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   Table of Contents - Current issue
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July-September 2022
Volume 15 | Issue 3
Page Nos. 113-170

Online since Wednesday, September 21, 2022

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REVIEW ARTICLE  

Bigels: A newer system – An opportunity for topical application p. 113
Nensi Raytthatha, Jigar Vyas, Isha Shah, Umesh Upadhyay
DOI:10.4103/hmj.hmj_33_22  
Introduction: A gel is a solid or semisolid system composed of at least two parts, namely a condensed mass containing and interpenetrating a liquid. Hydrogel, emulgel and organogel are novel gel systems that are widely known but have some drawbacks. For example, hydrogel delivers hydrophilic but not poorly water-soluble drugs and has a lower ability to penetrate the stratum corneum, organogel has a greasy nature that causes stickiness and difficulty in removal and emulgel has different mechanical phases that cause instability. This impediment can be solved by using a unique and innovative formulation termed bigels. Method: The aqueous phase is typically made by a hydrophilic polymer, while the organic phase is comprised of gelled vegetable oil due to the presence of an organogelator. For the bigel manufacturing process, the percentage of the respective gelling agent in each phase, the organogel/hydrogel ratio, as well as the mixing temperature and speed, should be considered. The presence of desirable characteristics in both hydrogels and organogels increases patient compliance as well as the loading capacity of both lipophilic and hydrophilic drugs. Result: The substantial focus of this descriptive review is to look at the possible correlations (i.e. cross-linked polymer structures) among various parts of hybrid systems (i.e. bigels or multi-component organogels). Bigels are systems formed by combining a hydrogel with an organogel. Discussion: So far, researchers have mostly investigated bigel systems for regulated drug administration in topical applications. These bigels are investigated in research, yet to find popularity in the market.
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ORIGINAL ARTICLE - PROSPECTIVE COHORT STUDY Top

Lactate dehydrogenase as marker for foetal outcome in pre-eclampsia p. 122
Seema-Gul Salman, Maria Rafiq
DOI:10.4103/hmj.hmj_3_22  
Background: Studies have shown LDH is raised in Pre-eclampsia (PE) with levels increasing with increased severity of PE. Aims and Objectives: To study lactate dehydrogenase (LDH) as a marker for foetal outcome in mothers with pre-eclampsia (PE). Materials and Methods: A prospective cohort study was conducted at our facility from February 2019 to November 2021 on all admitted patients with PE. Two hundred and two patients were studied during this period. The inclusion criteria were mild and moderate PE. The exclusion criteria were severe PE, haemolysis, elevated liver enzymes and low platelets syndrome, eclampsia, any comorbid disease, and multiple gestations. Patients were divided into two groups. Group 0 had mothers with LDH <600 IU/L and Group 1 included mothers with LDH ≥ 600 IU/L. Both groups were documented and monitored until delivery to document foetal outcome as live birth or death in utero. Results: The mean maternal characteristics were as follows: age in years (26.45 ± 3.74), body mass index (30.04 ± 1.58), parity (2.39 ± 0.91), and age of gestation in weeks (33.27 ± 1.18). Group 1 had 61 (30.2%) previous history of PE, 84 (41.6%) live births, and 17 (8.4%) deaths in utero. Group 0 had 60 (29.7%) previous history of PE, 95 (47%) live births and 6 (3%) deaths in utero. The mean gestational age of Group 1 was shorter; 32.29 ± 1.17 weeks versus 33.23 ± 1.16 for Group 0. LDH as a marker for death in utero had a P = 0.01 which is significant. Conclusion: LDH can be used as a marker for foetal outcome in women with PE.
