day with the invention of newer technologies and application of it as a treatment modality in modern medicine. It also contributes to around 25% of births because of Assisted Reproductive Technology (ART) procedures worldwide today. Methods A prospective longitudinal study was conducted at ART Center of tertiary care hospital. Couples with infertility planned to undergo FET were included in the study. Following FET, all positive cases were followed up till 14 weeks period of gestation. Data were collected and analyzed with appropriate statistical test using Epitable, 6.04 version, and SPSS, version 18, software. Results During the study period, a total of 470 FET cycles were carried out, and 1108 cryopreserved embryos were subjected to thawing procedure. Overall survival rate of 93.86% was noted. Among various stages of embryos thawed, the lowest survival rate (64.62%) was found in blastocyst group. Biochemical pregnancy rate, clinical pregnancy rate, and ongoing pregnancy rate were also analyzed in different subgroup of transferred embryos. The blastocyst group showed best implantation and clinical pregnancy rate but lowest survival rate among all subgroup of embryos. Conclusion The blastocyst transfer during FET cycle showed best clinical and ongoing pregnancy rate. So if clinical situations were favorable for blastocyst stage transfer, the same should be preferred for FET cycle.

Hyperglycaemia as a risk factor for the development of retinopathy of prematurity: A cohort study Publication date: Available online 10 July 2019 Source: Medical Journal Armed Forces India Author(s): Harikrishnan Vannadil, P.S. Moulick, M.A. Khan, Sandeep Shankar, Jaya Kaushik, Alok Sati Abstract Background Retinopathy of prematurity (ROP) is a preventable cause of childhood blindness. Without treatment, over 45% of eyes can develop permanent visual loss. Hyperglycaemia has recently been described as a risk factor for the development of retinopathy of prematurity (ROP), a proliferative vascular disease of the retina that primarily affects premature infants. The characteristic neoproliferative growth of blood vessels in the retina is very well under stood with the clinical and experimental experiences with Diabetic retinopathy. The purpose of this study was to evaluate a possible relation between glucose levels in VLBW (Very Low Birth Weight) infants and development of ROP. Method All at risk infants of a Neonatal Intensive Care Unit (NICU) of a tertiary care centre in western India were included in the study. The blood sugar values of the neonates were recorded at multiple times during their first week of life. On completion of 31 weeks of gestational age or 04 weeks of birth age, the neonates were subjected to ROP screening as per standard protocols. Result A total of 103 neonates were included in the study and were subjected to ROP screening. A total of 32 neonates developed ROP at the end of the study. It was found with statistical significance that the neonates with higher average blood glucose values in the initial period of life had higher incidence of ROP at the time of screening with a Relative Risk of 2.506 (CI = 1.287, 4.882). Conclusion A high average blood glucose level in neonates during the first week of life is an indicator for developing ROP at a later date. These neonates should be kept under close follow up in order to facilitate timely detection and prompt intervention.

Cost-effectiveness of a novel strategy of HIV/AIDS care in Armed Forces: A stochastic model with Monte Carlo simulation Publication date: Available online 10 July 2019 Source: Medical Journal Armed Forces India Author(s): S. Shankar, Santosh Karade, Rajul K. Gupta, M.V. Singh Abstract Background Despite the initial success of HIV/AIDS policy, an increasing number of patients are failing the first-line antiretroviral therapy (ART) each year and the failure rates are increasing. There is a need for identification of novel strategies to reduce failure rates. The aims of the study are (1) to design a novel strategy to reduce ART failure rates and (2) to create a stochastic model using Monte Carlo (MC) simulation comparing the novel strategy with existing strategy. Methods A novel strategy based on annual plasma viral load testing and resistance testing for HIV treatment at baseline and at the time of failure was designed. A cohort of 1000 patients each was created for the existing strategy and a novel strategy. Assumptions were included from Indian studies and own data. The two strategies were compared over 20 years of follow-up using stochastic modeling and MC simulation was done for death rates, failure rates, and cost-effectiveness analysis. SimVoi add-in software for MS Excel was used for simulations. Student's t-tests were performed for comparing continuous variables, and the cumulative rates for various outcomes were plotted using Kaplan–Meier analysis. Results The novel strategy resulted in lower mortality over a 20-year period (279.9 + 7.13 deaths vs 130.43 + 6.03 deaths) with incremental cost per life saved at Rs 32,925 per year. Incremental cost-effectiveness ratio cost per quality-adjusted life year was Rs 1.33 lakhs/annum at constant rate of discounting and just under Rs 90,000 per annum using differential discounting. Conclusion Armed Forces are likely to benefit by adopting the novel strategy that is cost-effective with a significant mortality benefit.

