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   Table of Contents - Current issue
April-June 2022
Volume 20 | Issue 2
Page Nos. 55-121

Online since Saturday, May 7, 2022

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Challenge ahead: The new level 1 trauma center of christian medical college, Vellore, Ranipet Campus Highly accessed article p. 55
Kundavaram Paul Prabhakar Abhilash
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Impact of perceived self-efficacy among hypertensives in adapting to low salt diet Highly accessed article p. 57
Venmathi Elangovan, AY Nirupama
Background: Hypertension is a crucial health problem worldwide, and its snowballing epidemiology demands stern caution to increase the focus on this silent disease. Evidence exists that a considerable decline in salt consumption decreases blood pressure (BP) by around 5–7 mm of Hg systolic, in patients with increased BP. Materials and Methods: A cross-sectional study was conducted among known hypertensive patients attending a health-care setting for routine check-up. This included patients of both genders, diagnosed with hypertensive at least 3 months prior, irrespective of their adherence to medication. Thus, convenient sampling was used to recruit participants after obtaining informed consent. The participants, who did not consent or cases of emergency such as myocardial infarction, malignant hypertension or arrhythmias and association with confirmed diabetes mellitus, were excluded. The study tool consisted of prevalidated and semistructured interview schedule.Results: Median (inter-quartile range) age of the study participants was 60 (15) years with 59% of the population constituting of females. The consumption of dietary sodium was observed to be 2–4 g/day among 74.3% (78) of the study participants, and >5 g among 22.8% (23) of the study participants. Nearly 70% of the participants had higher to moderate perceived self-efficacy scores indicating an overall higher self-efficacy among participants in adapting to the practice of salt restriction. Perceived self-efficacy scores negatively correlated with dietary sodium intake by Spearman's correlation (rho = −0.667, P < 0.001). Conclusion: The perceived self-efficacy scores of the participants showed a strong negative correlation with the dietary sodium intake, this may be an indication of need for self-motivation and patient participation in the control of factors such as restricted salt intake in patients with hypertension and warrants further research.
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Acute anterior wall myocardial infarction: The importance of ST-Segment change in lead aVR p. 63
Vivekanand Gupta, Sheikh Mohamad Tahir, RD Yadav
Background: According to recent research, examining the ST-segment shift in lead aVR provides valuable information on coronary angiographic anatomy and risk categorization. In acute anterior wall myocardial infarction (MI), lead aVR has diagnostic and prognostic relevance. The purpose of this study is to look at the relationship between presenting clinical status and coronary artery disease risk factors and ST-segment deviation in lead aVR. Methods: This prospective observational hospital-based study was carried out in the Department of Cardiology at Batra Hospital and Medical Research Centre in New Delhi. Patients with acute anterior wall ST-elevation MI who presented within 24 h of symptoms were included in the study. Continuous data were expressed as mean standard deviation and categorical variables as the number or percentage of patients. Results: The study involved 73 individuals who met the inclusion and exclusion criteria and had acute anterior wall ST-elevation MI. Thirty of the 73 patients (41%) had ST-segment elevation in lead aVR larger than 0.5 mm. In two groups, the distribution of various cardiovascular risk factors was examined. In all of the cases, the left anterior descending artery was affected. Patients with double- and triple-vessel disease were seen in more significant numbers in Group A than in Group B. Cardiogenic shock occurred in 6 of 30 patients in Group A and 3 of 43 patients in Group B. Conclusions: ST-elevation in lead aVR has predictive value. Patients with higher ST-segment elevation in aVR are more likely to suffer angina, CHF, and cardiogenic shock complications. Providing these patients with percutaneous or surgical revascularization therapy as soon as possible can reduce mortality.