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ORIGINAL ARTICLES Top

Outcome of craniotomy and membranectomy in the management of chronic subdural haematoma recurrence: A series of 17 patients p. 126
Toufik Bennafaa, Adel Khelifa, Walid Bennabi, Yacine Felissi, Fayšal Aichaoui, Abdelhalim Morsli
DOI:10.4103/hmj.hmj_10_22  
Background: Chronic subdural hematoma (CSDH) is a proportionally frequent neurosurgical pathology, and burr hole craniotomy is the most commonly used procedure in its treatment. However, currently, there is no real consensus on its management, especially recurrences. Many authors forwarded each management modality for the recurrence of CSDH; bone flap craniotomy was less frequently defended. Aims and Objectives: we aim to confirm the superiority of bone flap craniotomy with membranectomy over other techniques in the management of CSDH recurrences. Materials and Methods: We studied retrospectively 17 patients operated on at our department from February 2016 to February 2020, for particular situations of CSDH recurrence. Results: 17 patients with recurrent chronic subdural hematomas were operated on with bone flap craniotomy and membranectomy; with main age of 67 years old. Only one patient (5.8 %) presented recurrence of the hematoma after bone flap craniotomy. We have got one case (5.8%) of suspect osteitis on the bone flap managed successfully. Unfortunately, one patient in this series died. Conclusion: In careful surgical hands, the bone flap is not more harmful than other surgical procedures and it is found to be effective in CSDH recurrence management.
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Effects of ramadan fasting on diabetic nephropathy in patients with type 2 diabetes p. 132
Magda Shukry Mohammad, Maram Maher Aboromia, Nesma Ali Ibrahim, Nouralhoda Ahmed Abdul Jalil
DOI:10.4103/hmj.hmj_11_22  
Background: Many patients with type 2 diabetes (T2D) insist to fast during the holy month of Ramadan against medical advice. Aims and Objectives: The study aimed to evaluate the effects of Ramadan fasting on diabetic nephropathy in patients with T2D. Materials and Methods: The present study was conducted on ninety patients with T2D who intended to fast Ramadan; they were divided into the following groups: Group 1: 30 patients with T2D, without albuminuria (normoalbuminuria); Group 2: 30 patients with T2D, with microalbuminuria; and Group 3: 30 patients with T2D, with macroalbuminuria. Laboratory tests including fasting plasma glucose, 2-h postprandial plasma glucose, haemoglobin A1c, serum creatinine, blood urea and urinary albumin/creatinine ratio (UACR) were measured 2 weeks before Ramadan fasting and then repeated within 2 weeks after Ramadan. Results: On comparing data before and after Ramadan, there was a significant increase in creatinine and urea levels, while there was a significant decrease in the estimated glomerular filtration rate (eGFR) and UACR in all the study groups. There was no significant difference between the study groups regarding the percentage of increase in creatinine (P = 0.204) and urea (P = 0.505), while the percentage of decrease in eGFR was significantly higher in the macroalbuminuria group (P = 0.038), and the percentage of decrease in UACR was significantly higher in the normoalbuminuria group (P = 0.001). Conclusion: Ramadan fasting adversely affects the renal function and causes a decrease in the eGFR in type 2 diabetic patients with diabetic nephropathy. Fasting should be under close medical supervision with strict attention to fluid intake and daily activity, as well as adjustment of drug regimens.
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An observational study of risk association of diabetes mellitus and hypertension in the first-degree relatives of patients with diabetes mellitus p. 139
Divya Rani, Pradyumna Kumar Singh
DOI:10.4103/hmj.hmj_16_22  
Background: Occurence of diabetes and hypertension is affected by the genetic modulation and environmental factors. Thus it becomes important to determine associated factors governing them among the relatives. Aims and Objectives: The objectives of this study were to determine the prevalence of diabetes mellitus (DM) and hypertension (HTN) and associated risk factors in the first-degree relatives (FDRs) of the patients with type 2 DM (T2DM). Materials and Methods: The study design was cross-sectional for a period of 18 months from September 2017 to March 2019 wherein 200 people who were FDRs of T2DM patients, visiting Holy Family Hospital, New Delhi, were enrolled. The demographic details, anthropometric measurements, blood pressure and HbA1c levels were assessed, based on which the FDRs were classified into pre-diabetes, diabetes and hypertensive. The odds ratio was calculated for risk association to predict the occurrence of DM and HTN. Results: The age of the study population ranged from 30 to 50.25 years, with a median age of 38 years. There were 116 (58%) males and 84 (42%) females. The median body mass index (BMI) was 24.5, with 49.5% having normal BMI, 43% being pre-obese and 7.5% obese. As per the glycaemic parameters, 80 (40%) had normal glucose tolerance, 50 (25%) were pre-diabetic and 70 (35%) had diabetes. Amongst the 200 FDRs, HTN was prevalent in 95 (47.5%) cases. Higher age was found to be a significant risk factor for DM, with a higher odds of 1.056 (P = 0.021), while higher age and female gender carried a significantly higher odds of occurrence of HTN in FDRs, with an odds ratio of 1.049 and 2.178. Conclusion: DM and HTN are prevalent in FDRs of T2DM patients. Higher age is a significant risk factor for both DM and HTN, necessitating a regular screening of FDRs for an early interception to prevent these diseases.
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Study of surgical and functional outcome in the management of proximal tibial fracture with circular wire-based external fixation p. 145
Tushar Mondal, Soumya Ghosh, Soma Ghosh
DOI:10.4103/hmj.hmj_20_22  
Background: The principle of treatment in proximal tibial fracture includes soft tissue care, restoring articular surface congruity and reduction of anatomical alignment enabling early joint mobility. Aim: Assessing surgical, and functional outcomes by evaluating pain, range of motion (ROM) and muscle power in circular wire-based external fixation procedure in proximal tibial fractures with complications. Objectives: Documenting clinical observations, preoperative, and postoperative symptoms in the study population with time for bony union and complications. Materials and Methods: Thirty patients aged 18–70 years with proximal tibial fractures excluding polytrauma and pathological fracture cases were included in the prospective observational study. Surgery and post-operative follow-up were done at 6, 12, 24 weeks and 6 months. Functional assessment is done by the knee society score system. Removal of fixator followed evidence of clinical and radiological union with advice for full weight bearing. Results: Road traffic accident was a major injury, right laterality more than left. The type of tibial fractures was 41A2, A3 and C3. Eighty per cent of patients had no persistent residual pain after fracture union; 80% showed normal relative to age walking capacity, and 95% showed normal to <10° lack of extension. Fourteen patients had ROM of 125° and 120° in ten. Twenty-six patients showed normal stability in extension and 20° flexion. Twenty-five patients showed excellent knee scores, 24 showed excellent functional scores; four showed good knee scores and five showed good functional scores. Post-operative complications included pin-tract infection in four patients followed by delayed and non-union in one patient each. Conclusion: Circular wire-based external fixation in the proximal tibial fracture is an effective method of treatment even with moderate soft-tissue injury showing excellent to good functional outcome.
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Experience of implementation of enhanced recovery after surgery in colorectal surgeries in rashid hospital p. 151
Abdulaziz AlBaroudi, Noura AlZarooni, Labib AlOzabi, Nour Aldeen Hejazi
DOI:10.4103/hmj.hmj_21_22  
Background: Enhanced Recovery After Surgery guidelines in colorectal surgery state that there is improvement in general post-operative outcomes including reduction in operative complications and 30 days readmission rates. These recommendations were originating from high flow, excellence and academic centers. Aim and objectives: Demonstrating the feasibility of ERAS protocols application in low-flow centres as our hospital is the aim of this study. Materials and Method: A retrospective cohort study was performed at a tertiary hospital. A total of 99 patients were included over a period of 6 years from January 2014 till January 2020 for all elective colorectal cases after being filtered through inclusion and exclusion criteria. They were divided into two groups Pre-ERAS (n=29) and ERAS group (n=70) starting from August 2016 the date of beginning implementation of the local protocol. Results: It was observed that there was statistical significance in reducing the length of hospital stay from an average of 13 days in Pre-ERAS to average of 8 days in the ERAS group and a decrease in day 1 post-operative pain score were achieved without adverse impact in surgery related morbidities or readmission rate. Conclusion: ERAS protocol can be applied to improve surgical outcomes in colorectal surgery without increased risk of complications.
