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   Table of Contents - Current issue
Coverpage
May-August 2022
Volume 8 | Issue 2
Page Nos. 93-185

Online since Tuesday, August 23, 2022

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ORIGINAL ARTICLES  

Perception of Medical Faculty and Students about Online Teaching during the COVID-19 Pandemic in a Tertiary Care Teaching Institute p. 93
Nidhi Maheshwari, Bhupinder Singh Kalra, Vandana Roy
DOI:10.4103/mamcjms.mamcjms_121_21  
Background: Classroom teaching has been found to be the most common modality used for teaching. The unusual situation of the coronavirus disease 2019 (COVID-19) pandemic led to the shutdown of all educational institutions across the country. To limit the spread of the coronavirus, classroom teaching had to be abandoned and online teaching was sought for to continue the learning process. The study was conducted with the aim of assessing the perception of faculty as well as undergraduate medical students toward online teaching and learning methodology. Methods: A cross-sectional observational study using two separate pretested, structured questionnaires for faculty and students was conducted. The questionnaire had a total of 45 questions for collecting data on demographic information, awareness, perception and knowledge toward online teaching, perception about establishing connect between teachers and students through online portal, and operational and technical aspects. These questionnaires were mailed to faculty and students using Google forms (Google Survey platform). Results: A total of 47 teaching faculty and 386 students responded to the questionnaires. More than 70% faculty availed the training and guidance provided for online teaching. The move to switch over to online mode of teaching during lockdown was appreciated by majority (95%) of respondents. The faculty members made use of online polls, surveys, and educational videos for making online lectures interesting. In addition, online assessments (72%) and use of an interactive software (70%) were found worthy and useful. Majority of (80%) students missed direct and in person contact with instructor. Majority of the students (60%) felt isolated and alone during online teaching sessions. One-third of the students believed that instructors were able to generate interest in the topic and 63% of students were satisfied with the explanations delivered with regard to queries during online lectures. The major disadvantages that surfaced were limited options for two-way communication (55%), technical glitches (70%), social isolation (63%), eye strain, and other health-related issues (62%). Internet connectivity emerged as the biggest limitation by faculty members. Conclusion: Overall, the respondents were of the opinion that online teaching was a useful modality during COVID-19 and can be used as a complementary aid to regular teaching in. Adequate infrastructure and uninterrupted internet connectivity is vital for smooth conduct of online teaching.
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A Study on Perception of Stress Among First-Year Medical Undergraduates During COVID-19 Pandemic p. 100
Shilpa Khullar, Suman Das, S Aijaz Abbas Rizvi, Praveena Sinha, Syed Sibte Akbar Abidi, Rahul Baisla
DOI:10.4103/mamcjms.mamcjms_3_22  
Background: Medical students have been reported to suffer from a higher degree of perceived stress compared to the age-matched population doing other courses. Stress caused by the ongoing coronavirus disease (COVID-19) pandemic, lockdown, and the consequent shift of teaching methods to digital format has further compounded the stress associated with pursuing the medical curriculum. Aims and Objectives: Our study aimed to assess perceived stress among first-year MBBS students during COVID-19 induced lockdown using a self-administered Perceived Stress Scale (PSS-10) questionnaire. Materials and Methods: A total of 108 first-year MBBS students in the 18–25 years age group of both sexes were administered a 10-item questionnaire: PSS-10 during 2 months from June-July 2021and depending on their scores of PSS were divided into three groups Group A, B, and C signifying mild, moderate, and severe stress perceived by them, respectively. The continuous variables are presented as mean ± standard deviation and the categorical variables as proportions. Analysis of Variance (ANOVA) was used to compare the data between continuous variables in the three groups. Result: There was a statistically significant difference in the PSS scores between the three groups when a comparison was done (P < 0.05). A larger segment of the first-year medical students undergoing medical curriculum during the COVID-19 pandemic were found to be moderately (63%) to severely (4%) stressed. Conclusion: Our study suggested that the stress induced by the pandemic in addition to the stressors associated with undertaking medical courses creates a highly stressful environment for the medical students predisposing them to significant psychological morbidity.