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The role of ictal brain single photon-emission tomography in refractory epilepsy complementary to magnetic resonance imaging and electroencephalogram – Our experience p. 69
Justin Benjamin, Saumya Sara Sunny, Julie Hephzibah, David Mathew, Anitha Jasper, Maya Thomas, Nylla Shanthly, Regi Oommen
Background: Correct identification of the epileptogenic zone (EZ) is essential for surgical success for focal epilepsy. There are multiple modalities which are available for detecting the anatomical and the functional abnormalities. The purpose of this study was to determine the complementary role of ictal brain single photon-emission tomography (SPECT) in delineating the EZ in addition to electroencephalogram (EEG) and magnetic resonance imaging (MRI). Methodology: Clinical and diagnostic data from patients with refractory epilepsy undergoing ictal brain SPECT (IEBS), EEG, MRI between 2014 and 2019 were analyzed retrospectively. Tc99m-ethyl cysteinate dimer was administered intravenously during or within 30 s of onset of seizure activity. Results: Eighty-nine patients aged: Four months-32 years (median age: Eight years) were studied. The concordance of IEBS with MRI and EEG were studied. Among them, EEG was normal in 22 and abnormal in 67 (multifocal: 40, unifocal: 8, generalized: 19). MRI was normal in 36, abnormal in 26, nonspecific in 24 and not done in three patients. Of the 80 patients showing tracer uptake in IEBS, 14-multifocal uptake and 66-unifocal uptake (EEG and MRI were not showing any abnormality in 15 and 27 patients, respectively). Unifocal uptake in IEBS was concordant with EEG in 11 (16.67%) and MRI in 15 (27.72%). The concordance and nonconcordance of the results among the two imaging modalities or EEG assuming surgical site as the gold standard was noted. Twenty-two had undergone surgical removal of the EZ, 15 was conformable with MRI or IEBS. Conclusion: In patients with noncontributory EEG and MRI, IEBS could detect the epileptogenic focus. Therefore, depending entirely on EEG and MRI may limit its diagnosis. IEBS, MRI and EEG are complementary to each other in the detecting the epileptogenic focus.
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Predicting functional outcomes in severe traumatic brain injury: Role of S100B along with other clinical and imaging parameters p. 74
Judy Ann John, Jane Elizabeth Sajan, Anna Oommen, Mathew Joseph, Suranjan Bhattacharji
Background: The objective of this prospective cohort study was to evaluate the role of serum S100B, along with other clinical and imaging parameters, in predicting functional outcome in severe traumatic brain injury (TBI). Methodology: We included 23 patients with severe TBI admitted within 48 h of injury. The Glasgow Coma Scale (GCS), pupil reactivity, and Marshall's computerized tomography grade were assessed at admission and serum levels of S100B were estimated at 48 h and 21 days post injury. ROC curve was generated to determine the cutoff value for S100B levels. Clinical data were analyzed to study their association in predicting the functional outcome as assessed by the Glasgow coma scale (GOS), Functional Independence Measure (FIM), and Modified Mini-Mental State Examination (3MS) at 6 months. Results: S100B levels above 1.37 μg/L at 48 h significantly predicted poor outcomes at 6 months as assessed by GOS (sensitivity of 64%, specificity of 83%, and likelihood ratio (LR) of 3.76), FIM (sensitivity of 75%, specificity of 85%, and LR of 5.0), and 3MS (sensitivity of 60%, specificity of 83%, and LR of 3.53). On linear regression analyses, GCS motor score at 96 h and S100B levels were independent predictors of GOS, FIM, and 3MS. The positive predictive value for poor outcome (GOS ≤3 or FIM <72 or 3MS <75) was 100% when S100B levels at 48 h ≥1.37 μg/L were combined with GCS motor scores at 96 h ≤3. Conclusion: S100B levels at 48 h post injury and GCS motor score at 96 h were significant predictors of long-term functional outcome in severe TBI.
