Acanthosis nigricans in Insulinoma: Reversible experiments of the nature Publication date: Available online 18 October 2019 Source: Medical Journal Armed Forces India Author(s): Vijay Sheker R. Danda, Paidipally Srinivas Rao, Chaitanya Konda, Piyush Lodha Abstract Acanthosis Nigricans is considered to be a skin marker of insulin resistance and atherosclerosis. It is rarely reported in cases of insulinoma where there is marked hyperinsulinaemia. We report two cases of insulinoma with acanthosis nigricans which regressed, concomitant with significant weight loss and reduction in blood pressure following surgical resection. This strengthens the hypothesis that hyperinsulinaemia is responsible for Acanthosis nigricans and atherosclerotic risk factors.

Food safety and quality control: Best practices in the Indian Armed Forces Publication date: Available online 17 October 2019 Source: Medical Journal Armed Forces India Author(s): A.K. Jindal Abstract The Army Marches on its Stomach". To provide nutritious, wholesome, safe and quality food to the large Indian Armed Forces, spread over various terrains, ranging from the icy Himalayas to the burning deserts of Rajasthan or the humid jungles of the North East and over various platforms like tanks, ships and aircraft is a challenge. The major issue in this is to procure and supply the food while ensuring that it is safe and retains its quality till it is cooked. This vital part of the supply chain viz from farm to the military cook house is the responsibility of the Army Service Corps (ASC) supported by the Army Medical Corps (AMC) and the Remount and Veterinary Corps (RVC). The Food Inspection Organization of the ASC lays down the best practices to be followed in terms of inspection, sampling, analysis, dispatch and issue of both fresh and processed edible foodstuff. The Armed Forces have their own network of Composite Food Laboratories for sampling and analysis of the food items. To ensure superior quality the Defence Food Specifications are much higher than legislated by the Food Standards and Safety Authority of India (FSSAI) for the general public. This paper highlights the best practices followed to ensure food safety and quality control in the Indian Armed Forces.

Efficacy of group intervention on tobacco cessation among male employees in health-care setting: A randomized controlled trial Publication date: Available online 16 October 2019 Source: Medical Journal Armed Forces India Author(s): S.K. Swain, Kunal Chatterjee, D.R. Basannar Abstract Background The tobacco epidemic is one of the biggest public health threats the world has ever faced. World Health Organization has estimated that tobacco use (smoking and smokeless) is currently responsible for the death of about 7 million people across the world each year. The objective of the study was not only to find the effect of group intervention on tobacco cessation but also to describe certain epidemiological factors associated with tobacco cessation and make suitable recommendations to tackle this epidemic. Methods A randomized controlled trial was carried out among male employees who were tobacco users in health-care setting in Western Maharashtra. In the study, 60 subjects each in intervention and control arm were taken. Pretested validated questionnaires were used for the study. The intervention comprised of two sessions delivered 5 weeks apart. Control arm received self-help material (Booklet) immediately after baseline data collection. The outcomes were measured using structured interview schedule. The data were analyzed using SPSS, version 20. Results Overall, 13.3% of the study subjects had quit tobacco use post intervention. In the intervention group 21.7% of the participants had quit tobacco since past one month and 5% in the control group (relative risk (RR) = 4.33). Low to moderate nicotine dependence (p = 0.023, RR = 6.46) and stage of contemplation (p = 0.018) were found to be important predictors of abstinence. Conclusion Community-based group intervention for tobacco cessation is the way forward to tackle the tobacco epidemic.

Gut microbiota profiling in hematopoietic stem cell transplant recipients: Toward personalized medicine Publication date: Available online 16 October 2019 Source: Medical Journal Armed Forces India Author(s): J.S. Gill, S.P. Singh, Sanjeevan Sharma, Ashwini Agarwal Abstract Background Antibiotic resistance in bacteria is a cause for concern, especially in hematopoietic stem cell transplant (HSCT) patients. Endogenous bowel microflora in HSCT patients get replaced by hospital multidrug resistant flora and pose risk of serious bacterial infection during the pre-engraftment stage. For decades, many methods to reduce the translocation of gut microbiota in HSCT patients have been attempted. Despite the logic, of using prophylactic antibiotics, there is no consensus on standard regimen. Personalized antibiotic prophylaxis-based on gut microbiota and clinical profile has been suggested by researchers. In this study, gut microbiota in HSCT recipients has been studied with antimicrobial susceptibility testing and detection of various antibiotic resistance phenotypes. Methods Seventy-six HSCT patients (2016–2018) were included. Stool surveillance cultures and antibiotic susceptibility testing were performed. Bacterial isolates were classified into various antibiotic resistance phenotypes. Results This study revealed that 73.75% HSCT recipients had gut colonized with antibiotic resistance microbiota which included extended-spectrum β-lactamase-, multidrug- and extensively drug-resistant phenotypes. Conclusion This study reiterates the importance of individual profiling of gut microbiota in HSCT patients.

