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   Table of Contents - Current issue
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January-March 2023
Volume 21 | Issue 1
Page Nos. 1-77

Online since Tuesday, January 17, 2023

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EDITORIAL  

Dr. John S. Carman p. 1
Reena George
DOI:10.4103/cmi.cmi_121_22  
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ORIGINAL ARTICLES Top

Clinical significance of repeat fine-needle aspiration in managing patients with suppurative lesion p. 3
M Elancheran, K Siva, V Sriram, V Archana, S Ragavendran
DOI:10.4103/cmi.cmi_107_22  
Background: Fine-needle aspiration (FNA) has been challenged about its role in the management of patients with clinical suspicion of infective or neoplastic etiology but cytological picture showing features of acute suppuration. This study emphasizes the need to perform repeat FNA cytology (FNAC), especially if the mass lesion is indicating suppuration and has not responded to the initial course of antibiotics. Materials and Methods: All patients with a previously diagnosed suppurative lesion on cytology smears who have undergone repeat FNA were included in the study. Insufficient material on FNA and the nonavailability of slides were excluded from this study. Results: Repeat FNA assisted in the detection of malignant lesions (3), tubercular lesions (20), fungal lesions (9), and benign lesions (9) out of the 123 cases of previously diagnosed acute suppurative lesions. Comparison of FNAC findings with histopathological specimens was available for 52 cases, following which repeat FNA had a sensitivity of 66.67% (95% confidence interval 34.89%-90.08%) in detecting neoplastic, specificity was 100%, positive predictive value was 100%, negative predictive value was 90.91%, and the total diagnostic accuracy was 92.31%. Conclusion: Patients with acute suppurative lesions should be followed by repeat FNA, especially if the lesion is not responded to initial antibiotic therapy. Repeat FNA will enhance the diagnostic accuracy of malignant lesions and many other lesions, such as fungal or tubercular infections. It will reduce the need for surgical interventions and molecular detection of infectious diseases.
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Low back pain among nurses as related to work environment: A cross-sectional observational study Highly accessed article p. 9
Ngozi Rosemary Osunde, Chinomso Ugochukwu Nwozichi, Olaolorunpo Olorunfemi, Jaminat Omotade Sodimu, Omotayo Mercy Olorunfemi
DOI:10.4103/cmi.cmi_46_22  
Background: Low back pain (LBP) is a major problem in the nursing profession and it is been reported that more nurses experience LBP during the nursing practice. Studies show that only 15.9% of nurses had LBP before coming into nursing while 84.5% complained they had LBP after working in the nursing environment. Aim: The aim of this study was to determine factors responsible for low back ache, as related to the work environment in the University of Benin Teaching Hospital, Benin City, Nigeria. Materials and Methods: A cross-sectional descriptive study was conducted from January 2019 to February 2020, with probability sampling to select a sample size (n = 260). Data collected were analyzed using tables; percentages, bivariate analysis, and and multivariate logistic regression were used for data analysis at 0.05 level of significance, through a statistical package for the social science software. Results: Among 260 nurses with backache, 159 (61.15%) were male and most of the participants' ages were between 25 and 34 years, with a mean age of 26.5 (0.37). The multivariate logistic regression analysis showed that heavy manual lifting (odd ratio [OR] 0.21, 95% confident interval [CI] 0.54–0.73), body posture (OR 0.31, 95% CI 0.20–1.08), the length of working shift (OR 0.60, 95% CI 0.74–0.86), awkward postures (OR 0.68, 95% CI 0.65–1.10), and prolonged standing during nursing care (OR 0.73, 95% CI 0.52–1.00) were the major factors for LBP among nurses, with <0.001, 0.001, 0.002, 0.002, and 0.003, respectively. Conclusions: The finding implies that all effort should be directed toward policies which have positive effects on proper management of the work environment and other conditions, such as health and safety training. Prevention of work overloads through appropriate work shifting, and the mechanism of body posture should be improved. Furthermore, periodical flexing of feet, knees, and hip is necessary in a condition where there is a need to stand for a long period of time.
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Clinicoetiological profile of cerebral venous sinus thrombosis patients at a tertiary care center p. 14
Adnan Firdous Raina, Amit Chandra, Waseem Dar, Hilal Ahmad Ganie, Zubair Kawaja, Maqbool Wani, Ravouf Asimi
DOI:10.4103/cmi.cmi_111_22  
Background: Cerebral venous sinus thrombosis (CVST) accounts for 10%–20% of strokes in young persons. In India, CVST accounts for around 30% of all strokes. The majority of CVSTs are caused by procoagulant circumstances, with pregnancy and early puerperium being well-established risk factors. The study aimed to look into the clinical profile, radiological characteristics, etiological variables, and outcome of CVST in venous stroke patients admitted to a tertiary care facility. Methods: We included individuals between the ages of 18 and 75 years who had a cerebral venous thrombosis (CVT) diagnosis confirmed by magnetic resonance imaging (MRI) + magnetic resonance venography computed tomography (CT) plus CT venography. The research included all individuals suspected of having CVST with or without particular neurological deficits and a confirmed imaging diagnosis. Patients were removed in situations of ambiguous neuroimaging, arterial strokes, space-occupying lesions, metabolic encephalopathy, and patient reluctance to participate. Results: This study included 82 patients, 21 (25.6%) males and 61 (74.4%) of whom were females. The most common presenting symptom was headache (79.2%), followed by vomiting (54.8%) and abnormal sensorium (35.3%). In this study, 34/82 (41.4%) patients had evident clinical triggers and were classified as induced CVT. Para infectious disease was recognized as a risk factor for CVT in 13/34 (38.2%) patients. A prothrombotic conditions could be established in 48 (58.5%) of these patients. Conclusion: CVST is a treatable and reversible cause of stroke in adolescents. The clinical presentation varies greatly, and symptoms may appear gradually over weeks or months. Although it is still an uncommon cause of headache and stroke, MRI has allowed for early detection.
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Safety of ultrasound-guided percutaneous injection of alcohol as a scolicidal agent for the treatment of liver hydatid cysts p. 19
V John Samuel, Arul Babu, Vinu Moses, MJ Aparna, Munawwar Ahmed, George M Varghese, Philip Joseph, Shyamkumar N Keshava
DOI:10.4103/cmi.cmi_71_22  
Background: Hydatid disease is a health problem in the developing world. Percutaneous therapy with various scolicidal agents has been described; however, there is a paucity of literature on the use of absolute alcohol injection without reaspiration as a sole scolicidal agent. The study carried out in a tertiary hospital aimed to prospectively evaluate the safety and outcomes of ultrasound-guided percutaneous injection of alcohol for liver hydatid cyst. Methodology: Consecutive patients with liver hydatid cysts were evaluated with ultrasound, classified according to the WHO classification between June 2012 and January 2020. Eligible patients underwent ultrasound-guided percutaneous therapy after three courses of oral albendazole. Patients having elevated cyst fluid bilirubin levels were excluded. Patients who underwent percutaneous alcohol injection were followed up clinically and with imaging. Data were entered in Microsoft Excel spreadsheet and analyzed. Results: Fifty-two consecutive patients with hydatid cyst were evaluated during the study. Among these, 27 patients underwent percutaneous alcohol injection. Follow-up data were available for 25 patients. There was a favorable imaging outcome in 21/25 (84%). One patient developed anaphylaxis during cyst access, which was managed medically with an uneventful recovery. No instances of cholangitis or sepsis following injection were observed. Conclusion: Percutaneous alcohol injection therapy for liver hydatid cysts is a minimally invasive, safe, and an effective procedure in selected group of patients.
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Intrapartum electronic fetal monitoring and perinatal outcomes: Analysis of components of fetal heart rate pattern p. 26
Minakshi Kumari, Anuja Abraham, Kavitha Abraham, Preethi Navaneethan, Reka Karuppusami, Santhanam Sridhar, Annie Regi
DOI:10.4103/cmi.cmi_75_22  
