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   Table of Contents - Current issue
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July-September 2022
Volume 71 | Issue 3
Page Nos. 167-250

Online since Tuesday, September 20, 2022

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EDITORIAL  

Vertebral endplates, the anatomically discrete structures of the vertebral column Highly accessed article p. 167
Vishram Singh, BV Murlimanju, Rajanigandha Vadgaonkar
DOI:10.4103/jasi.jasi_118_22  
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ORIGINAL ARTICLES Top

Carotid intima–Media thickness: An independent risk factor for stroke prediction – A call for revised framingham score system Highly accessed article p. 169
Garima Khatri, Mohan Singh, Sunita Bika, Khushboo Joshi, Nirmala Swami
DOI:10.4103/jasi.jasi_212_21  
Introduction: Stroke is the second leading cause of death globally, with more than 85% of deaths from stroke occurring in developing countries. It is also reported as the major sequel of head and neck irradiation and has not received the attention it deserves. The contribution of various risk factors to the burden of stroke worldwide is unknown, particularly in countries of low and middle income. We aimed to establish the association of known and emerging risk factors, the carotid intima–media thickness (IMT), with stroke in postradiotherapy patients with head and neck malignancies, also aimed to establish whether carotid IMT (cIMT) is an independent risk factor to predict future stroke. Material and Methods: The study recruited 501 subjects. 151 irradiated patients with head and neck malignancy, formed case group. Three hundred and fifty nonirradiated apparently healthy controls formed control group. Each group was subdivided into four subgroups on the basis of gender and presence or absence of classical atherogenic risk factors, i.e. totally 8 groups were structured. All subjects were measured for their cIMT by color Doppler, b-mode ultrasonography and were also made to complete a questionnaire to assess other cardiovascular risk factors. The Framingham score system was used to predict probability of stroke. Results: Study described higher values of cIMT and total points for risk factors in cases than in controls and the difference was again statistically significant (P = 0.0001). Discussion and Conclusion: CIMT clearly indicated to act as an independent risk factor to predict stroke and is suggested to be worked on to be incorporated in the Framingham score.
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Problem-based learning using online platforms: An interactive alternative to mandatory e-learning during the COVID-19 pandemic Highly accessed article p. 178
Mamata Chimmalgi, S Rajesh, KV Anil Kumar, UV Asha, Jesin Elsa Jose, Komalavallyamma Chandrakumari
DOI:10.4103/jasi.jasi_13_22  
Introduction: Problem-based learning (PBL) helps in contextual and experiential learning. PBL using online platforms (PBL-op) was introduced to counter the declining interest in the mandatory e-learning during the COVID-19 pandemic. The purpose of this study was to determine the effect of PBL-op on learning outcome; student perception of PBL-op; effect of communication and motivation on learning outcome; and performance in PBL-op. Material and Methods: Study participants were introduced PBL-op and the control group to PBL in classroom setting. Five-way assessment was done: learning outcome by pre-and postintervention tests; performance by project reports and presentations; communication skills; motivation; and student satisfaction through an anonymous survey. Data were analyzed using descriptive statistics, paired or independent t-tests to compare paired variables, Spearman's correlation to establish association, and theme-based analysis for qualitative inputs. Results: Students showed better learning outcome with PBL op than with e learning (t = 11.199; P < 0.001*), traditional teaching (t = 12.193; P < 0.001*) and PBL in classroom setting (t = −15.493; P < 0.001*; d = 1.83). Women outperformed men with PBL-op (t = −2.74; P = 0.0034*; d = 0.48). Performance in PBL was better when conducted using online platforms than in classroom setting (t = 8.5471; P < 0.001*; d = 1.01). However, learning outcome and performance in PBL-op did not show a significant association with motivation or communication skills. Students favored PBL-op as it offered them an opportunity for active participation. Discussion and Conclusion: PBL-op offers all the advantages of PBL and allows productive teamwork using familiar online platforms and freedom from restrictive class timings. It is, therefore, suggested that PBL-op may be used as a feasible and effective alternative to PBL even after the pandemic.
