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   Table of Contents - Current issue
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July-September 2020
Volume 10 | Issue 3
Page Nos. 147-221

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EDITORIAL  

Obesity treatment – Is pharmacotherapy the answer? p. 147
Aditya Kumar Rangbulla
DOI:10.4103/ijabmr.IJABMR_113_20  
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EDUCATIONAL FORUM Top

Online teaching in medical training: Establishing good online teaching practices from cumulative experience Highly accessed article p. 149
Shaista Saiyad, Amrit Virk, Rajiv Mahajan, Tejinder Singh
DOI:10.4103/ijabmr.IJABMR_358_20  
Online teaching has the potential to transcend geographical boundaries, is flexible, learner centered and can help students develop self-directed learning skills. The recently introduced competency-based curriculum has also advocated e-learning as an indispensable tool for self-directed learning. For effective online learning, good online teaching practices should be adopted. These include alignment of online teaching and learning with delivery of curriculum and objectives, synchronous, and asynchronous interaction between teacher and student, encouraging the development of higher-order thinking skills, active learning, and self-directed learning in students. In addition, good online teaching practices should have an inbuilt component of feedback and provide for effective time management, respect for diverse talents and ways of learning with continuous monitoring and mentoring of the learners. Online assessments, both formative and summative should also aim to ensure student involvement in the process. Capacity building of faculty through faculty development programs for the development of specific competencies such as social competency, pedagogical competency, managerial competency, and technical competency in the times of COVID-19 is now recognized as the need of the hour. Although online teaching and learning in medical education is new, it has the potential to become mainstream in future.
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ORIGINAL ARTICLES Top

Increasing prevalence of Escherichia coli and Klebsiella pneumoniae producing CTX-M-type extended-spectrum beta-lactamase, carbapenemase, and NDM-1 in patients from a rural community with community acquired infections: A 3-year study p. 156
Leimapokpam Sumitra Devi, Shobha Broor, Rajendra Singh Rautela, Shyam Sunder Grover, Anita Chakravarti, Debasish Chattopadhya
DOI:10.4103/ijabmr.IJABMR_360_19  
Background: Increasing prevalence of community-acquired infections (CAIs) due to Escherichia coli and Klebsiella pneumoniae producing extended-spectrum beta-lactamase (ESBL), especially the Cefotaxime-Munich (CTX-M) type, carbapenemase, and New Delhi metallo-β-lactamase (NDM), has been reported globally posing a serious public health threat that has complicated treatment strategies for Gram-negative bacterial infections. While most of the reports in this regard are based on hospitalized patients from the urban community, there is a paucity of data in a rural community presenting with CAIs. Materials and Methods: A total of 1275 strains of E. coli and K. pneumoniae isolated over a period of 3 years from patients with CAIs were subjected to the detection of ESBL by double-disc synergy test; carbapenemase by modified Hodge test; metallo-β-lactamase by MIC test strip metallo-β-lactamase (MBL); and blaTEM, blaSHV, blaCTX-M, and blaNDMgenes by polymerase chain reaction. Results: Among 1275 E. coli and K. pneumoniae isolated during the study period, 773 (60.6%), 102 (8%), and 28 (2.2%) isolates were detected as ESBL, carbapenemase and MBL producers, respectively. Of the 773 ESBL producers, 635 (82.1%) were found to harbor blaCTX-M genes, and of the 102 carbapenemase producers, 12 (11.8%) were found to harbor blaNDMgenes. Gene sequencing of all the 12 NDM-positive isolates revealed blaNDM-1 genes. Antibiotic resistance pattern of the ESBL-positive isolates revealed a high degree of co-resistance to noncephalosporin antibiotics such as amoxyclav, co-trimoxazole, chloramphenicol, and fluoroquinolones. Conclusion: The present study showed the increasing the prevalence of ESBL including CTX-M variety, carbapenemase production by E. coli and K. pneumoniae isolates, and spread of NDM-1 in the patients from the rural community of North India.
