Journal of Postgraduate Medicine
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  :: Table of Contents - Current issue
Coverpage
October-December 2020
Volume 66 | Issue 4
Page Nos. 179-227

Online since Tuesday, October 27, 2020

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EDITORIAL  

Type 2 diabetic Asian Indians and COVID-19: Lessons learnt so far from the ongoing pandemic Highly accessed article p. 179
VK Shivane, AR Lila, TR Bandgar
DOI:10.4103/jpgm.JPGM_602_20  PMID:33037170
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EDITORIAL COMMENTARIES Top

Progression of diabetic kidney disease: Who is at risk? p. 182
T Jamale
DOI:10.4103/jpgm.JPGM_1014_20  PMID:33109780
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Assessment in competency-based medical education : A paradigm shift p. 184
NN Rege
DOI:10.4103/jpgm.JPGM_1182_20  PMID:33109781
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ORIGINAL ARTICLES Top

Modifiable factors related to 7-year renal outcomes in subjects with type 2 diabetes and chronic kidney disease stage 3 p. 187
CH Huang, CP Chen, YY Huang, B R S Hsu
DOI:10.4103/jpgm.JPGM_680_19  PMID:33037171
Background and Aims: Subjects with diabetes are prone to a rapid decline in renal function and major adverse cardiovascular events when they reach chronic kidney disease (CKD) stage 3. This study aimed to identify modifiable risk factors associated with the progression of CKD in this population. Settings and Design: An observational cohort study. Methods and Materials: A total of 320 type 2 diabetic patients with CKD stage 3 registered in the shared-care-system in our hospital in 2010 were regularly followed up for 7 years. Demographic, laboratory, medication, and fundus examination data of these subjects were collected and analyzed. Statistical Analysis Used: Cox regression was used to identify factors associated with changes in CKD stage. Results: During the 7-year follow-up period, 204 cases (63.7%) remained at CKD stage 3 while 79 cases (24.7%) progressed to stage 4 or 5 and 37 cases (11.6%) improved to stage 1 or 2. The change in estimated glomerular filtration rate (eGFR) in the first 2 years and variations in glycated hemoglobin (HbA1c) over 7 years were independent factors of both progression (hazard ratio (HR) 1.098 and 1.710, respectively) and improvement (HR 0.919 and 0.231, respectively) of CKD stage. Variations in systolic blood pressure (SBP) was also found as an independent factor for progression of renal function (HR 1.052). Conclusions: Our results demonstrated that fluctuations in HbA1c and SBP, and changes in eGFR during the first 2 years of treatment were associated with the long-term renal outcomes in type 2 diabetic patients with CKD stage 3.
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Vitamin D assessment and precision of clinical referrals: Insights gained from a teaching hospital in southern India p. 194
A Jose, AJ Binu, KE Cherian, N Kapoor, HS Asha, TV Paul
DOI:10.4103/jpgm.JPGM_599_19  PMID:33037169
Objective: Vitamin D deficiency is widely prevalent worldwide. This has led to a significant surge in referrals for vitamin D assessment in recent years. The cost-effectiveness and rationalization of this practice is uncertain. This study aimed to evaluate the referral pattern for vitamin D testing from a tertiary center in southern India. Materials and Methods: This was a cross-sectional study done over a period of one year (2017). A total of 95,750 individuals, referred for vitamin D screening were included in this study. Details regarding referring departments and indications for referral were obtained from the computerized hospital information processing system (CHIPS). Results: The study population exhibited a female preponderance (54.1%) with mean (SD) age of 40.3 (18.5) years. Overall, 44% were found to have vitamin D deficiency. Most of the referrals were from nephrology (15.4%), neurology (10.1%), and orthopedics (9.1%). Nevertheless, dermatology, the staff-clinic, and hematology which contributed to 3.3%, 1.7%, and 1.7% of referrals, had a higher proportion of vitamin D deficiency of 59.1%, 57.7%, and 64.6%, respectively. Although the most common indications for referral were generalized body aches (20.5%) and degenerative bone disorders (20.1%), the proportion of subjects with vitamin D deficiency referred for these indications were 46.1% and 41.6%, respectively. In contrast, chronic steroid use that accounted for 3.3% of the referrals had 59.1% of subjects who were deficient in vitamin D. Conclusion: To ensure a rational approach to vitamin D testing, clinicians ought to use their discretion to screen those truly at risk for vitamin D deficiency on a case to case basis and avoid indiscriminate testing of the same.
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EDUCATION FORUM Top

The power of subjectivity in competency-based assessment p. 200
A Virk, A Joshi, R Mahajan, T Singh
DOI:10.4103/jpgm.JPGM_591_20  PMID:33037168
With the introduction of competency-based undergraduate curriculum in India, a paradigm shift in the assessment methods and tools will be the need of the hour. Competencies are complex combinations of various attributes, many of which being not assessable by objective methods. Assessment of affective and communication domains has always been neglected for want of objective methods. Areas like professionalism, ethics, altruism, and communication—so vital for being an Indian Medical Graduate, can be assessed longitudinally applying subjective means only. Though subjectivity has often been questioned as being biased, it has been proven time and again that a subjective assessment in expert hands gives comparable results as that of any objective assessment. By insisting on objectivity, we may compromise the validity of the assessment and deprive the students of enriched subjective feedback and judgement also. This review highlights the importance of subjective assessment in competency-based assessment and ways and means of improving the rigor of subjective assessment, with particular emphasis on the development and use of rubrics.
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CASE SERIES Top