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Dimensional accuracy of medical models of the skull produced by three-dimensional printing technology by advanced morphometric analysis p. 186
Sharmila Aristotle, Shantanu Patil, Saikarthik Jayakumar
DOI:10.4103/jasi.jasi_202_21  
Introduction: Three-dimensional (3D) printing creates a design of an object using software, and the process involves by converting the digital files with a 3D data using the computer-aided design into a physical model. The aim of the study was to investigate the accuracy of human printed 3D skull models from computed tomography (CT) scan data via a desktop 3D printer, which uses fused deposition modeling (FDM) technology. Material and Methods: Human anatomical cadaver skulls were CT scanned in 128-slice CT scanner with a slice thickness of 0.625 mm. The obtained digital imaging and communications in medicine files were converted to 3D standard tessellation language (STL) format by using MIMICS v10.0 software (Materialise, Leuven, Belgium) program. The 3D skull model was printed using a Creatbot DX desktop 3D FDM printer. The skull model was fabricated using polylactic acid filament with the nozzle diameter of 0.4 mm and the resolution of the machine was maintained at 0.05 mm. The accuracy was estimated by comparing the morphometric parameters measured in the 3D-printed skull with that of cadaver skull and with CT images to ensure high accuracy of the printed skull. Fourteen morphometric parameters were measured in base and cranial fossa of the skull based on its surgical importance. Results: Analysis of measurements by inferential statistical analysis of variance for all three groups showed that the 3D skull models were highly accurate. Reliability was established by interobserver correlation for measurements on cadaver skull and the 3D skulls. Dimensional error was calculated, which showed that the errors between three groups were minimal and the skulls were highly reproducible. Discussion and Conclusion: The current research concludes that a 3D desktop printer using FDM technology can be used to obtain accurate and reliable anatomical models with negligible dimensional error.
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Age- and gender-based morphometric variation of macula in indian population using optical coherence tomography p. 191
Pareesa Rabbani, Shalini Kumar, Taskin Khan, Shayama K Razdan
DOI:10.4103/jasi.jasi_205_21  
Introduction: Histological morphometric analysis of retinal layers has inherent limitations while processing the specimen. A new in vivo technique, optical coherence tomography (OCT), has been developed that can be used to analyze and differentiate normal and pathological retina. To do a morphometric analysis of normal macula in the adult population of India and study its variations on the grounds of sex and age. Material and Methods: One hundred (200 Eyes) healthy adult subjects (18–65 years) underwent macular cube scanning using Zeiss spectral-domain OCT (SD-OCT). Macular thickness from all nine regions of the Early Treatment Diabetic Retinopathy study map was documented for each subject. Their variations for age and sex were determined manually and automatically. Statistical analysis was done by entering into an MS Excel sheet using IBM SPSS Statistics for Windows,Version 25.0. Armonk, NY: IBM Corp. (2017). The data were also analyzed using an independent t-test and analysis of variance. Results: The mean age of the subjects was 34.2 ± 13 (range, 19–65) years. The mean Central Subfield Thickness (CST) measured automatically (foveal thickness) and manually was 239.52 ± 22.9 μm and 167.75 ± 21.94 μm, respectively, while mean macular thickness was 284.73 ± 15.7 μm and 276.76 ± 14.84 μm. Males were associated with greater foveal, central foveal thickness, and mean macular thickness than females (P < 0.0001). There was no significant correlation of CST, outer and inner ring, and mean macular thickness with increasing age (>30 years). However, with respect to gender in the inner ring (parafoveal region), all the quadrants except the inferior quadrant, CST was significantly (P < 0.0001) higher in males than females while in the outer ring (perifoveal region), it was the temporal quadrant that had statistically significant higher CST in males compared to females. Discussion and Conclusion: The results will add evidence and can serve as a normal database in morphometry of macula in Indians, created and found significantly different in already fed normal comparative data in SD-OCT machines. It will help analyze morphometry of macula and understand macular pathologies in Indian eyes.
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Cardiac morphometry in healthy young Indian adult males: An evaluation of chamber thickness and left ventricular cardiac mass p. 199
Rohit Aggarwal, Ruchi Gautam, Abdul Raheem Sheik
DOI:10.4103/jasi.jasi_77_21  
Introduction: Measurement of cardiac chambers is an important tool in the assessment of cardiac disease. Cardiac imaging can be used for the accurate assessment of these parameters. The primary objective of this study is to estimate various clinically relevant cardiac measurements including the left ventricular (LV) myocardial mass using cardiac magnetic resonance imaging (CMRI). The secondary objective is to correlate these measurements with the patient's body mass index (BMI). Material and Methods: A descriptive cross-sectional observational study was done at a tertiary care hospital. A total of 100 healthy young Indian adult males between 18 and 30 years of age underwent cardiac MRI on a 1.5Tesla Magnetic Resonance Imaging scanner. The thickness of various cardiac chambers and LV cardiac mass was measured. The results were compared with BMI. Results: Mean left atrial wall thickness is 1.6 mm in End -systole (ES)) and 1.5 mm in end diastole (ED). Mean Right atrial thickness is 1.5 mm (ES) and 1.8 mm (ED). Mean left ventricular wall thickness is 17.7 mm in End -systole (ES)) and 10.9 mm in end diastole (ED). Mean Right ventricular thickness is 6.9 mm (ES) and 3.2 mm (ED). Mean interventricular wall thickness is 14/9.7 mm in ES and ED, respectively. LV cardiac mass is 119.97 g. There is weak-to-moderate association between cardiac chambers and BMI. Discussion and Conclusion: Assessment of cardiac chamber thickness and LV cardiac mass in healthy adults can be made using CMRI. These values can be used as baseline to compare with measurements in various diseases of the heart.