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Perspective of Medical and Dental Students and Teachers Toward Online Teaching in Pharmacology During COVID-19 Pandemic p. 106
Sahil Kumar, Vandana Tayal, Razi Akhtar, Shalini Chawla, Vandana Roy
DOI:10.4103/mamcjms.mamcjms_120_21  
Introduction: In the light of the disruption caused by the coronavirus pandemic on medical education systems worldwide, several institutions switched to online mode of teaching-learning. Therefore, this study was planned to evaluate the perception, difficulties faced, and preference of second year medical/dental students and their teachers toward the online learning and live-streamed lectures during the COVID-19 pandemic. Methods: This was a cross-sectional, questionnaire based observational study. Data were collected by administering pretested, self-administered, online circulated, structured questionnaire via Google Forms. Descriptive statistics were used to summarize the study results. Results: In this study, 198 and 77 responses were obtained from MBBS and BDS students, respectively, and 14 responses from their teachers. Most students agreed that it was a good idea to conduct online teaching during lockdown. Majority of the students were able to adapt even without previous experience. “GoToWebinar” and “Cisco Webex” were reported as good online teaching platforms. Smart phones or tablets were most commonly used to attend classes. Major challenges reported were related to lack of skills, interest, attention, time management, resources (including internet connectivity), and poor communication among others. The students felt that the optimum duration of lectures should be 30 to 45 minutes. Majority of students and teachers alike felt that online teaching is a good option to be adopted for repeat classes or to gain extra knowledge in the future. Overall rating of online teaching (out of 10) was reported as good by both students (MBBS students mean score: 7.49 ± 1.57) and teachers (mean score: 7 ± 1.58). Conclusions: The situation arising out of the pandemic gave rise to a situation where online resources had to be used for teaching. The shift of medical education to online platforms presented a spectrum of issues for educators and students alike. It would be worth considering addressing these issues, so as to strengthen electronic learning processes in the institute.
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Anxiety and Depression in Undergraduate Students Due to Altered Screen Time and Physical Activity Patterns in COVID Times: A Survey p. 113
Aditya Gupta, Siddharth Trivedi, Keshave Singh, Sagar Bagwe, Lalit Maini
DOI:10.4103/mamcjms.mamcjms_128_21  
Objective: This study was done to assess anxiety and depression in undergraduate students due to altered levels of screen time (ST) and physical activity (PA) during the COVID-19 pandemic. Various studies have been carried out about the mental health impacts of ST and PA, but there is a paucity of literature when it comes to exploring these parameters in undergraduate students and the Indian population. This study aims to address this gap. Methods: Data were collected through a survey using an online questionnaire. Participants reported daily ST and weekly PA, both moderately vigorous physical activity (MVPA) and vigorous physical activity (VPA). Symptoms of anxiety and depression were ascertained using the Hospital Anxiety and Depression Score. Results: Out of the total 165 students analyzed, we found that 63% had borderline or pathological anxiety levels while 41.2% had borderline or pathological depression levels. There was a negative correlation between depression score and PA, for both MVPA (r = –0.233, P = 0.001) and VPA (r = –0.268, P = 0.0002). A negative correlation was found between anxiety score and PA for MVPA (r = –0.151, P = 0.024). There was a positive correlation between ST and scores of anxiety (r = 0.305, P = 0.006) and depression (r = 0.257, P = 0.02) in females but no correlation was found in males. Conclusion: The present study suggests that there is a high prevalence of borderline and pathological anxiety and depression amongst undergraduate students. High levels of PA and low levels of ST are separately associated with a lesser risk of anxiety and depression.
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Quality of Life of Health Care Professionals During COVID-19 Pandemic in India p. 121
Banipreet Kaur, Yash Aggarwal, Nidhi Bhatnagar, Sumeet Singla
DOI:10.4103/mamcjms.mamcjms_134_21  
Introduction: Nature of disease, poor working conditions, prolonged work duration, stigma, and discrimination in the community have worsened the well-being of health care professionals in COVID-19. This survey is conducted to understand the quality of life and its key determinants among health care workers (HCWs) during the COVID-19 pandemic in a low middle-income country like India. Methodology: A cross-sectional study using a Google form-based online questionnaire survey was planned at two COVID dedicated centers of New Delhi. A convenience sample of 300 HCWs involved in patient care at the study sites was studied using an SF-36 questionnaire for quality of life assessment and a self-made questionnaire (risk exposure assessment). Results: In the study, 61.0% were males and 40.72% were females across all specialties. The majority (77%) were single and 81.4% were from the age group of 20 to 30 years. 84% of the study subjects belonged to clinical specialties. Nearly 56% of study subjects reported being not satisfactory or uncomfortable in the personal protective equipment (PPE). Shortage of PPE was reported by 10% of study subjects. The majority (82.35%) of study subjects were satisfied with the quality of PPE. Satisfaction of the study subjects was less than satisfactory among food provided, accommodation, and transport facilities. Social isolation (70.5%) and lockdown restraints (57.6%) were reported by the majority of study subjects. The median score for the domain of general vitality was 55, for the emotional domain was 33, and for social was 62. The domains of quality of life were not significantly affected by place of work, discipline, age, sex, and type of work. Conclusion: The overall well-being of HCWs was affected during the pandemic mostly across mental, social, and general vitality domains. Social isolation was a key concern reported by the majority of HCWs.
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A Study on Prevalence of Depression Among Health Care Workers of a Tertiary Care Center in Northern India During COVID-19 Pandemic p. 127
Vikesh Gupta, Sukhjit Singh, Vineet Kumar, Pankaj Kanwar
DOI:10.4103/mamcjms.mamcjms_111_21  
Background: COVID-19 pandemic has given rise to a diverse set of problems related to mental health, employment, economic wellbeing, access to education, inflation, transportation, and vaccination in addition to physical health consequences. Health care workers (HCWs), being in forefront of providing care to COVID-19 patients, are a special vulnerable population suffering from COVID-19-related mental health problems. Method: A cross-sectional study to assess the prevalence of depression among HCWs working in different specialties of a tertiary care health center of Northern India was done. A self-designed performa containing sociodemographic details along with the “Zung self-rating depression scale” was used to obtain the prevalence of depression among HCWs. Result: Among 192 participants, 14.58% had signs of depression, out of which 11.96% had mild, 1.56% had moderate, and 1.04% had signs of severe depression. Conclusion: The depression among HCWs has increased after the onset of the COVID-19 pandemic.
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Psychological Impact of COVID-19 Pandemic on Healthcare Workers Posted in the Obstetric Unit p. 131
Shikha Chadha, Sonal Prasad, Dinesh Tyagi, Aaliya Ansari, Govind R Kahar
DOI:10.4103/mamcjms.mamcjms_41_22  
Objective: This study was done to determine the prevalence and predictors of depression, anxiety, and stress among doctors in COVID MCH unit in Delhi. Method: A cross-sectional study was conducted in India among 356 doctors to evaluate the mental health of doctors working in COVID-infected maternity wards over a period of 6 months using a predesigned, semistructured Depression, Anxiety, and Stress Scale (DASS-21) questionnaire which was developed on Google Forms. The predictors to stress, anxiety, and depression were subject to univariate logistic regression. Result: Out of the total 356 participants, 38.76% felt stressed, 56.46% were anxious, while 43.25% felt depressed. The mean DASS-21 score for stress, anxiety, and depression was 7.46, 4.12, and 4.29, respectively. Female gender was found to be a significant predictor of stress, anxiety, and depression. Staying with parents/children was a significant predictor for stress and living alone was found to be a significant predictor of depression. Fear of infecting their family members was the main concern among those tested positive. Conclusion: The present study has shown a significant psychological impact arising from this pandemic. Early screening targeting the medical workforce and the implementation of psychological interventions is essential for maintaining the functionality of the healthcare system.
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Seroprevalence of Sexually Transmitted Infections (Hepatitis B Virus, Hepatitis C virus, Syphilis, and HIV) in Pregnant Women and Evaluation of Sociodemographic Characteristics and Awareness Regarding STIs in North Indian Population p. 137
Ruby Bhatia, Girisha Mehta, Sukhbir Pal Kaur Sidhu, Trisha Arora, Renuka Raina
DOI:10.4103/mamcjms.mamcjms_98_21  
Context: Sexually transmitted infections (STIs) are a problem of increasing concern among men and women. They can affect fertility, increase maternal and neonatal morbidity, and can become a burden on both physical and emotional health. Owing to lack of awareness and partly due to the social stigma attached, couples do not come forward for screening. Antenatal testing for STIs is an effective strategy recommended to detect STIs in this subset of the population. Aims: To estimate the seroprevalence of four STIs (hepatitis B, hepatitis C virus, HIV, and syphilis) in pregnant women, to evaluate its correlation with sociodemographic characteristics and sexual behavior, and to check awareness regarding STIs. Settings and Design: It was an observational study on 500 pregnant women attending an antenatal clinic at a tertiary care hospital in rural Haryana, India. Methods and Material: Pregnant women were screened for four STIs – hepatitis B, hepatitis C virus, HIV, and syphilis. Statistical Analysis Used: The sample size was calculated considering the mean reported seroprevalence of infections in pregnant women in previous studies. The power of the study was kept 80% and the alpha error was 0.05. Results: Seroprevalence for STIs in pregnancy was 5.2% – hepatitis C virus (2.6%), hepatitis B (2.4%), and syphilis (0.4%). Conclusions: Viral STIs are more prevalent among pregnant women. Antenatal screening is an effective strategy for the detection of STIs in pregnant women.
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Prevalence and Determinants of Exclusive Breastfeeding Among Children Less Than Two Years of Age in a Rural Area of Delhi, India p. 144
Pallavi Singh, Rajesh Kumar, Gajendra S Meena, Panna Lal
DOI:10.4103/mamcjms.mamcjms_133_21  
Context: Exclusive breastfeeding for the first 6 months of life is highly beneficial to the child. Unfortunately, it is frequently not practiced among women due to a lack of knowledge. Aims: The study aims to to find the prevalence of exclusive breastfeeding among children aged less than 2 years of age and to study the factors influencing the practice of exclusive breastfeeding among the mothers of the study participants. Methods and Material: The design was a community-based cross-sectional study. Between January 2019 and January 2020, we enrolled 190 children aged less than 2 years of age and their mothers residing in a rural area of Delhi, India. We collected baseline sociodemographic data and details of feeding practices followed using a pretested semi-structured questionnaire. To measure association, the chi-square test or Fischer exact test was used. Statistical analysis used: Collected data was entered into MS-Excel and analyzed using IBM Statistical Package for the Social Sciences – 25 for descriptive and inferential statistics. Results: Of the 190 participants with complete information, 74 were under 6 months of age and it was found that 57 (77.0%) of those were exclusively breastfed till their present age. The remaining 116 children were aged between 6 and 23 months and the prevalence of exclusive breastfeeding in these children was found to be 55.2% (64). The mean duration of exclusive breastfeeding was 5.75 ± 1.79 months. The age of the child was found to be statistically significant with the practice of exclusive breastfeeding (P = 0.01). Conclusions: The exclusive breastfeeding up to 6 months of age was practiced only by approximately half of the mothers.
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An Audit of Antibiotic Prescribing Pattern Among Children in Emergency Settings of a Tertiary Medical College and Hospital p. 149
Vikas Manchanda, Urvashi Suman, Urmila Jhamb, Rincy Shaji
DOI:10.4103/mamcjms.mamcjms_4_22  
Background: Resistance to antimicrobials is increasing, which leads to a significant increase in mortality, morbidity, and health care costs. In order to promote rational antibiotic uses, standard policies must be set and can be done only after the current antibiotic prescription has been audited. Objective: The aim of the study was to describe the antibiotic prescribing patterns in the pediatric emergency of a tertiary care hospital. Methods: The data were collected from the pediatric emergency over the period of 6 consecutive days from August 6, 2018 to August 11, 2018. The methodology recommended by the World Health Organization (WHO) for the investigation of drug use in a health facility was followed. The data were analyzed for the percentage of antibiotics prescribed by generic name, prescribed from essential medicine list of government, drugs with fixed-dose combination, and percentage of broad- and narrow-spectrum antibiotics used. Result: A total of 600 prescriptions were analyzed in the study. Most of the children were less than 1 year of age (30.8%). Combination of three antibiotics were prescribed in 8.8 % of patients. A 100% of antibiotics were prescribed from the essential drug list. Antimicrobials prescribed by generic name were 52%. Injection ceftriaxone was the commonest antibiotic prescribed (43.3%), followed by amikacin (25.2%). The broad- and narrow-spectrum antibiotics prescribed were 86.6% and 13.4 %, respectively. Conclusion: The antibiotics are used cautiously in the paediatrics emergency department of this institute. Among those who were prescribed antibiotics, all prescriptions were from the essential drug formulary. Our findings provide support for investigating antibiotic utilization in other settings and work toward developing a national rational prescribing strategy.
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Nail Fold Capillary Changes in Diabetes Mellitus and Their Correlation with Diabetic Retinopathy p. 153
Niraj Bohania, Sumeet Singla, Sanjay Pandit, Anuj Achyut Ban, Richa Agarwal, Parul Jain
DOI:10.4103/mamcjms.mamcjms_5_22  
Background: Nail fold capillaroscopy (NFC) is mainly used in connective tissue diseases (scleroderma, mixed connective tissue disease, and inflammatory myositis). It is not used routinely in the evaluation of diabetic patients and no specific patterns of nail fold capillary changes have been established in diabetes. We studied morphological patterns of nail fold capillaries by video capillaroscope in diabetic patients and their association with diabetic retinopathy (DR). Methods and Material: Fifty diabetics were recruited after informed consent. The mean age of patients was 49.5 ± 10.6 years. Seventeen patients had DR. Capillary length, capillary density, and various morphological parameters were assessed and these parameters were compared between patients with DR and without DR. Results: The most frequent NFC morphological alterations, among diabetics as a group, were tortuous capillaries (56%), giant capillaries (46%), and cross-linked capillaries (44%). Overall, mean nail fold capillary length was reduced in diabetic patients. When individual morphological alterations were compared in patients with DR versus without DR, statistically significant differences were seen for presence of giant capillaries, tortuous capillaries, and avascular areas. On further analysis, mean nail fold capillary length and mean nail fold capillary density were also significantly lesser in patients with DR versus without DR. Conclusions: The presence of nail fold capillary morphological abnormalities among diabetics and a significant association with microangiopathic changes in the retina suggest that microvascular changes can be detected early using a simple, non-invasive office-based method of NFC. More large-scale studies in the future can establish a characteristic pattern for diabetes as seen in systemic sclerosis so that microvascular changes in diabetics can be detected at the earliest with the simple noninvasive method by using NFC.
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False Positive Reaction to VDRL Test with Prozone Phenomenon in a Case of Lepromatous Leprosy p. 158
Rohit Chawla, Preeti Thakur, Atul Mohan Kochhar, Sumeet Singla
DOI:10.4103/mamcjms.mamcjms_12_21  
Abstract The venereal disease research laboratory (VDRL) test, a nontreponemal test for syphilis, may under a certain set of conditions give false positive results in patients who are not infected with Treponema pallidum. A false positive reaction is defined as a positive reaction to nontreponemal tests, and a negative reaction to treponemal tests, in the serum of a patient who has no history or clinical evidence of syphilis or other treponematosis. A prozone phenomenon in nontreponemal tests is seen largely with secondary syphilis due to high-titer samples that show nonreactive results unless the specimens are diluted. We report here perhaps the first case of lepromatous leprosy, which had a false positive reaction to the VDRL test with the prozone phenomenon. The case initially presented to the outpatient clinic with complaints of epistaxis with nasal stuffiness. The finding of septal perforation on nasal endoscopy is what led to the initial suspicion of syphilis and the subsequent syphilis workup. It was only when the false positive reaction to VDRL test with the prozone phenomenon was noted that the search for other causes was made, which eventually lead to the diagnosis of lepromatous leprosy.
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Diaphragmatic Hernia in Pregnancy – A Case Report p. 163
Anjali Tempe, Vedika Bali, Devender Kumar, Chaithanya Guguloth
DOI:10.4103/mamcjms.mamcjms_8_22  
Background: Maternal diaphragmatic hernias (DH) identified during pregnancy are rare and pose significant management challenges with respect to the timing of delivery, mode of delivery, and hernia repair. Case presentation: We describe a case of traumatic maternal DH, diagnosed at 31 weeks of gestation presenting with multiple episodes of vomiting. Owing to no evidence of visceral compromise and a stable maternal and fetal condition, the patient was conservatively managed allowing further fetal maturation and was delivered by cesarean section at 34 weeks. This was followed by laparoscopic intraperitoneal mesh hernial repair at 6 weeks postpartum. The patient had an uncomplicated recovery. Conclusion: Maternal DH in pregnancy require multidisciplinary care and individualized management for the optimal outcome for mother and fetus.