Seroprevalence of influenza A H1N1 (swine) infection in the human population in a cantonment Publication date: Available online 4 June 2019 Source: Medical Journal Armed Forces India Author(s): Arvind Singh Kushwaha, Atul Kotwal, C.I. Biradar, Ajoy Mahen, Mahadevan Kumar, Shailesh D. Pawar, Mandeep Chadha, Seema Patrikar Abstract Background Various serosurveys and studies were conducted globally on pandemic influenza. H1N1 virus reported so far provides ample evidence of differing perspectives, regarding its epidemiology especially with regard to prevalence, populations groups, and behaviour related to vaccine acceptance. A multigroup, cross-sectional survey among 658 healthy subjects was carried out, in Pune among students, health-care workers (HCWs), and soldiers to assess the seroprevalence of pandemic influenza H1N1 virus and its associated factors. Methods The total sample size, based on forecasted prevalence of 33%, worked out to be 640. We studied 658 subjects including 103 students, 201 HCWs, and 354 serving soldiers. The sample for each group was selected from the respective study population by simple random sampling using a random number table. Haemagglutination inhibition test was carried out at the National Institute of Virology. Results The overall seroprevalence of pandemic influenza H1N1 (2009) virus was found to be 46.5% (95% confidence interval 42.6–50.4) which was adjusted to 39.4% after excluding those vaccinated. The availability of vaccine for high-risk group such as HCWs did not find much favour with the HCWs who did not accept vaccine for various reasons. Whereas only one student was vaccinated, 21.4% of HCWs and 32.5% of soldiers were vaccinated. Conclusion Based on high seroprevalence of antibodies against H1N1 virus during pandemic, vaccination of general population is not recommended. However, high-risk groups and HCWs need to be protected with flu vaccine. There is a need to encourage HCWs for accepting vaccination.

Evaluation of nomophobia among medical students using smartphone in north India Publication date: Available online 3 June 2019 Source: Medical Journal Armed Forces India Author(s): Janki Bartwal, Bhola Nath Abstract Background Smartphone's popularity has risen to such an extent in recent years that it is unimaginable for the people to stay away from it for a minute. The excessive usage has given rise to a condition termed as nomophobia or a feeling of discomfort or anxiety experienced whenever unable to use the smartphone. The aim of this study was to evaluate nomophobia among medical students who are using smartphones. Methods A cross-sectional study was conducted among the undergraduate medical students. A 20-item nomophobia questionnaire was used to assess the prevalence of nomophobia among the students, and also the purpose and in which context smartphone was used was also asked. Data collected were coded and entered into a Microsoft Excel spreadsheet. It was analysed using the Statistical Package for the Social Sciences, version 16, software (SPSS Inc., Chicago, IL, USA). A chi-square test was used to test the association, and p < 0.05 was considered significant. Results The mean age of the 451 students was 20.7 ± 1.72 years, and the majority were females. Mild nomophobia was seen in 15.5% of the students; 67.2% were having moderate nomophobia, while 17.3% were suffering from severe nomophobia. The overall highest mean score was for ‘not able to communicate’ dimension of nomophobia and lowest for ‘giving up convenience.’ Conclusion Nomophobia is an emerging behavioural problem which needs attention. It is of serious concern that all medical students were suffering from nomophobia, with varying grade of severity. Increasing awareness regarding the harmful effects of smartphone addiction is needed.

Evidence-based adoption of purse-string skin closure for stoma wounds Publication date: Available online 3 June 2019 Source: Medical Journal Armed Forces India Author(s): Nilotpal Behuria, Jayant Kumar Banerjee, Sita Ram Ghosh, Shrirang Vasant Kulkarni, Ramanathan Saranga Bharathi Abstract Background Opinion is divided on the optimal technique of skin closure after stoma reversal as most conventional techniques compromise either on speed/neatness of wound apposition or on the incidence of surgical site infection (SSI). Evidence suggests that purse-string skin closure (PSSC) may achieve both objectives. This study aims to compare conventional primary closure (PC) with PSSC to determine the efficacious technique for stoma wound closure. Methods Patients undergoing stoma reversal between April 2015 and September 2017 were prospectively studied. Patients were divided into two groups based on the technique of skin closure (PC or PSSC). The following parameters were assessed: SSI, hospital stay, additional outpatient visit, wound healing time and patient satisfaction based on a standardised questionnaire. Results Forty one patients underwent stoma reversal (20 PSSC vs 21 PC). Wound infection, need for wound care, length of hospital stay, healing time and scar size were significantly less, whereas average patient wound satisfaction scores were significantly more in the PSSC group. Conclusion Purse-string skin closure (PSSC) proves efficacious and hence merits adoption as the technique of choice for closure of stoma wounds.