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MMTV-like Env sequences from human breast cancer patients cannot yet be considered as a separate species p. 155
Waqar Ahmad, Thanumol A Khader, Neena G Panicker, Shaima Akhlaq, Jasmin Baby, Bushra Gull, Farah Mustafa
DOI:10.4103/hmj.hmj_35_22  
Background: Mouse mammary tumour virus (MMTV), a betaretrovirus, causes breast cancer in mice. Since its discovery, scores of studies have reported the detection of MMTV-like antigens and sequences primarily in human breast cancer, but not normal tissues. The presence of these sequences in humans has been hypothesised to be possibly due to zoonosis of MMTV into humans, named human mammary tumour virus (HMTV). However, many groups have not been able to repeat these findings, making these observations controversial. Over the years, an increasing number of HMTV env gene sequences from human breast cancer patients worldwide have been deposited in GenBank and other repositories. Aims and Objectives: The aim of this study was to use the current bioinformatic tools to analyse these highly homologous sequences to determine if any signature sequences could be associated specifically with HMTV. Materials and Methods: We first built an MMTV env gene consensus sequence (MMTV_CON) from the 41 MMTV sequences available in the database that was used to align the reported HMTV sequences (n = 333). Results: As expected, the MMTV envs showed 4-5% genetic variation within the mouse isolates. Alignment of MMTV_CON with those from HMTV revealed ten nucleotide variations that were like those observed within MMTV env, showing that the two viral strains could not be distinguished. Conclusion: Thus, we conclude that despite extensive data, inadequate env coverage, conservation of MMTV and HMTV envs and limitations in HMTV study design suggest that HMTV cannot be considered a separate species until the availability of more data covering full-length env or HMTV genome.
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CASE REPORTS Top

Internal hernia in pregnancy after Roux-en-Y gastric bypass: A surgical diagnostic dilemma p. 164
Hadiel A Kaiyasah, Maryam Al Ali, Laila Alhubaishi, Shiney Oliver, Faiza Badawi, Ali Al Ani
DOI:10.4103/hmj.hmj_74_21  
Rationale: Internal hernia after Roux-en-Y gastric bypass (RYGB) is a lifelong risk. During pregnancy, this risk increases due to the rise in the intra-abdominal pressure. Early recognition and intervention are the keys to have a better outcome. The aim of this case report is to shed the light on the possibility of such occurrence. Patient Concerns: A 40-year-old woman presented to the emergency department at 36 weeks of gestation with acute abdominal pain. Diagnosis: She was in labor. In view of her past history of gastric bypass, a surgical consult was obtained. Patient developed episodes of hypotension with deceleration, so an emergency caesarean section was performed. Interventions: The abdomen was explored Intraoperatively. An internal hernia with small bowel volvulus was found. Outcomes: The hernia reduced and bowel revived. Postoperatively, the patient had a smooth recovery and a healthy baby. Lessons: Nowadays, due to the global obesity epidemic, lots of women of childbearing age are undergoing bariatric surgery all over the world. Having the knowledge about the possible complications of such procedures is of paramount importance. This is in order to be able to have an earlier operative intervention whenever indicated, hence, decreasing the maternofetal morbidity and mortality. Internal herniation after RYGB exemplifies a rare, high-risk complication that might occur in pregnancy. A high index of suspicion is required for early diagnosis and better outcome.
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Adenocarcinoma of the appendix p. 168
Gbemi Henry Ano-Edward, Kehinde J Aworinde-Olufemi, Enugwaronu A Agbakwuru, Mathew E Lasisi, BM Famoroti
DOI:10.4103/hmj.hmj_9_22  
Rationale: Adenocarcinoma of the appendix is a rare disease which is often diagnosed after surgery by a pathologist. Patient concerns: This case is that of a 50 year old man who presented with an acute abdomen. Diagnosis: A diagnosis of acute appendicitis was made. Interventions: He had an appendectomy and a subsequent right hemicolectomy performed. In the laboratory, the diagnosis of moderately differentiated adenocarcinoma of the appendix and chronic granulomatous inflammation of lesions within the abdomen was made after surgery. Outcome: The patient did well after surgery and was followed up for three years in the outpatient clinic. Lessons: Although, a simple appendectomy may be sufficient for incidental adenocarcinoma of the appendix but for optimal outcome right hemicolectomy is advised for a suspicious mass or lesions. Furthermore, adenocarcinoma of the appendix is a very rare disease in our environment, surgeons are encouraged to submit appendectomy specimens for histopathological diagnosis.
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