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Gender prediction with the parameters obtained from pelvis computed tomography images and machine learning algorithms p. 204
Yusuf Secgin, Zulal Oner, Muhammed Kamil Turan, Serkan Oner
DOI:10.4103/jasi.jasi_280_20  
Introduction: In the skeletal system, the most dimorphic bones employed for postmortem gender prediction include the bones in the pelvic skeleton. Bone measurements are usually conducted with cadaver bones. Computed tomography (CT) is an increasingly popular method due to its ease of use, reconstruction opportunities, and lower impact of age bias and provides a modern data source. Even when parameters obtained with different or same bones are missing, machine learning (ML) algorithms allow the use of statistical methods to predict gender. This study was carried out in order to obtain high accuracy in estimating gender with the pelvis skeleton by integrating ML algorithms, which are used extensively in the field of engineering, in the field of health. Material and Methods: In the present study, pelvic CT images of 300 healthy individuals (150 females, 150 males) between the ages of 25 and 50 (the mean female age = 40, the mean male age = 37) were transformed into orthogonal images, and landmarks were placed on promontory, iliac crest, sacroiliac joint, anterior superior iliac spine, anterior inferior iliac spine, terminal line, obturator foramen, greater trochanter, lesser trochanter, femoral head, femoral neck, body of femur, ischial tuberosity, acetabulum, and pubic symphysis, and coordinates of these regions were obtained. Four groups were formed based on various angle and length combinations obtained from these coordinates. These four groups were analyzed with ML algorithms such as Logistic Regression, Linear Discriminant Analysis (LDA), Random Forest, Extra Trees Classifier, and ADA Boost Classifier. Results: In the analysis, it was determined that the highest accuracy was 0.96 (sensitivity 0.95, specificity 0.97, Matthew's Correlation Coefficient 0.93) with LDA. Discussion and Conclusion: The use of length and angle measurements obtained from the pelvis showed that the LDA model was effective in estimating gender.
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Description of an atypical vascular arch in the renal parenchyma p. 210
Alberto Garcia Barrios, Ana Isabel Cisneros Gimeno, Jesus Obon Nogue, Jaime Whyte Orozco
DOI:10.4103/jasi.jasi_83_21  
Introduction: Variability in renal vascularization occurs with a frequency of around 30%. During the routine dissection of one cadaver without renal pathology, we revealed the presence of one. Material and Methods: Dissection of a cadaver carried out in the practicing room of School of Medicine. Results: During the routine dissection of one cadaver without renal pathology, we revealed the presence of an early bifurcation of the renal artery on the left side, and the presence of two polar arteries – superior and inferior -, the latter presenting an anterior and posterior vascular arch to the renal pelvis in the parenchyma, which anastomoses the pre- and retro-pyelic branches of the renal artery with the pre- and retro-pyelic branches of the inferior accessory polar artery. In addition, the presence of an accessory polar artery was observed in the right kidney. Discussion and Conclusion: For vascular surgeons, knowledge of this anatomical variation is of real clinical relevance in cases such as fenestrated endografting in order to preserve the function of the entire kidney.
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Relationship between digit ratio of 2D:4D and The physical health among college students of han ethnicity in Southern Fujian p. 214
Tongjun Chen, Jianmei Xiang, Shaokang Teng, Zhongqing Huang, Xiaoliang Li, Liping Huang, Huihua Chen, Baoying Luo
DOI:10.4103/jasi.jasi_189_21  
Introduction: Studying the association between finger length ratios of 2D:4D and the physical health among college students of Han ethnicity in Southern Fujian can provide an indirect macrobiology reference index for early predictions of physical health status. Material and Methods: A total of 835 students in Southern Fujian were selected as test subjects through a stratified cluster sampling method. The 2D:4D ratio was recorded using physical measurement methods. The body mass index (BMI), vital capacity, 50-m run, and sit-and-reach test results were collected and analyzed based on the National Student's Health Standards. Results: Among male Han college students in Southern Fujian, the left 2D:4D ratio was negatively correlated with the vital capacity and sit-and-reach test results, while the right 2D:4D ratio was negatively correlated with the vital capacity, 50-m run, and sit-and-reach test results, as well as the comprehensive evaluation result of physical health. Among female Han college students in Southern Fujian, the left 2D:4D ratio was positively correlated with BMI and negatively correlated with the vital capacity, 50-m run, and 800-m run results, as well as the comprehensive evaluation result of physical health. The right 2D:4D ratio was negatively correlated with the vital capacity, 50-m run, 800-m run, and sit-and-reach test results, as well as the comprehensive evaluation results of physical health. The comprehensive evaluation results of physical health were statistically significant differences among low, medium, and high bilateral 2D:4D groups of female students, with poorer results in the high 2D:4D group than that of the medium and low 2D:4D groups. Discussion and Conclusion: The bilateral 2D:4D ratio of female and right 2D:4D ratio of male Han college students in Southern Fujian has a correlation with the comprehensive evaluation of physical health, which can serve as one of the reference indexes for adolescents' early health education, physical health monitoring, dietary intervention, and athlete selection.
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Variations of the circle of willis determined via magnetic resonance angiography: A single-center analysis of the serbian population p. 220
Mimoza Ðevukaj, Igor Nosek, Miloš Vuković, Duško Kozić
DOI:10.4103/JASI.JASI_78_20  
Introduction: The circle of Willis (CoW) represents the collateral pathway between large brain-feeding arteries, the knowledge of which is important in interventional and neurosurgical procedures, in the diagnosis and planning of procedures in acute stroke and subarachnoid hemorrhage. Aim: The study aims to determine the prevalence of variations of the CoW in patients from Serbia via magnetic resonance angiography (MRA). Material and Methods: The study was conducted as a retrospective study at the Center for Imaging Diagnostics, Oncology Institute of Vojvodina. Magnetic resonance imaging was analyzed in 665 patients of both sexes (471 females and 194 males), who underwent MRA during 2018 and 2019. Results: Complete CoW was found in 48.42% of cases, mostly in females (68.01%). Partially complete CoW and incomplete CoW were encountered in 38.05% and 13.55% of patients, mostly in females (73.52% and 73.33%). Anterior circulation variations were seen in 27.41% of cases, higher in females (63.83%), most commonly A1 anterior cerebral artery hypoplasia (9.32%). Posterior circulation variations were seen in 46.36% of cases, higher in females (79.25%), most commonly posterior communicating (PCom) artery hypoplasia (25.56%). Combined variations were seen in 26.24% of patients, with higher prevalence in females (73.33%). The prevalence of variations of posterior circulation between male and female patients was statistically significant (P = 0.007) and was higher in females. Discussion and Conclusion: This study showed that the most common variations were that of the posterior circulation, most commonly PCom artery hypoplasia. Complete CoW was found in <50% of cases (48.42%).
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The normal vermiform appendixin adults: its anatomical location, visualization, and diameter at computed tomography p. 225
Aysegul Altunkas, Fatma Aktas, Zafer Ozmen, Eda Albayrak, Osman Demir
DOI:10.4103/JASI.JASI_135_19  
Introduction: The anatomic location of the appendiceal tip is not certain and it may extend to the retrocecal, pelvic, subcecal, paracecal, postileal, or preileal positions. Its positional variations may alter the degree of inflammation and lead to further illness diagnoses such as colitis, ureteric colic, or pelvic inflammatory disease. Increase in appendiceal diameter is very important regarding the diagnosis of appendicitis. Therefore, the determination of cut-off values for normal appendiceal diameter in computed tomography (CT) would aid in ruling out appendicitis in suspected cases. We aimed in this study to evaluate the frequency of visualization and determine the location and diameter of the normal appendix on CT. Material and Methods: We scanned 1842 abdominal CT that were performed in our hospital for any reason, retrospectively. A total of 597 patients were excluded with various indications. Results: Lower-upper abdominal CT examinations of a total of 1245 patients were evaluated, and the appendix could be visualized in 984 patients (79%). The appendiceal diameter was ranged between 2.7 mm and 10 mm and it was >6 mm in 19% of the patients. The most common location of the appendiceal tip was pelvic in 318 (32%) appendices. The appendiceal tip was subcecal in 222 (23%), retrocecal in 180 (18%), postileal in 180 (18%), preileal in 54 (6%), and paracaecal in 30 (3%) appendices. Discussion and Conclusion: This study showed that the most frequent location of the normal appendix is pelvic type both in women and men.
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REVIEW ARTICLE Top

An anatomical description of the obturator region with clinical aspects p. 234
Lidija Kocbek Šaherl, Mateja Rakuša
DOI:10.4103/JASI.JASI_134_20  
Structures surrounding the obturator foramen, the obturator internus and obturator externus muscles and regional neurovascular bundle, the obturator artery, vein, and nerve, pass through from the lesser pelvis into the medial compartment of the thigh and build up the obturator region. The region is demanding and complex both in terms of anatomical and clinical points of view. This article aims to write an overview of the obturator region about normal and variant anatomy and relate its various parts to their importance in clinical practice. The connections between various anatomical structures, concerning their different critical sites in the obturator region, as well as a thorough overview essential for clinicians, especially surgeons, are discussed.
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CASE REPORTS Top

True hermaphrodite of ovotestis in a 5-year-old child p. 242
James Joseph Yahaya
DOI:10.4103/JASI.JASI_90_20  
Assigning possible and correct sex of individuals born with ambiguous genitalia, notably those with true hermaphroditism (TH) at their neonatal stage, is of paramount psychosocial advantage. A 5-year-old child with karyotype of 46, XX who was reared as male is herein presented. The right testicle was neither palpable in the scrotal sac nor in the inguinal canal. The left testicle was palpable in the scrotum and was of adequate size according to the child. A hormonal profile showed a testosterone level of 2.30 ng/dl (normal value: 30–50 ng/dl). Both testicular and ovarian tissues were found on one side (ovotestis), hence TH of ovotestis was confirmed. It is important to assign true sex for patients with an intersex disorder particularly those with TH so as to give positive psychosocial benefits for them as well as removing gonadal tissues which would lead to the development of gonadal malignancies.
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Bilateral tripartite dural septation of the jugular foramen p. 245
Joastin Naidoo, Carmen Olivia Rennie, Lelika Lazarus
DOI:10.4103/JASI.JASI_123_19  
We present a case of bilateral tripartite dural septation on the internal aspect of the jugular foramen (JF) in a 71-year-old White South African male. Dura mater at the intracranial aspect of the JF forms the neurovascular compartment, which houses the cranial nerves (viz. glossopharyngeal (9th), vagus (10th), and accessory (11th) cranial nerves), as well as the jugular vein. In the present case, a dural septation was seen between the 9th and 10th cranial nerves and between the 10th and 11th cranial nerves; therefore, the 9th cranial nerve traversed the anterior compartment, the 10th cranial nerve traversed the intermediate compartment, and the 11th cranial nerve traversed the posterior compartment. Clinical implications of this variation of the JF arise due to the occurrence of glomus jugulare tumors, as well as other pathologies such as meningiomas and neuroinomas, and these tumors occur in the region in which the neurovasculature exits the cranium. The tumors then lead to compression of these structures within the foramen. Since two dural septa at the intracranial aperture of the JF are reported bilaterally, the rootlets of the cranial nerves were more tethered within the JF. This has surgical implications as substantial tethering of these rootlets requires additional dissection during surgery, thereby increasing the risk of iatrogenic injury to the cranial nerves. It has also been reported that compartmentalization of the JF accentuates the clinical presentation of the glomus jugulare tumor. Thus, a knowledge of variations within the JF becomes imperative to ENT and neurosurgeons.
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Multiple intracranial vessel fenestrations: A report of two cases from a tertiary care center p. 248
Amlan Kusum Datta, Subhadeep Gupta
DOI:10.4103/jasi.jasi_167_21  
Intracranial vascular fenestrations are unique anatomical anomalies, consequential to developmental perturbations in vessel embryology. The importance of identification rests on its frequent association with disturbed cerebral flow dynamics and intracranial pathologies. Herein, we report two cases from the same institute of such an association. One presented with an isolated intraventricular hemorrhage, found to have basilar artery fenestrations, whereas the other presented with subarachnoid hemorrhage, with fenestrations involving both the anterior and posterior circulations. Neither of the two patients had any evidence of aneurysms, arteriovenous malformations, or dissections and were managed conservatively. Being acquainted with the anatomy and pathophysiology of these vascular aberrations are paramount in achieving optimal patient outcomes in certain vascular catastrophes.
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