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Objectives: The aim of this study is to assess the utility of plasma von-Willebrand factor (VWF) levels in predicting in-hospital survival for patients with severe alcoholic hepatitis. Methods: From a prospectively collected database of acute-on-chronic liver failure (ACLF) patients, we retrospectively selected all severe alcoholic hepatitis (discriminant function [DF] ≥32) patients and correlated baseline plasma VWF (antigen, Ag and collagen-binding activity [CBA]) levels with disease severity. In-hospital survival was classified as discharged alive (or) died/discharged in a terminal condition (poor outcome). Results: Of 34 consecutive severe alcoholic hepatitis patients (age: 40.5, 30–63 years; median, range, hospital stay: 6, 2–15 days) studied, 15 had a poor outcome. Plasma VWF-CBA was higher in patients with poor outcome (736 [396–1157] IU/dL) as compared to patients discharged in stable state (492 [97–986] IU/dL; P = 0.03). VWF-CBA correlated well with VWF-Ag, model for end-stage liver disease (MELD) score, sequential organ failure assessment score and ACLF grades. AUROC to predict composite poor outcome was similar for plasma VWF-CBA (0.72, 0.54–0.89) and MELD score (0.71, 0.53–0.89). Plasma VWF-CBA was higher in 23 “very severe” alcoholic hepatitis (DF >60 or MELD >30) patients. Combining plasma VWF-CBA (>750 IU/dL) and criteria for “very severe” alcoholic hepatitis had a sensitivity of 100% (81%–100%) and negative predictive value of 100% (68%–100%) for predicting poor outcome. Conclusions: Plasma VWF levels are markedly elevated, correlate with organ failure, and predict in-hospital survival in severe alcoholic hepatitis, and also in “very severe” alcoholic hepatitis, patients.

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Background: Laryngoscopy and intubation form an indispensable step in general anesthesia. They elicit significant sympathoadrenal responses. Suppression of these responses forms an essential step in general anesthesia. The aim of our study is to compare the efficacy of nebulized lidocaine versus intravenous (IV) lidocaine in suppressing the pressor response to laryngoscopy and intubation. Materials and Methods: One hundred patients within the age group of 18–65 years undergoing elective surgery under general anesthesia were randomly allocated into two groups: group IV lignocaine (IVL) (n = 50) and group nebulized lignocaine (NL) (n = 50). Baseline values of heart rate (HR), systolic blood pressure (BP), diastolic BP, mean arterial pressure (MAP), and saturation were noted. Patients received either nebulized or IV lidocaine according to the group. HR, saturation, BP, MAP, and arrhythmias were noted every minute from laryngoscopy up to 5 min postlaryngoscopy and intubation. Results: There was an increase in HR and BP from baseline in both the groups with laryngoscopy and intubation, and the increase is significantly less in NL (P < 0.05). The parameters in both the groups attained the baseline values at the 3^rd min postintubation. However, the 4^th- and 5^th-min readings showed values below baseline in the nebulization group. Conclusion: This study suggests that NL may be more effective than IVL in suppressing pressor response to laryngoscopy and intubation.

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The ever-growing menace of Coronavirus Disease of 2019 (COVID-19) has ravaged mankind the world over. There has been a lot of exploratory work going on to unravel the pathophysiology of the disease and to come up with a rationale and realistic management protocol. Here is one such attempt to present the Government, Societal and Medical measures framed by Tertiary Care Medical College Teaching Hospital of State of Rajasthan, namely, S. M. S. Medical College and Attached Hospitals, Jaipur. These measures were undertaken for the entire state so as to curtail the rise of COVID-19 pandemic to some extent. The combative approach was multi-focal and multi-axial with the aim to address issues from all conceivable angles inclusive of preparative ground-work, fluidic containment, slowing of transmission, and appropriate logistics to ensure steady-state supplies.

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Secondary osteoporosis is an important clinical condition associated with significant morbidity and mortality. Many systemic conditions like autoimmune inflammatory disease, diabetes mellitus and drugs like glucocorticoid use are associated with secondary osteoporosis, diagnosis of which often requires high index of suspicion. Identification and treatment of the underlying cause itself can result in significant improvement in bone health. In this review we describe 5 case based scenarios discussing the diagnosis and management of some important causes of secondary osteoporosis.