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Osteoporosis among bahraini citizens: The first report p. 164
Mir Sadat-Ali, Mai E Mattar
DOI:10.4103/ijabmr.IJABMR_102_19  
Background and Objective: Osteoporosis and its complications are increasing as the population is aging world over. Every country needs an initial assessment of prevalence to take appropriate steps in limiting the complications of osteoporosis. The objective of this study was to find the prevalence of osteoporosis in the Kingdom of Bahrain. Methods: We retrospectively reviewed dual-energy X-ray absorptiometry scans of patients who underwent scans for the diagnosis of osteoporosis between January 2016 and December 2017 at the University Medical Center, King Abdullah Medical City, Dr. Sulaiman AlHabib Hospital, Kingdom of Bahrain. The data were collected from the picture archiving and communication system for the study period. Patients' medical records were reviewed for the investigations and treatment ordered. The data were entered into the database and analyzed using SPSS Inc., version 19. Results: A total of 205 patients with an average age of 58.39 ± 12.12 years were included in the study. There were 185 (90.25%) females and 20 (9.75%) males. Seventy-nine (38.5%) were osteoporotic based on the T score of either at the hip (−<2.61 ± 1.08) or the spine (−<3.26 ± 0.78), with a mean age of 60.8 ± 13.1 years. Seventy-two (91.1%) of the osteoporotic patients were female and 42 (58.4%) were ≥65 years. Patients who were osteoporotic were significantly older withP < 0.001. There were 9 patients (4.39%) who had osteoporosis-related fractures. Conclusions: This study indicates that the prevalence of osteoporosis is common among Bahraini citizens. As the country's total population is <1.2 million, it will not be difficult to target the ≥65-year-old men and women in early diagnosis and treatment to prevent osteoporosis-related fractures.
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In Vivo Effects of nonselective, partially selective, and selective non steroidal anti-inflammatory drugs on lipid peroxidation and antioxidant enzymes in patients with rheumatoid arthritis: A clinical study p. 167
Alok Dixit, Pinki Pandey, DC Dhasmana
DOI:10.4103/ijabmr.IJABMR_344_19  
Background: The relationship between oxidative stress, decreased antioxidant status, and rheumatoid arthritis (RA) has been widely investigated. To date, few clinical studies have assessed the role of conventional nonsteroidal anti-inflammatory drugs (NSAIDs) in the modulation of oxidative stress in patients with RA. Aim: The aim of this study was to compare the effects of nonselective, partially selective, and selective cyclooxygenase (COX) inhibitors on markers of oxidative stress in patients with RA. Materials and Methods: Thirty RA patients were enrolled in this open label, prospective study for 12 weeks and randomly assigned to either group receiving diclofenac 100 mg, meloxicam 15 mg, or celecoxib 200 mg daily (n = 10 in each group). Patients were evaluated for superoxide dismutase (SOD) and serum malondialdehyde (MDA) as oxidative markers at the baseline and at the end of 12 weeks. Various parameters for efficacy were also assessed. Results: The baseline values of the SOD enzyme were significantly lower and MDA values were significantly elevated in patients randomized to the three treatment groups as compared to the control group (P < 0.05). MDA level was significantly decreased in patients across all the treatment groups (P < 0.05) after 12 weeks. There was an improvement in mean SOD enzyme levels at the end of 12 weeks; the difference for SOD was significant as compared to the baseline in the meloxicam group only (P < 0.05) but not in diclofenac- and celecoxib-treated patients. Significant improvement was observed in all the treatment groups as regards patient assessment of pain visual analog scale, tender and swollen joint count, and patient global assessment. Conclusions: Diclofenac, meloxicam, and celecoxib carry antioxidant effects to a variable extent. NSAID possesses additional mechanism independent of COX inhibition which modulates oxidative stress.
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The putative role of thyroid hormones and vitamin d on severity and quality of life in psoriasis p. 173
Kulkarni Sweta, M Monica Freeda, M Lenin
DOI:10.4103/ijabmr.IJABMR_437_19  
Introduction: Psoriasis is a chronic immune-mediated inflammatory skin disease. The thyroid hormone receptors are expressed in human skin and the hormones exert their effects on epidermal proliferation and differentiation; they have been hypothesized to play a role in the pathogenesis of psoriasis. Vitamin D is involved in the maintenance of cutaneous barrier homeostasis. Several studies identified an association between polymorphisms of Vitamin D receptor and psoriasis susceptibility. Subjects and Methods: Thirty clinically diagnosed psoriasis patients in the age group between 20 and 50 years of both genders attending the outpatient department of dermatology were included as cases. Thirty healthy subjects attending routine health checkup were included as controls. Serum 25 hydroxycholecalciferol was estimated in Mini Vidas autoanalyzer by immunofluorescence technique and Thyroid stimulating hormone (TSH), free T3, and free T4 were estimated by chemiluminescence technology in Cobas e411. Dermatology quality of life index (DLQI) and psoriasis area severity index (PASI) questionnaire was used to assess the quality of life and severity of psoriasis respectively. Results: TSH level was significantly increased in psoriasis cases when compared to healthy controls but within reference range (P < 0.05). There is a significant negative correlation between PASI and 25-hydroxycholecalciferol and significant negative correlation between PASI and DLQI. Conclusion: Our study emphasizes the relationship between biochemical markers, severity of psoriasis, and quality of life. A multimodal holistic approach is needed for the treatment of psoriasis. Psychological support for stress management, drug therapy, and biochemical markers assessment for severity of psoriasis are the need of the hour.
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Treatment outcomes of patients receiving combination antiretroviral therapy under the national acquired immunodeficiency syndrome control programme p. 178
Vishal Malhotra, Sanjeev Mahajan, Virender Verma, Apurba Patra, Rajinder Singh Balgir
DOI:10.4103/ijabmr.IJABMR_423_19  
Introduction: The free antiretroviral therapy (ART) initiative of the Government of India was launched on April 1, 2004, since then it is being scaled up in a phased manner. The aim of this study was to analyze the treatment outcome of patients receiving first-line ART through the National Acquired Immunodeficiency Syndrome Control Programme of India. Materials and Methods: This was an record-based retrospective analysis of data of patients who were put on ART from January 2009 to December 2009. Results: Of the 548 patients (63.87% males; median age of 37 years), 55% of patients were employed and majority of them have low monthly income. Patients showed a significant improvement in clinical and functional status after staring ART therapy, as percentage of patients in clinical Stage 1 increased significantly (from 35.5% to 90.3%) and that of Stage 3 and 4 decreased drastically. Ninety percent of patients were working, and none was bedridden after 2 years of ART. Patients with >95% adherence to ART showed more improvement than those with <95% adherence (40% patients). The median increase in cluster of differentiation 4 (CD4) count was 134 cells/mm3 at 6 months, 185 cells/mm3 at 12 months, and 255 cells/mm3 at 24 months. Majority of patients died in clinical staging 4 with CD4 cell count <50 cells/mm3. Over 2 year's period, 20% patients died and 9.31% were lost to follow-ups (LFUs). Conclusion: Early detection, timely treatment, and long-term adherence are the keys for the success of ART programme in India; it is of utmost importance to do intense Information Education Communication/Behavioral Change Communication, regular monitoring, up-to-date record keeping, tracking of LFUs, and triangulation and data analysis for timely action and for consolidation of success made so far.
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Prevalence of menopausal symptoms and its effect on quality of life among rural middle aged women (40–60 Years) of Haryana, India p. 183
Meenakshi Kalhan, Komal Singhania, Priyanka Choudhary, Seema Verma, Pankaj Kaushal, Tarun Singh
DOI:10.4103/ijabmr.IJABMR_428_19  
Background: Demographic and epidemiological transitions have increased the life expectancy of middle aged women, resulting in higher burden of morbidities related to menopausal symptoms and also effect the quality of life (QOL). Objectives: To study the prevalence of menopausal symptoms and its effect on QOL among rural middle aged women (40–60 years) of Haryana, India. Materials and Methods: A community based cross-sectional study was conducted in 400 middle aged women (40–60 years) from April 2018 to March 2019 by random sampling technique. The menopause rating scale was used to assess the prevalence of menopausal symptoms and the QOL and data were collected for sociodemographic factors, relevant menstrual history and other variables. Results: Prevalence of menopausal symptoms was found to be 87.7%. Majority of the study subjects had anxiety (80%), followed by physical and mental exhaustion (71.5%), sleep problem (61.2%), irritability (60.7%), Joint and muscular discomfort (56%) and heart problems (54%). The most classical symptom of menopause i.e., hot flushes were reported in 36.7%. The mean age of menopause was 47.53 standard deviation 4.5 years. Statistical significant difference was seen for the mean score of few symptoms i.e., hot flushes, sweating (P < 0.003) and joint and muscular discomfort (P < 0.014) between post and peri-menopausal groups. The QOL was impaired in 70.2% of study subjects. The psychological symptoms attributed 70.8% to the poor QOL. Conclusion: To improve the QOL and to decrease the menopausal symptoms in these women, a holistic approach in the form of lifestyle and behavioral modification are required.
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Effect of chrysin on mechanical hyperalgesia in chronic constriction injury-induced neuropathic pain in rat model p. 189
Rama Krishna Rayiti, Siva Ram Munnangi, Ramya Bandarupalli, Vennela Chakka, Sree Lakshmi Nimmagadda, Lal Saheb Sk, Sireesha Uppalapati, Revathi Bolla, Siva Reddy Challa
DOI:10.4103/ijabmr.IJABMR_58_19  
Objective: The present study aimed to assess the effect of Chrysin on mechanical hyperalgesia in chronic constriction injury (CCI)-induced neuropathic pain in Wistar rats. Materials and Methods: Neuropathic pain was induced by CCI to the sciatic nerve in rats. Oral treatment of chrysin was given at doses of 50 mg/kg, 100 mg/kg, and 200 mg/kg in neuropathic rats. Mechanical hyperalgesia (in terms of paw withdrawal threshold [PWT]) was measured using Randall–Selitto analgesy-meter, and percent PWT was determined. Statistical analysis was carried out using GraphPad Prism 5 tool. Results: In mechanical hyperalgesia test, treatment with chrysin 200 mg/kg, naive PWT, predose PWT, 0.5 h, 1 h, 2 h, and 4 h postdose PWT were found to be 141 ± 8.94 g, 60 ± 7.91 g, 107 ± 9.08 g, 113 ± 5.70 g, 106.0 ± 7.42 g, and 97 ± 9.08 g, respectively. The peak effect was observed at 2 h posttreatment for 50 mg and 100 mg while the peak effect for 200 mg was reached at 1 h, and the same was maintained till 2 h posttreatment. Chrysin 200 mg dose has shown maximal percent reversal (74%) at 2 h posttreatment. The percent reversal PWT of 50 mg/kg, 100 mg/kg, and 200 mg/kg at 2 h were 68%, 67%, and 74%, respectively. Chrysin has exhibited dose-dependent efficacy in CCI-induced neuropathic pain. In mechanical allodynia test, In chrysin (200 mg/kg) treatment group, naive PWT, predose PWT, 0.5 h, 1 h, 2 h, and 4 h postdose PWT were found to be 60.0 ± 0.0 g, 5.0 ± 1.10 g, 22.45 ± 6.62 g, 52.64 ± 18.29 g, 37.33 ± 17.56 g, and 29.83 ± 9.22 g, respectively. The percent reversal PWT of 50 mg/kg, 100 mg/kg, and 200 mg/kg at 2 h were 43%, 68%, and 87%, respectively. Conclusion: Chrysin attenuates neuropathic pain by ameliorating mechanical hyperalgesia and allodynia. Further studies are warranted to establish the mechanism.