Aim: The aim of this study was to assess the components of cardiotocography (CTG) during labor to identify the variables associated with the risk of adverse perinatal outcomes and to ascertain the mode of delivery in these women. Materials and Methods: This prospective observational study included 191 women at term with singleton pregnancy in labor. The CTG findings including baseline heart rate, accelerations, beat-to-beat variability, and type and severity of decelerations were noted as per the International Federation of Gynecology and Obstetrics classification and grouped into Category II or III patterns as per the National Institute of Child Health and Human Development classification. Low APGAR score, cord PH <7, neonatal intensive care unit admission, respiratory distress, and hypoxic-ischemic encephalopathy were considered adverse neonatal outcomes. Results: Persistent fetal tachycardia, poor beat-to-beat variability, and severe variable deceleration showed a significant association with adverse neonatal outcome and delivery by cesarean section (P < 0.05). Adverse neonatal outcomes were noted in 4.2% of babies and 40.9% of babies born to mothers whose CTG was categorized as II and III patterns, respectively (P < 0.001). Birth by cesarean section was significantly different between those with Category II and Category III patterns, 33.7% and 65.4%, respectively (P < 0.01). Conclusion: Reduction in the beat-to-beat variability and presence of severe variable decelerations are independent risks for adverse neonatal outcomes, irrespective of the category of CTG pattern. Category III fetal heart rate pattern shows a significant association with adverse outcomes and risk of cesarean delivery. Grading the Category II patterns may help in identifying variables that are truly associated with acidemia and further research into this is recommended.
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Anxiety, depression and stress among female medical students during the second wave of the COVID-19 pandemic and their association with family functioning, coping and personality p. 31
Ganesh Kumar Mallaram, Subahani Shaik, Dheeraj Kattula
DOI:10.4103/cmi.cmi_81_22  
Background and Aims: This research examined anxiety, depression, and stress levels in female medical students during the second wave of coronavirus disease 2019 (COVID-19) and the association between these variables and family functioning, coping, and personality factors. Materials and Methods: The cross-sectional online observational study was conducted using Google Forms. Anxiety, depression, and stress were assessed using the Depression, Anxiety, and Stress Scale (DASS-21), family functioning using Family Adaptability, Partnership, Growth, Affection, and Resolve, coping using Brief COPE, and personality using the Big Five Inventory 10-item version. Results: Out of 750 students, 500 thoroughly responded to the online survey. Based on the DASS-21 scores, 57.6% of participants had some stress, 63.4% had some anxiety, and 54.8% had some degree of depression. Anxiety, depression, and stress were highly correlated with each other. Stress, anxiety, and depression were weakly linked with problem-focused coping, moderately correlated with emotion-focused coping, and strongly correlated with avoidant coping. Better family functioning was associated with lesser self-reported stress, anxiety, and depression. Neuroticism was associated with higher anxiety, depression, and stress, while agreeableness and conscientiousness were with lower psychological distress. Conclusion: High level of psychological suffering was prevalent among medical students during the COVID-19 pandemic. Their anxiety, depression, and stress must be adequately managed.
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Missing the trees for the forest: A survey of sub-district-level mortality pattern in North Bihar, India p. 37
Sharon Cynthia, Miriam Thankam George, Philip Finny, Mathew Santhosh Thomas, Lois Joy Armstrong
DOI:10.4103/cmi.cmi_92_22  
Background and Objective: The paucity of knowledge on mortality patterns in a state such as Bihar with its population of 200 million contributes to misdirected planning and prioritization of health expenditure. This study aims to estimate the regional differences in mortality rates between a region in North Bihar and the rest of state and country. Methodology: Using a multi-stage cluster design, 4159 households were interviewed across six Community Development blocks in North Bihar, identifying deaths between the Chhath festivals of 2014 and 2015. The cause of death was assessed by verbal autopsy and coded using the International Classification of Disease 10. Proportionate and specific mortality rates were calculated. Results: Of 229 deaths, only 7% were registered. The epidemiological transition level for the region was 1.12 with an infant mortality rate of 72 per 1000 live births (95% confidence interval [CI] 55.7–88.4) and under-five mortality rate of 93.2 per 1000 live births (95% CI 74.6–111.7). These rates were double that of the state estimates. Among infant deaths, infections predominated over prematurity while in adult deaths diseases of the respiratory system exceed diseases of the circulatory system as seen in the state and country mortality rates. Conclusions: This study indicates that regional mortality patterns widely differ from state and national average estimates. Deaths due to maternal and neonatal conditions along with communicable diseases still predominate over other causes. Obtaining disaggregated information on causes of death by strengthening the vital registration system will bring these variations into focus.
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The utility of an electrocardiogram in high-, intermediate-, and low-risk patients presenting with chest pain to emergency department p. 44
M Sanjay, Anju Susan Kurien, Merin Hanna Abraham, Abraham Speedie
DOI:10.4103/cmi.cmi_102_22  
Background: In emergency department (ED), though electrocardiogram (ECG) is obtained for both typical and atypical chest pain, at certain times, it is overutilized even in patients with low-risk factors for acute coronary syndrome (ACS). This study aimed to assess the utility of an ECG in patients presenting with chest pain to the ED. Materials and Methods: This prospective study included patients presenting with chest pain to the ED during August and September 2018. Following their initial assessment at triage, patients were grouped into high-, intermediate- and low-risk categories based on their risk factors for an ACS. ECGs were acquired and categorized into ACS and non-ACS pattern and their utility in each group was assessed. Results: This study cohort contains 313 patients with a male predominance 59.1%. The mean age was 52.6 ± 15.2 years. Typical chest pain was prominent in 95 (30.4%) patients. The incidence of ischemic and structural heart diseases was 53 (16.9%) and 31 (9.9%), respectively. ACS was diagnosed in 92 (29.3%) patients; among them, ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina were noted to be 51 (16.3%), 27 (8.6%), and 14 (4.5%), respectively. The incidence of ACS based on risk category classification was as follows: high risk 38.9% (44/113) and intermediate risk 33.8% (48/142) and no patients in low risk had ACS. Conclusions: ECG though a useful screening test to diagnose ACS, should be used judiciously in patients with low risk of ACS to optimally utilize the limited resources in ED.
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The study of offspring and mothers with gestational diabetes treated with metformin or glibenclamide in a randomized controlled trial after 9 years p. 50
Praveen George Paul, Beena Ruth Kingsbury, Hilda Yenuberi, Richa Sasmita Tirkey, Santosh Joseph Benjamin, Swati Rathore, Babuji Manimegalai, Antonisamy Belavendra, Jiji Elizabeth Mathews
DOI:10.4103/cmi.cmi_95_22  
Introduction: Follow-up of the mothers and their offspring recruited to a randomized controlled trial comparing neonatal outcomes in women with gestational diabetes treated with metformin or glibenclamide was conducted 9 years ago. A significant decrease in neonatal hypoglycemia in the group treated with metformin was seen in the original study. Methodology: Results of clinical examination, blood sample collection, and dual-energy X-ray absorptiometry (DEXA) scan not published in a brief communication are described in this study. The nutritional status was assessed using a 3-day recall method using the Indian Food Composition Table 2017. The physical activity of offspring was assessed using the Global Physical Activity Questionnaire. Results: The overall follow-up rate of the cohort was 49% and similar in both the groups. The anthropometric details, blood tests, and DEXA in the women and their offspring were similar except that the offspring of the group on metformin had higher triglyceride values than the offspring of the women treated with glibenclamide. The average body mass index of the offspring was similar and was 18. Currently, women who were treated with glibenclamide 9 years ago had higher fasting plasma glucose levels (9.2 [7.3, 12.6]) than the metformin group (7.2 [6.1, 8.4] median [interquartile range]), P = 0.02. They also had significantly higher diastolic blood pressure readings 77.1mmHg (8.9) and 72.1mmHg (11.7) mean (SD), P = 0.035. (Information from the previously published brief communication). Conclusion: No significant adverse outcome was seen in women treated with metformin and the offspring 9 years later.
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BRIEF REPORT Top

Knowledge, attitudes, and practice to COVID 19 infection among outpatients attending a general medicine department p. 57
Amita Jacob, J Grace Rebekah, Ronald Albert Benton Carey
DOI:10.4103/cmi.cmi_79_22  
Background and Objectives: We aimed to assess the knowledge, attitudes, and practices regarding COVID-19 among general medicine outpatients. Materials and Methods: We recruited people attending a general medicine outpatient department of a tertiary hospital. We assessed knowledge, attitudes, and practices toward COVID-19 using a specially designed questionnaire. Results: Two hundred and sixty-eight participants were recruited. The study documented high knowledge, positive attitude, and good practice among patients and their relatives. Knowledge was significantly associated with higher education (odds ratio [OR] = 2.87; 95% confidence interval [CI] = 1.127.36; P = 0.029) and the use of the Internet as a source of information about COVID-19 (OR = 5.17; 95% CI = 2.2611.85; P = 0.000). However, Internet use (OR = 0.23; 95% CI = 0.100.54; P = 0.001) was associated with a more negative attitude. Good practice was associated with high levels of knowledge (OR = 2.20; 95% CI = 1.223.96; P = 0.009), a positive attitude (OR = 2.31; 95% CI = 1.134.71; P = 0.022), and a professional or semi-professional occupation (OR = 2.80; 95% CI = 1.077.32; P = 0.036). Residence outside of the district (OR = 2.79; 95% CI = 1.077.32; P = 0.036) was associated with better practice related to COVID-19 suggesting people who travel greater distances for health care may be more motivated at maintaining better practice. Conclusion: The study found that good practice in relation to COVID-19 was associated with higher levels of knowledge, a positive attitude, professional occupation, and distance traveled to reach hospital.
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REVIEW ARTICLE Top

Coexistence of obstructive sleep apnea and cardiovascular disease: A narrative review p. 62
Natasha Anindhia Harsas, Rana Zhafira Amanda, Sidhi Laksono Purwowiyoto, Hillary Kusharsamita
DOI:10.4103/cmi.cmi_101_22  
There is substantial evidence that patients with obstructive sleep apnea (OSA) have a higher incidence of cardiovascular disease (CVD). However, the exact mechanism that links OSA with CVD is still insufficiently understood and often underdiagnosed and undertreated. This review aims to summarize the pathomechanisms coexistence of OSA and CVD and a diagnostic evaluation of the treatment options for OSA. The Pubmed was searched using the keywords “OSA;” and “CVD.” Related papers published from 2013 to February 2022 were chosen. OSA has been associated with intermittent hypoxemia, significant intrathoracic pressure changes, and arousal from sleep, all of which have been linked to adverse health effects, particularly in the case of CVD. The need for the early detection of CVD patients and OSA screening is critical. Screening techniques include identifying specific OSA symptoms through medical history, using screening questionnaires or devices, followed by diagnostic testing thorough sleep evaluation that differs depending on the underlying cardiovascular condition. The need to improve the early diagnosis and treatment of OSA, a highly prospective modifiable CVD risk factor, is crucial given the growing body of research on the relationship between OSA and CVD as well as the effectiveness of OSA treatment.
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CASE REPORT Top

A case of solitary neurofibroma involving the lower limb in a young tribal girl p. 68
Alisha Kalyanpur, Royson Dsouza, Binu Kurien
DOI:10.4103/cmi.cmi_83_22  
We describe a 17-year-old girl who presented with a nontraumatic gradually progressive swelling in the right leg for 2 months. Clinically, there was a diffuse swelling involving the lower third of the lateral aspect of the right leg, which was firm and nontender. There were no similar swellings elsewhere. The radiological findings were inconclusive and she underwent an excision biopsy. Histopathology revealed features consistent with a neurofibroma. Solitary neurofibromas of the lower extremity are extremely rare benign lesions, having nonspecific clinical and radiological features. Histopathology is the mainstay of the diagnosis. Wide local resection is mandated as the treatment as these lesions have a propensity for recurrence.
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MEDICAL EDUCATION Top

Scope of portfolio in medical training p. 71
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_73_22  
The introduction of competency-based medical education has brought about a paradigm shift in the delivery of medical education in both undergraduate and postgraduate courses. A portfolio can be regarded as an instrument that can be employed for the storage of learning on a day-to-day basis and for recording the self-reflection by the students. As a matter of fact, the compilation of learning from different sessions gives an opportunity for the students to look back, analyze the overall process and thus reflect on the same, and this process plays a crucial role in ensuring deep learning. At the same time, the compiled information is being used for making evidence-based and well-informed decisions about the overall progress of the student. Further, we also cannot ignore the fact that a well-maintained portfolio can be looked on as one of the indicators of the quality assurance processes employed in an institution. To conclude, portfolios in the field of medical education are an important option to ensure learning and even promote the assessment of medical students. The need of the hour is that every medical institution should look to implement the same in their own settings and help the students in their journey to become competent.
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Proposing a framework to plan and implement problem based learning sessions for undergraduate medical students p. 73
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_100_22  
The process of transforming a freshly joined medical student into a competent medical graduate is a complex one. It is an indisputable fact that having good knowledge (cognitive domain) is crucial for better performance in psychomotor and affective domains. In the global vision to improve health-care delivery, it is crucial that medical students are trained in critical thinking, clinical reasoning, and problem-solving skills. Problem-based learning (PBL) is a student-centered teaching–learning strategy, which ensures the active engagement of learners. As students get an opportunity to perform a literature search or explore different learning resources, they attempt to learn through self-directed learning, and in the process understand the need to be a lifelong learner for a successful clinical practice in future. In conclusion, PBL session is an effective way to inculcate complex cognitive skills among medical students, and thus, it is quite essential that medical colleges should initiate and implement PBL in their settings after proper planning and with the support of the Medical Education Unit.
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LETTER TO THE EDITOR Top

Understanding catastrophic healthcare expenditures - Implications for research p. 77
Hari Teja Avirneni, Sinthu Sarathamani Swaminathan, Anugraha John
DOI:10.4103/cmi.cmi_61_22  
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