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Review of current evidence in management of oleander poisoning p. 82
Vineeth Varghese Thomas, Nalini Newbigging, Jacob Johnson, Murugabharathy Kalimuthu, Karthik Gunasekaran, Ramya Iyadurai
India has a high incidence of poisoning, especially in the rural setting with plant-based compounds being used as a common agent. Oleander poisoning is a common shrub seen throughout the tropics including nearly all parts of India. It continues to remain an important cause for both accidental and deliberate self-harm in the community with all parts of the plant containing toxin sufficient to cause poisoning. There is enough evidence to show that oleander poisoning continues as one of the more common plant-based causes for poisoning. This review looks at the common management principles and provides an update on the currently available treatment strategies and evidence for them.
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Polycystic ovary syndrome: Current perspectives and recent advances p. 89
AY Nirupama, Jennifer Britto John, D Vinoth Gnana Chellaiyan
Excess ovarian activity, chronic anovulation, and androgen excess are the common traits of polycystic ovary syndrome (PCOS). Several advances have been made in understanding the pathophysiology in the process of finding quicker and more effective management measures. Androgen excess in PCOS was found to correlate with markedly elevated luteinizing hormone pulsatility. Impaired insulin response is also attributed to PCOS. Regimen with 3 mg drospirenone + 20 μg ethinyl estradiol combination is beneficial for hormonal imbalance and lipid profile while having a substantial safety profile. Clinical evidence has demonstrated that a 40:1 combination of Myo-inositol and D-chiro-inositol restores ovulation in PCOS women. For women with clomiphene citrate-resistant PCOS, laparoscopic ovarian drilling has proved to be a safe and effective surgical alternative. PCOS is also an indication of bariatric surgery. To conclude, constitutional management by a multidisciplinary team may be helpful for women with PCOS. Lifestyle interventions are best advised and, in so doing, decrease body adiposity and recuperate their metabolic and reproductive health.
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Inflammatory bowel disease in pregnancy: case series with review of literature p. 95
Audrin Lenin, George Abraham Ninan, Reeta Vijayaselvi, Swati Rathore, Sudha Jasmine Rajan
Inflammatory bowel disease (IBD) affects women in their reproductive years with severe disease associated with maternal morbidity and adverse fetal outcome. A retrospective chart review was conducted for all patients admitted under the departments of Medicine and Obstetrics from 2012 to 2018. The patients with IBD in pregnancy were identified. The inpatient and outpatient charts of these patients were reviewed for the clinical profile, treatment received, and outcomes. We report our experience of managing pregnant women with IBD in South India. Of the five patients, two presented with the active severe disease during pregnancy and were treated with steroids and azathioprine of whom, one developed chorioamnionitis and the other metabolic complications. All except one pregnancy required operative delivery. Pregnancy outcomes in IBD are dependent on the disease activity status at conception. Diagnosis of IBD in pregnancy is a challenge, as full-length colonoscopy and computed tomography imaging is not feasible. Chorioamnionitis is a complication associated with IBD, probably due to immunosuppressive drugs.
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Clinical profile of anti-transcription intermediary factor-1 gamma-positive adults from a single tertiary care center p. 99
Avanish Jha, John Mathew, John Antony Jude Prakash, Susmitha Karunasree Perumalla
Anti-transcription intermediary factor-1 γ (TIF-1 γ) antibody is a myositis-specific antibody. These cases had specific clinical features in the past studies. There is no published data on such patients from South Asia. We retrospectively looked at data from patients with positive anti-TIF-1 γ antibodies from our hospital database between May 2019 and October 2020. Their clinical presentation, muscle and extra muscular involvement, investigations, presence of malignancy, and treatment with subsequent follow-up were retrieved using the electronic medical records. TIF-1 γ was rare at our center and was 2.46% out of the total positive myositis immunoblot results. Seven adult patients had significant anti-TIF-1 γ positivity. Five out of them had clinical muscle weakness; none had severe or respiratory muscle weakness. No patients had cancer-associated myositis. The skin was the most common extra muscular organ involved. The absence of cancer-associated myositis with anti-TIF-1 γ subjects in our series may represent the difference in phenotype in the South Asian population.