Age at first drink and severity of alcohol dependence Publication date: Available online 16 October 2019 Source: Medical Journal Armed Forces India Author(s): K. Chatterjee, A.K. Dwivedi, R. Singh Abstract Background Early age at first drink (AFD) has been linked to early onset and increased severity of alcohol dependence in various studies. Few Indian studies on AFD have shown a negative correlation between AFD and severity of alcohol dependence. Our study aimed to explore this relationship in patients with alcohol dependence syndrome (ADS) diagnosed using ICD-10 criteria. Methods One hundred fifty-one consecutive patients freshly diagnosed with ADS were included in the study, which was conducted at the psychiatry unit of a tertiary care, multispecialty hospital. The Addiction Severity Index (ASI) was used to assess severity of alcohol dependence. Results Mean AFD was 24.85 years (range = 13–40 years). Median ASI score was 36 (range = 21 to 57). The study yielded a weak negative correlation (ρ = −.105) between AFD and ASI, which was statistically not significant. Conclusions We found no correlation between AFD and severity of alcohol dependence at detection in Indian Armed Forces personnel, which is contrary to what has been reported worldwide and in previous Indian studies. Delayed initiation of alcohol use among those enrolling in the Indian Armed Forces and early detection of alcohol dependence within the military environment are possible explanations.

Immune activation markers in individuals with HIV-1 disease and their correlation with HIV-1 RNA levels in individuals on antiretroviral therapy Publication date: Available online 15 October 2019 Source: Medical Journal Armed Forces India Author(s): Jyoti Sangwan, Sourav Sen, Rajiv Mohan Gupta, K. Shanmuganandan, Rajan S. Grewal Abstract Background Currently CD4+ T lymphocyte counts and HIV-1 RNA levels are being utilized to predict outcome of human immunodeficiency virus (HIV) disease. Recently, the role of immune activation in HIV disease progression and response to treatment is being investigated. This study focused on the expression of CD38 and HLA-DR on lymphocyte subsets in various groups of HIV-infected individuals and to determine their association with HIV-1 disease progression. Methods Ninety-eight cases of patients with HIV/AIDS in different disease stages and twenty-four healthy HIV-negative individuals were included in the cross-sectional study. Their immune function and abnormal immune activation markers (CD38 & HLA-DR) were detected using a flowcytometer, and HIV-1 RNA levels in individuals receiving antiretroviral drugs were estimated. Results The immune activation marker levels were significantly different between patients with different disease stages (P < 0.001). A significant negative correlation was observed between peripheral blood CD4+ T cell counts and immune activation markers. Also, a significant positive correlation was observed between HIV-1 RNA levels and CD38+CD8+ T lymphocyte. Conclusion Immune activation markers (CD38 & HLA-DR) increase with disease progression. CD38+ on CD8+ T lymphocyte correlates well with HIV1 RNA levels in individuals failing on antiretroviral therapy.

Catheter-related blood stream infections: prevalence, risk factors and antimicrobial resistance pattern Publication date: Available online 15 October 2019 Source: Medical Journal Armed Forces India Author(s): Priyanka Pandit, A.K. Sahni, Naveen Grover, Vaibhav Dudhat, N.K. Das, A.K. Biswas Abstract Background Intravascular devices have significant potential for producing iatrogenic diseases resulting in catheter-related blood stream infections (CRBSIs). A study was undertaken to find the prevalence of CRBSI among patients in acute wards and to analyze the associated risk factors, causative pathogens with their antibiotic susceptibility (ABST) patterns. Methods Randomly ten days per month were chosen, for a period of two years. All the acute wards patients who were on indwelling blood catheters were identified. Those fulfilling the CRBSI criteria were further worked up for confirmation of diagnosis by differential time to positivity. The catheter tip was cultured by Maki's semiquantitative method. ABST of the isolates obtained was performed by Kirby–Bauer disk diffusion method. Results The prevalence of CRBSI was found to be 39.25% with the most common organism isolate being Serratia marcescens (23.81%). The immunocompromised status of the patients and catheterisation time were significant risk factors. Methicillin resistance was found to be 33.33% in coagulase-negative staphylococci. The resistance to vancomycin among the Entercoccus faecium isolates was found to be 33.33%. Among the gram negatives, resistance to aminoglycosides, fluoroquinolones and third-generation cephalosporins was high. Conclusion The study highlights the importance of regular surveillance programs, an efficient infection control program, strict adherence to antiseptic measures and use of a rational antibiotic policy for the early diagnosis and better management of CRBSI.

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

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.

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.