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Immunoglobulin receptors expression in indian colon cancer patients and healthy subjects using a noninvasive approach and flowcytometry p. 194
Rama Chaudhry, Vishwa Deepak Bamola, Projoyita Samanta, Divya Dubey, Tej Bahadur, Monica Chandan, Shyam Tiwary, Abhipray Gahlowt, Neha Nair, Harneet Kaur, Chena Passi, Atul Sharma, Dinesh S Chandel, Pinaki Panigrahi
DOI:10.4103/ijabmr.IJABMR_191_19  
Background: Isolation of viable colonocytes from human stool is a noninvasive and convenient approach that can be used for diagnostic, screening, management, and research on various gastrointestinal (GI) diseases including colon cancer. Limited studies are available globally and for the first time in this article, we have reported the immunoglobulin (Ig) (IgA and IgG) receptors concentration on viable colonocytes for Indian colon cancer patients using this noninvasive approach. Materials and Methods: Viable colonocytes from stool were isolated by the Somatic Cell Sampling and Recovery method (Noninvasive Technology, USA) and processed for the assessment of Igs (IgA and IgG) receptors expression using standard immunophenotyping and flow cytometry. Results: IgA and IgG receptor expression was measured and reported on these viable colonocytes. There was a significant difference in the expression of IgA and IgG receptors on viable colonocytes between colon cancer patients and healthy individuals. Conclusion: This noninvasive technique is a promising approach for the detection of molecular and immunological markers that will help clinicians in the diagnosis, screening, monitoring, and management of different GI diseases including colon cancer.
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Red cell distribution width as a predictor of malignancy in patients who underwent upper gastrointestinal system endoscopy p. 200
Okan Murat Akturk, Mikail Çakir
DOI:10.4103/ijabmr.IJABMR_329_19  
Introduction: Red cell distribution width (RDW) has predictive properties in different benign and malignant diseases. Aim: Our aim was to evaluate the predictive value of RDW for malignant gastric lesions by upper gastrointestinal screening. Materials and Methods: Data of 91 male patients (Group A) who underwent upper gastrointestinal endoscopy and subsequent surgery for gastric malignancy and age-matched 91 healthy male patients (Group B) with benign disorders were reviewed in this retrospective cohort study. The pathology reports, laboratory parameters, and demographics of the patients were recorded for comparison. Receiver operating characteristic curves were plotted for RDW, and a threshold for prediction of malignancy was calculated. Results: The average age of the patients with gastric cancer was 62 (interquartile range [IQR]: 53–70) years. The difference in RDW levels between Group A and Group B was found to be significant: 14.40% (IQR: 13.40–16.40) versus 13.10% (IQR: 12.55–13.50) for the malignant and benign groups, respectively, P = 0.000. The area under the curve was 0.81 (95% confidence interval [CI]: 0.76–0.86), P = 0.000. For the threshold of 13.45%, the positive predictive value (PPV) for malignancy was found to be 69.15 (95% CI: 61.77–75.67) and negative predictive value (NPV) was 70.45 (95% CI: 62.60–77.26). Conclusion: RDW was found to have a PPV for malignancy in nearly two-thirds of the patients and had a similar NPV.
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Introduction and Implementation of Early Clinical Exposure in Undergraduate Medical Training to Enhance Learning p. 205
Kapil Gupta, Gurpreet Singh Gill, Rajiv Mahajan
DOI:10.4103/ijabmr.IJABMR_270_20  
Context: Conventional medical curricula have created an impenetrable wall between the preclinical and clinical years of training, thus submerging relevance of basic sciences in clinical setup. Recently, the Medical Council of India has introduced a number of changes and updates in the medical education, including “early clinical exposure” (ECE) in newly proposed competency-based medical education. ECE does not replace the basic and clinical sciences but enriches and contextualizes that learning, therefore motivating the students to develop a better insight into medical profession. Aims: (1) To develop a protocol for the introduction of ECE in undergraduate medical training, (2) to validate and to deliver it to the 1st year MBBS students and assess their perceptions. Settings and Design: It was a prospective, nonrandomized, interventional study. Subjects and Methods: After taking permission from the institutional research committee and institutional ethical committee, a protocol for the introduction of ECE in Biochemistry was developed. The feedback questionnaire for the students and the faculty and retro-preself-efficacy questionnaire for the students were designed and validated. The ECE protocol was delivered to 143 1st-year MBBS students, and perceptions of concerned were collected and analyzed. Statistical Analysis Used: Collected data were analyzed in terms of percentages, medians, and satisfaction index and were represented in graphs. Results: Students reported that the ECE session was an enjoyable, satisfactory, and effective learning tool, with the improvement in knowledge, retention, attention, and motivation. Students also reported that this method of teaching–learning should be implemented in other topics as well as in other subjects of the first professional course. Conclusions: ECE protocol was perceived as very satisfactory by the students, and it helped in improvement of knowledge and to understand the relevance of preclinical subject in clinical setup.
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Effect of faculty training on quality of multiple-choice questions p. 210
Piyush Gupta, Pinky Meena, Amir Maroof Khan, Rajeev Kumar Malhotra, Tejinder Singh
DOI:10.4103/ijabmr.IJABMR_30_20  
Background: Multiple-choice question (MCQ) is frequently used assessment tool in medical education, both for certification and competitive examinations. Ill-constructed MCQs impact the utility of the assessment and thus the fate of examinee. We conducted this study to ascertain whether a short training session for faculty on MCQ writing results in desired improvement in their item-writing skills. Methods: A 1-day workshop on constructing high-quality MCQs was conducted for the faculty as a before-after design, following training session of 3 h duration. 28 participants wrote preworkshop (n = 133) and postworkshop (n = 137) MCQs, which were analyzed and compared for 17 item-writing flaws. A mock test of 100 MCQs (selected by stratified random sampling from all the MCQs generated during the workshop) was conducted for MBBS-passed students for item analysis. Results: Item-writing flaws reduced following the training (15% vs. 27.7%,P < 0.05). Improvement mainly occurred in quality of options; heterogeneity dropped from 27.1% prior to the workshop to 5.8% postworkshop. The proportion of MCQs failing the cover test remained similarly high (68.4% vs. 60.6%), and there was no improvement in writing of the stem before and after the workshop. The item analysis did not reveal any significant improvement in facility value, discriminating index, and proportion of nonfunctioning distractors. Conclusion: A single, short-duration faculty training session is not good enough to correct flaws in writing of the MCQs. There is a need of focused training of the faculty in MCQ writing. Courses with a longer duration, supplemented by repeated or continuous faculty development programs, need to be explored.
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CASE REPORTS Top

The stromal dictators in a concomitant case of oral submucous fibrosis - Oral Squamous Cell Carcinoma p. 215
Anupama Mukherjee, Anita Spadigam, Anita Dhupar
DOI:10.4103/ijabmr.IJABMR_222_19  
Oral submucous fibrosis (OSMF) is a potentially malignant disorder, characterized by alteration in the connective tissue stroma. Its association with oral squamous cell carcinoma (OSCC) has been recognized and conferred a special status as a distinct disease entity with improved prognosis as compared to conventional squamous cell carcinoma. Such cases of concomitant presentation of OSMF and OSCC have not yet been defined, leading to ambiguity regarding the evaluation. The concomitant occurrence of OSMF-OSCC is associated with histopathological features, unlike OSMF, yet similar to an aggressive presentation of OSCC. An indepth evaluation of the connective tissue, along with other tumor characteristics such as tissue hypoxia, inflammatory cell population, neoangiogenesis, and stromal cells fortify the possibility of these cases of concomitance being as aggressive, if not more, as compared to conventional OSCC. Thus, recognizing such cases along with the evaluation of probable prognostic indicators is necessary to improve the current understanding of tumorigenesis and progression in concomitant cases of OSMF-OSCC.
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Malignant melanoma: A double malignancy or second malignant neoplasm in a patient of acute lymphoblastic leukemia following therapy with a composite karyotype p. 218
Pranita Mohanty, Nibedita Sahoo, Debasmita Das
DOI:10.4103/ijabmr.IJABMR_143_19  
Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy of lymphoid origin seen with a peak incidence between 2 and 5 years. New drug regimen has increased the cure rate, although the risk of developing a second malignancy still persists. The common second malignant neoplasms in survivors of childhood ALL are hematolymphoid malignancies, central nervous system tumors, carcinomas, sarcomas, and bone tumors with a median latency of at least 10 years. There are also examples of nonmelanotic skin tumors such as basal cell carcinoma following ALL chemotherapy, but malignant melanoma is an extremely uncommon malignancy encountered. Melanoma is associated with genetic mutations such as CDKN2A, and CDK4 with an increased prevalence of second malignancy such as the lung, pancreas, and breast. However, double malignancy of melanoma with ALL is rare. Here, we report a rare case of malignant melanoma following ALL therapy associated with composite karyotype and early relapse.
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