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CASE REPORTS Top

A Giant Angiolipoma: A Case Report p. 167
Vaibhav Aggarwal, Suneha Kumari, Kamal Kataria, Ankur Goyal
DOI:10.4103/mamcjms.mamcjms_105_21  
Angiolipomas are uncommon benign vascular adipocytic mesenchymal tumors and generally present as painful subcutaneous nodules in the extremities and trunk. Chest wall is a rare site for angiolipoma. We describe a case of a giant retromammary angiolipoma that presented clinically as an apparent large breast lump. This tumor was surgically excised after preoperative angioembolization. Latter was carried out to reduce intraoperative bleeding and facilitate the excision. We recommend keeping benign tumors such as angiolipomas in differential when dealing with apparent breast/chest wall lumps. We also advocate preoperative angioembolization in select cases while excising large angiolipomas to decrease perioperative blood loss.
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Secondary Amyloidosis with Fatal Outcome in a Child with Meningomyelocele: Need for a Closer Renal Surveillance p. 171
Madhavi Bharadwaj, Aashima Dabas, Mukta Mantan, Vineeta Batra, Sangeeta Yadav
DOI:10.4103/mamcjms.mamcjms_60_21  
Amyloidosis constitutes a group of diseases characterized by extracellular deposition of fibrils composed of low molecular weight subunits of a variety of proteins. Secondary amyloidosis may result from chronic inflammatory conditions such as familial Mediterranean fever, juvenile idiopathic arthritis, tuberculosis, and bronchiectasis. Myelomeningocele is reported rarely in literature as a cause of amyloidosis. We report here a case of 6-year-old boy with operated congenital lumbar myelomeningocele with paraparesis and neurogenic bladder, who was diagnosed with nephrotic syndrome with hypertension. He underwent a renal biopsy which showed amyloidosis. During the course of treatment, he acquired a perigenital infection and later succumbed to it. A closer follow-up of patients with neurogenic bladder can help identify and manage renal complications early.
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Massive Hemoptysis in Post-Tubercular Sequelae: A Multidisciplinary Critical Care Team in Action p. 174
Neeraj Kumar Gupta, Rohit Kumar, Puneet Garg, Pranav Ish, Vipin Aggarwal, Nitesh Gupta
DOI:10.4103/mamcjms.mamcjms_35_21  
Massive hemoptysis can lead to respiratory failure and life-threatening hypoxia in patients with underlying post-tubercular fibrocavitary disease. In the absence of urgent surgical interventions in a resource-poor country, interventional bronchoscopy and bronchial artery embolization (BAE) can be lifesaving in critical care management of such patients. We present a young male who required mechanical ventilation, emergency bronchoscopic intervention, and BAE, and showed recovery.
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Spontaneous Resolution of Type 1 Macrocystic Congenital Cystic Adenomatoid Malformation: A Rare Presentation p. 178
Shishir Kumar, Shasanka Shekhar Panda, Sujoy Neogi, Simmi K Ratan
DOI:10.4103/mamcjms.mamcjms_79_21  
Abstract We present a case of 6-month-old boy who presented with respiratory distress due to empyema, which was initially managed by the intercostal drain. Computed tomography scan confirmed the diagnosis of type 1 congenital cystic adenomatoid malformation (CCAM). Subsequently, there was the spontaneous resolution of empyema and CCAM prior to surgical intervention. Our case illustrates the postnatal spontaneous resolution of CCAM, which is rare.
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Anesthesia Concerns and Management in Case of Severe Hemophilia A: A Case Report and Review of Literature p. 180
Deepali Jamgade, Manasa Kantha, Sanjay Agrawal, Debarati Chattopadhyay, Uttam K Nath
DOI:10.4103/mamcjms.mamcjms_115_21  
Abstract Hemophilia is a genetic disease presenting with increased chances of perioperative bleeding. Preoperative recognition, assessment of risk, and careful titration of factor VIII transfusion are important for anesthesia management and decrease of morbidity. Here we present a case of severe hemophilia with an open wound of the knee scheduled for flap rotation and cover.
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LETTERS TO THE EDITOR Top

Periarticular Injections After Bipolar Hemiarthroplasty p. 183
Akhil Wadhawan, Yasim Khan, Sumit Arora
DOI:10.4103/mamcjms.mamcjms_100_21  
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A Possible Cause of Incorrect Dose Administration of Insulin in ICU p. 185
Summit Dev Bloria, Jetinder Pal Singh
DOI:10.4103/mamcjms.mamcjms_129_21  
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