Endoscopic management of pleural effusion caused by a pancreatic pleural fistula p. 206
SV Sasturkar, S Gupta, S Thapar, SM Shasthry
DOI:10.4103/jpgm.JPGM_720_20  PMID:33109782
Pancreatic-pleural fistula (PPF) is a rare sequela of pancreatitis. High degree of clinical suspicion is required to diagnose a PPF. Confirmation is done by high amylase content in pleural fluid analysis. Here, we present two cases with varied presentation of PPF. A 43-year-old man presented with acute on chronic pancreatitis with bilateral (predominantly right) pleural effusion. Another 57-year-old man, previously diagnosed with chronic calcific pancreatitis, presented with left pleural effusion. Both cases were effectively managed with endoscopic pancreatic duct stenting.
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CASE REPORTS Top

Bile duct wall calcification: A rare entity in portal cavernoma cholangiopathy p. 209
P N B Nitesh, B Pottakkat
DOI:10.4103/jpgm.JPGM_541_20  PMID:33037167
Cavernomatous transformation of the portal vein, seen in extrahepatic portal venous obstruction (EHPVO), can cause impingement or ischemic insult on bile ducts manifesting as “portal cavernoma cholangiopathy” (PCC). Bile duct wall calcification in portal biliopathy is a rare occurrence and has not been reported in the literature to the best of our knowledge. We report a 59-year-old male, a known case of EHPVO, who had undergone laparoscopic cholecystectomy, splenectomy, and splenorenal shunt in the past. The patient had now presented to us in view of recurrent episodes of cholangitis for which a bilioenteric bypass was planned. Intraoperatively, dilated and densely thickened bile ducts with multiple pericholedochal collaterals were noted. Incision of common hepatic duct and left hepatic duct showed completely calcified ductal wall with no visible healthy mucosa. Calcifications were removed partially from the bile duct walls near choledochotomy site. With the anticipation of futile benefit from bilioenteric bypass, Roux-en-Y HJ was abandoned. Hepaticoduodenostomy was done to prevent bile leak from choledochotomy site.
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Isolated truncal contrapulsion as a rare presentation of acute thalamic infarct p. 212
S Sheetal, SA Kumar, R Thomas
DOI:10.4103/jpgm.JPGM_706_19  PMID:33078722
Infarcts involving the thalamus can yield many deficits, including sensory syndromes, altered consciousness, and cognitive disturbances, depending on the thalamic vascular territory involved. Isolated truncal contrapulsion due to pure thalamic infarct has been rarely reported. Truncal lateropulsion is a compelling sensation of being pulled toward one side that cannot be explained by weakness or limb ataxia. It is commonly reported in lateral medullary infarcts. It may occur with lesions that involve the peripheral vestibular system, brainstem, cerebellum, basal ganglia, ponto-mesencephalic, and thalamic lesions. We hereby report a 64-year-old woman who presented with truncal contrapulsion as the sole manifestation of an acute right lateral thalamic infarct.
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Retained pelvic pin site debris after navigated total hip replacement: Masquerading as an early-stage chondrosarcomatous lesion Highly accessed article p. 215
AP Kurmis
DOI:10.4103/jpgm.JPGM_605_20  PMID:33109783
Once purely the domain of knee surgery, the use of computer-navigated techniques in total hip arthroplasty (THA) is becoming progressively more commonplace. As with the adoption of any new technology-assisted approach, the uptake of navigated THA utilization has heralded a new suite of technique-specific potential complications. One such example – not usually seen with conventional instrumented THA – pertains to complications related to the insertion and use of fixed pelvic array trackers. This case report describes the unusual circumstance of retained local bony debris generated through application of self-drilling, self-tapping iliac crest pins (for rigid navigation tracker placement) being mis-interpreted on advanced imaging - at a hospital site remote from the index surgery - as an aggressive, early-stage, chondrosarcomatous lesion. This case highlights the critical importance of both a general awareness of common imaging findings after navigated THA surgery (whereby tracker pins have been employed) and the value of 'hands on' clinical assessment of patients to allow correlation with suspicious imaging findings.
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CASE SNIPPETS Top

Leishmaniasis recidivans in a nonendemic area that responded to doxycycline p. 218
S Pragna, R Sivayogana, R Sudha, S Vindu
DOI:10.4103/jpgm.JPGM_258_20  PMID:33063700
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An unusual case of metastatic choroidal deposits of renal cell carcinoma presenting with loss of vision p. 220
V Dave, A Shah, S Menon
DOI:10.4103/jpgm.JPGM_378_20  PMID:33037164
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Right atrial angiosarcoma presenting as supraventricular tachycardia p. 222
N Bachani, A Bagchi, P Vaideeswar, Y Lokhandwala
DOI:10.4103/jpgm.JPGM_477_20  PMID:33037166
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Short rib thoracic dysplasia without polydactyly due to novel variant in IFT172 gene p. 224
S Mhatre, M Muranjan, S Karande
DOI:10.4103/jpgm.JPGM_4_20  PMID:33037165
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LETTERS Top

Idiopathic CD4+T lymphocytopenia: A case report p. 226
FA Damara, AN Ramdhani
DOI:10.4103/jpgm.JPGM_718_20  PMID:33063701
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Reply to Letter to Editor regarding the article, “Idiopathic CD4+ T lymphocytopenia: A case report” p. 227
S Umamaheshwari, MN Sumana, MS Shetty, S Gopal
DOI:10.4103/jpgm.JPGM_782_20  PMID:33109784
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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow