Patna Journal of Medicine

Rheumatoid Arthritis: Beyond the Basics

Madhumita Das — 2025-12-30

East Zone Mid-term Rheumatology CME under the banner of Bihar Rheumatology Association held at All India Institute of Medical Sciences, Patna, on 9/3/2025.

This paper, presented at the CME, is an overview of the presentation, diagnosis, treatment and complications of rheumatoid arthritis.

Gout: Is it all Crystal Clear?

Arup Kundu — 2025-12-30

This article presents an overview of the pathophysiology and treatment of gout and hyperuricemia.

Clinical and Immunological Profile of Patients with Systemic Lupus Erythematous presenting to AIIMS Patna

Abhiraj Paul — 2025-12-30

Introduction: SLE is a disorder that shows marked geographical variation in its clinical manifestations, immunological markers, and pathological findings. Owing to the differential expression of both clinical and histopathological manifestations of SLE with respect to geography, it is important to have data about the same from different regions. There is a paucity of data from the eastern part of Bharat (India). This study is a small attempt to address the issue.

Methods: This is a hospital-based observational, cross-sectional study done on patients with SLE diagnosed by SLICC criteria and presenting to AIIMS Patna. The primary objective of the study was to find out the proportions of different clinical manifestations of SLE in the study population. The secondary objective was to find out the pattern of antibody profile in these patients.

Results: The median age of the study participants was 27 (range 16-53). The majority of the study participants were female (97.7%). Renal involvement (88.8%) was the most common manifestation, followed by musculoskeletal manifestation (71.1%), fever (66.7%), mucocutaneous manifeatation (62.2%), malar rash (53.3%), alopecia (55.6%), serositis (48.9%), discoid rash (15.6%), and neurological manifestation (17.7%).

The ANA screening result was available for 40 patients. Speckled and homogeneous patterns were seen in 52.5% and 50.0%, respectively. Out of the 41 patients who underwent tests for ANA profile, anti-SmD1, anti-histone, and anti-dsDNA were the most frequent antibodies, with frequencies being 70.7%, 68.3%, and 65.8%, respectively. Anti-U1snRNP (56.1%), anti-Ku (56.1%), anti-Ro 60 (51.2%), and anti-Nucleosome antibody (48.8%) were the other commonly detected antibodies.

Conclusion: Renal involvement was the commonest clinical manifestation, while anti-SmD1 was the commonest extractable nuclear antigen antibody in the study population.

A Case of Systemic Sarcoidosis presenting with UMN Paraparesis and Neuropsychiatric Manifestations

Mohd Adil — 2025-12-30

Introduction: Sarcoidosis is a multiorgan granulomatous disease of unknown etiology. Neurological sarcoidosis is a rare manifestation of this disease and occurs in approximately 5 to 10% of patients.

Common syndromes include cranial mononeuropathy, neuroendocrine dysfunction, focal or multifocal encephalopathy, myelopathy, aseptic meningitis, peripheral neuropathy and myopathy.

Case summary: We present a case report of a 43 years old female who presented with chief complaints of bilateral lower limb weakness for two months and altered sensorium for one day. She also had history of lesions on nose and cheeks as well as swellings in fingers of hand and toe for around six months. She also developed decreased vision during the hospital stay. On examination, she had reduced power in bilateral lower limbs along with increased tone, atrophy of lower limbs and exaggerated reflexes. Plantar reflex was extensor bilaterally. There were no sensory or autonomic features. Contrast MRI of the brain and spine showed multifocal non enhancing T1 hypointense and T2/FLAIR hyperintense lesions involving the cortex and subcortical white matter with thickened and enhancing optic chiasma including the pre and retrochiasmatic region up to the right Lateral geniculate body, and leptomeningeal enhancement in brain along with Multiple ill defined areas of enhancement along the length of spinal cord in cervico-dorsal region with associated patchy areas of leptomeningeal enhancement. CECT Thorax reveled multiple subpleural, perifissural and peribronchovascular nodules nodules coalescing around the central bronchovascular structures, smooth interlobular septal thickening in bilateral lung fields and multiple discrete and confluent bilateral hilar and mediastinal lymph nodes with some of them showing calcifications within and a few showing heterogenous enhancement. Biopsy of skin lesion showed granulomas. A diagnosis of Systemic sarcoidosis with neurological involvement was made and treated with IV methylprednisolone pulse followed by oral steroids. The patient showed significant clinical improvement.

Conclusion: This case highlights the importance of considering the differential diagnosis of sarcoidosis in patients presenting with myelopathies and other neurological features, especially with the involvement of other systems.

Spondyloarthritis: What do we need to know?

Bibhuti Nath Jha — 2025-12-30

There has been a paradigm shift in our understanding of Spondyloarthritis in the last 3-4 decades. In the past, late diagnosis, based on radiological findings, resulted in unfavourable outcomes. Another impediment was classifying the disease into 7 sub-groups, further delaying the diagnosis and treatment. Early diagnosis has now become a reality with the introduction of MRI in the diagnostic armamentarium. It has also been realised that it is better to classify the disease as predominantly axial and predominantly peripheral than into 7 different sub-groups as treatment protocols depend more on manifestation ( axial vs. peripheral) than on nosological sub-division. The changed paradigm has resulted in better outcomes for the sufferers.

Juvenile Idiopathic Arthritis: Diagnosis and Management

Prabal Barman — 2025-12-30

In India, JIA continues to present with joint complications due to delay in diagnosis. Understanding the typical clinical phenotype can help delineating JIA from other joint conditions. Over the past 20-years, significant progress has been made in the management of JIA, and introduction of biologics has dramatically improved its prognosis.

Salvage of Exposed Spinal Hardware With a Pedicled Latissimus Dorsi Muscle Flap After Kyphosis Correction in a Healed Post-Tubercular Pediatric Spine: A Case Report

Anup Kumar Mahato — 2025-12-30

Background: Spinal instrumentation in children with post-tubercular kyphosis carries a heightened risk of wound‐healing problems because of scarred, avascular tissue. Once hardware becomes exposed, timely vascularized soft-tissue coverage is essential to avoid implant removal.

Case Presentation: A 15-year-old boy with a healed history of spinal tuberculosis underwent vertebral column realignment and kyphosis correction using a PITKAR® implant system. On postoperative day (POD) 15, he developed midline wound dehiscence with purulent discharge and exposed hardware. Pre-referral CT demonstrated a rigid 68–70° angular kyphosis centered at D12–L1 without active infection. After radical debridement, an ipsilateral pedicled latissimus dorsi (LD) muscle flap, detached 5 cm proximal to its iliac-crest origin to gain reach, was rotated across the midline to blanket the implant; the residual raw surface was resurfaced with a split-thickness skin graft (SSG). The flap remained viable, cultures were sterilized, and the patient resumed rehabilitation without further wound complications.

Conclusion: Early plastic-surgical intervention with a pedicled LD flap offers reliable, single-stage salvage of exposed spinal instrumentation in complex pediatric spines, preserving deformity correction and avoiding the morbidity of implant removal.

Effect of Pneumoperitoneum on Pulse Oximeter Plethysmographic Wave form: A Case Report

Amarjeet Kumar — 2025-12-30

Laparoscopic surgeries utilize CO₂ pneumoperitoneum to enhance the surgical field, but it can induce significant physiological changes. This case report presents a 46-year-old male undergoing transabdominal preperitoneal (TAPP) repair for bilateral inguinal hernia, during which notable changes in the plethysmographic waveform were observed within 30 seconds of CO2 insufflation. These findings highlight the impact of intra-abdominal pressure on peripheral perfusion, emphasizing the need for vigilant intraoperative monitoring.

Cross-leg Flaps and Pressure Ulcers: An Experience from a Tertiary Care Centre in India

Vishwadeep — 2025-12-30

Cross-leg flaps are done infrequently today due to advancements in micro- and super micro-surgeries. Problems like pressure ulcers, joint stiffness, etc., have been seen in cross-leg flaps. Pressure ulcers develop due to awkward positioning and prolonged immobilization of limbs. Sites for these ulcers include usual predisposed locations like the heel and the malleoli. Unusual sites like the dorsum of the recipient foot have also been found to develop pressure ulcers. Immobilization has been achieved by methods like external fixators, POP and dressings. Pressure ulcers prevention has been done by offloading with non-surgical strategies like air mattresses, gloves, pillows, etc. These are useful only for usual predisposed sites. For unusual predisposed sites other methods have not been described literature. External fixators, which have been used for immobilization in cross-leg flaps can be used with modifications to achieve surgical off-loading of these unusual sites. Patients operated with cross-leg flap from 2021 to 2023 at All India Institute of Medical Sciences (AIIMS), Patna in the Department of Burns and Plastic Surgery were identified from the departmental database. Their case record was retrieved from MRD, and relevant data regarding the method of immobilization, method of off-loading, development of pressure ulcer and other complications were obtained and analysed, retrospectively. Three patients with history of RTA were operated with cross-leg flaps for various indications. Immobilization of legs was done by external fixators in first and third patient and with POP in second patient. Non-surgical off-loading with either air-mattress, gloves, pillows etc., was used in all three patients. Surgical off-loading with modifications in external fixators was used in the third patient. Pressure ulcer developed in first and second patients. In both these patients, it developed at usual predisposed site of the heel of the recipient leg as well as unusual site of the dorsum of the foot of the recipient leg. The third patient was free of pressure ulcer. Non-surgical off loading alone is insufficient. External fixators used for immobilization can be used for surgical off-loading by modifications and adjustments in its design. Improvisation by adjusting pins and bars can be used for off-loading usual sites for pressure ulcers, like the heels, the calcaneal areas as well as unusual sites such as the dorsum of the foot.

Comparison of Effectiveness of Conservative versus Surgical Management for Displaced Mid-Shaft Clavicle Fractures in a Tertiary Care Hospital in Eastern India

Aditya Kumar — 2025-12-30

Background: Fractures of the clavicle, particularly mid-shaft fractures, are prevalent injuries often resulting from high-energy impacts. The management of these fractures is crucial in a tertiary care setting in Eastern India due to their high incidence and impact on functional outcomes. Traditional treatment options include conservative and surgical approaches, each with its advantages and disadvantages, leading to ongoing debates regarding their effectiveness.

Objective: To evaluate and compare the effectiveness of conservative versus surgical management for displaced mid-shaft clavicle fractures.

Methods: A comparative observational study was conducted involving 100 patients diagnosed with displaced mid-shaft clavicle fractures. Patients were divided into two groups: Group A received non-operative management, while Group B underwent surgical intervention using a locking compression plate (LCP). Inclusion and exclusion criteria were established, and data were collected on demographic details, clinical assessments, and radiological examinations. Outcome measures included union time, non-union rates, functional scores (UCLA and DASH), and complications.

Result: The study found that surgical treatment resulted in significantly faster union times compared to conservative management (60% of surgical patients united in 2-3 months vs. 28% of conservative patients, p = 0.045). However, non-union rates were similar between groups (12% in conservative vs. 4% in surgical, p = 0.61). Functional outcomes, as measured by UCLA scores, showed no significant differences at any time point, while DASH scores indicated better functional results for conservative treatment at later stages (p<0.0001).

Conclusion: Surgical treatment for clavicle fractures leads to faster union times but does not significantly improve functional outcomes compared to conservative treatment. Conservative management may provide better long-term functionality, suggesting that treatment choice should consider patient priorities regarding recovery speed versus functional improvement.

Assessing the Outcomes of Displaced Acetabular Fracture Management Using A Single Non-Extensile Surgical Approach

Aditya Kumar — 2025-12-30

Background: Displaced acetabular fractures are complex injuries that significantly impact hip function and quality of life, often requiring surgical intervention to restore stability and mobility. Traditional surgical approaches can lead to complications and prolonged recovery, prompting the exploration of less invasive techniques.

Objective: This study aims to evaluate the efficacy and safety of a single non-extensile surgical approach for managing displaced acetabular fractures, assessing clinical and radiological outcomes.
Methods: An observational and prospective study was conducted involving 30 patients with displaced acetabular fractures treated at a tertiary care hospital in eastern India from February 2023 to February 2024. Patients underwent open reduction and internal fixation using standard non-extensile techniques, with outcomes evaluated through clinical grading and radiological assessments over a minimum follow-up of six months.

Result: Of the 30 patients, clinical outcomes were categorized as excellent (23.33%), good (60%), fair (10%), and poor (6.67%). Associated injuries significantly correlated with poorer outcomes (p=0.009). Radiological findings indicated that comminution and intra-articular fragments were significant predictors of poorer outcomes (p=0.0009 and p=0.023, respectively). The posterior surgical approach yielded better outcomes compared to the anterior approach, and shorter surgery duration was associated with improved results.
Conclusion: The study highlights that while demographic factors like age and sex do not significantly affect outcomes, associated injuries and specific radiological findings are critical determinants of clinical success. The posterior approach and reduced surgery duration are linked to better outcomes, emphasizing the potential benefits of a non-extensile surgical strategy in managing displaced acetabular fractures.

Timing of Primary Cleft Lip and Palate Surgery in India: A Multi-Regional Analysis Using Validated Institutional and Published Data

Siddarth Dubey — 2025-12-30

Background: Timely cleft lip and/or palate (CLP) surgery is critical for speech, feeding, and psychosocial outcomes. Ideal surgical benchmarks recommend lip repair by 12 months and palate repair by 18 months. However, delays are common in India.

Objective: To evaluate the timing of primary cleft surgeries in India using validated institutional and published information across various regions.

Methods: Eight sources from Sub-Himalayan, Himachal Pradesh, Tamil Nadu, Bihar, Uttar Pradesh, Maharashtra, and national datasets were analyzed. Metrics included mean/median age at lip and palate repair and proportion of patients treated on-time (≤12 months for lip, ≤18 months for palate).

Results: AIIMS Patna reported the lowest median lip repair age (11 months). Other centers reported delayed presentations: Diwana (33.6 months), Prabakaran (36 months), Gupta (162 months). On-time lip repair ranged from 15% (TISS report) to 43.6% (Dvivedi). On-time palate repair was consistently <20%.

Conclusion: Most Indian cleft patients undergo delayed surgery. Barriers include poor nutrition, referral delays, and lack of caregiver awareness. Improvements require integrated systems of early detection, caregiver education, and decentralized surgical access.