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A patient with recurrent fever – TRAPped for diagnosis! p. 104
Hari Kishan Boorugu, Rajendra Vara Prasad Irlapati, Pankaj Vinod Jariwala, Kartik Pandurang Jadhav
Hereditary recurrent fever syndromes are rarely diagnosed in India, and the age at diagnosis is usually childhood or early adulthood. We present an adult male patient with recurrent fever since childhood who presented to us at 59 years of age and was subsequently diagnosed to have TNFR1-associated periodic fever syndrome that responded well to colchicine.
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Use of prasugrel in patients with clopidogrel hypersensitivity p. 107
Aparna Joshi, Darpanarayan Hazra, Ankita Chowdary Nekkanti
Allergic response to clopidogrel is a significant and difficult clinical problem as it is one of the recommended drugs after coronary stenting to prevent thrombosis. We present the case of a 57-year-old man who underwent coronary revascularization and developed an urticarial rash after being started on dual antiplatelet medication (aspirin and clopidogrel). He was managed conservatively, to which he responded well and was discharged on prasugrel. This case study from India adds to the available literature and discusses the alternative drugs that could be used in patients with clopidogrel hypersensitivity.
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Herpes zoster after inactivated COVID-19 vaccination p. 109
Vincent Ongko Wijaya, Wulandari Berliani Putri, Haris Alwafi, Ester Puti Andyni Manalu
Previous evidence has linked the relationship between newly onset skin disorder and SARS-CoV-2 infection. Cutaneous manifestations have been reported after exposure to COVID-19 vaccines that are linked to body immune responses. There is limited information about skin disorder that occurs after the COVID-19 vaccination. We report a case of varicella-zoster virus reactivation following inactivated COVID-19 vaccination in a young female patient.
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Neglected domain of feminism in medical education: The need for curricular reform p. 112
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
Feminism can be acknowledged as a kind of movement to bring about an end to sexism, sexist exploitation, and domination of the male gender. The necessity to bring about an improvement in the health and well-being of women originated 4–5 decades ago, owing to the rising awareness about gender bias in a male-dominated medical community. This means that we continue to deliver medical education and produce medical students, wherein the training is still rooted in patriarchy, with the perspectives of women significantly being ignored. Further, most of the medical textbooks had limited content on women's gender-specific knowledge, and thus it was envisaged by some of the educationists to adopt specific corrective measures to minimize the imbalance and injustice. To conclude, the component of feminism in medical education has not been given due importance over the years. Thus, there is an indispensable need to address these components in the process of design, implementation, and evaluation of the curriculum to produce gender-sensitive medical graduates who play their part in overcoming different kinds of gender discrimination.
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Medicolegal practice in India: Is digitalization the way forward? p. 115
Daniel Manoj, Latif Rajesh Johnson, Ranjit Immanuel James
In India, most of the medicolegal records are still kept as paper documents, even though technology has become integral in every other field of the health sector. Digitalization of the medicolegal processes would allow records to be easily stored and accessed. In addition, it would improve security, accuracy, and readability. Despite some steps in the right direction, most Forensic Medicine departments in India seem to be lagging behind. The authors will attempt to highlight the pressing need for the digitalization of medicolegal services in our country.
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Ethics review for case studies p. 118
Sirshendu Chaudhuri, Kapil Goel, Aniruddha Basu
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The unknown etiology of new-onset refractory status epilepticus p. 119
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
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Acute surge in the incidence of overweight and obesity in children – A 'Spin-off' epidemic triggered by the ongoing COVID-19 pandemic p. 120
Thirunavukkarasu Arun Babu
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We are seeking partners who can join us in caring for severely injured people. As a generous individual or a Company through CSR and other philanthropic initiatives, you can help us save lives!
For more details, please visit https://givecmcv.org/trauma-centre/
OR https://www.cmch-vellore.edu/