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Providing continued cancer care during lockdown for a pandemic is a big challenge. There are several issues like lack of public transport, facilities for lodging as most of cancer patients undergoing radiation and chemotherapy are treated on day care basis, maintaining physical distancing in otherwise crowded government hospital, and safety of healthcare workers. We present here a brief report of the challenges and measures undertaken by a tertiary care cancer center in the North East India. Further, we also describe the pattern of cancer and consequent care of cancer patients' pre and post lockdown.

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Imatinib mesylate is a tyrosine kinase inhibitor approved for treatment of gastrointestinal stromal tumors and chronic myeloid leukemia. Several cutaneous adverse reactions have been reported with its use. There are a very few reports of imatinib induced bullous disorders. We report a case of pemphigus foliaceus associated with imatinib mesylate therapy in a patient with gastrointestinal stromal tumor.

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Subclavian artery dissection is an uncommon condition, with only a few cases reported in the medical literature. Reported cases have been due to traumatic, nontraumatic, and iatrogenic etiologies. The exact incidence or prevalence in the society remains unclear, and the cases reported are sporadic. Diagnosis is usually with computed tomography. The management usually depends on whether there is ischemia of the tissues supplied by the subclavian artery. Our objective is to present a patient who was diagnosed with nontraumatic subclavian artery dissection but presented with clinical features of aortic dissection prompting a further diagnostic investigation.

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The world has seen a sea of change in options available to patient's with peripheral vascular disease be it venous or arterial pathology – when it comes to endovascular therapy over the past decade. Intervention in most cases can be carried out as outpatient, day-care, or short stay in hospital. However, all this comes at a price. This article looks at the relevance of “The Endovascular revolution” in the context of Indian health care.

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Like the rest of the world, the onslaught of COVID-19 has hit India and poses as a major challenge to its country people. On January 31, India faced the jolt of COVID-19 for the first time when the maiden case was reported in Kerala. The numbers grew steadily in the following days. In the initial stages, the virus was contracted through patients with foreign travel history. However, as the numbers surged, the cases of local transmission also came to the fore. Various directives were issued by the administration to limit the spread of the virus. This included the closure of schools, colleges, and universities and the cancelation of visas. While the cases showed no signs of subsiding, the restrictions were intensified with the closure of interstate transport and cancelation of all flights. On March 24, the countrywide lockdown was announced for 21 days as a major precautionary measure against the growing virus. While the country continues to contain the coronavirus pandemic and the possible economic slowdown due to it, the newly formed union territory (UT) of Jammu and Kashmir has been put under another lockdown – this time due to the disease. However, this time, there is one silver lining in the dark cloud. The administration had been active beforehand. It had stepped up its preparedness measures before the outbreak of the pandemic in the UT.

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Background: The human cornea is the most densely innervated tissue, and the corneal sensitivity is a measure of its function and an indicator of the integrity of the protective mechanism. Corneal sensitivity plays a vital role in the protection and maintenance of corneal health and is known to vary with race, age, region, climate, environment, and the time of the day. The study was aimed to quantify and establish the range of corneal sensations in different age groups in an Indian population using the Cochet–Bonnet Esthesiometer (CBE). Materials and Methods: This was a cross-sectional study done at a tertiary care center in South India, between January and April 2018. One hundred and fifty patients (30 patients stratified by age into five groups) were enrolled after informed consent. The corneal sensations were measured using CBE by a single examiner in a specified period of a day over five regions and the data analyzed. Results: The average measured corneal sensitivity was 58.36 (21–30 years), 57.96 (31–40 years), 56.43 (41–50 years), 56.40 (51–60 years), and 54.84 (>60 years) mm, respectively. The frequency of having maximal measurable sensations (60 mm) in all the tested regions dropped with increasing age from 46.67% to 16.67%. All regions showed a sensitivity drop with an increase in age, the maximum in the nasal quadrant and the least drop in the central region. No statistically significant difference in the corneal sensitivity was found between the genders. Conclusions: An inverse linear correlation between the corneal sensitivity and age was evident. The central and the superior regions are the most and least sensitive regions of the cornea, respectively, in our study population. The varied pattern of change in corneal sensations in different populations highlights the importance of establishing normal ranges of corneal sensitivity in patients from different ethnic and geographical backgrounds.

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Background: Intentional exposure to agrochemicals is a major cause of premature mortality globally. Many such agrochemical compounds contain solvents that may result in severe methemoglobinemia that may be fatal. Acute methemoglobinemia is usually associated with high mortality; hence, an early aggressive management of poisoning in the emergency department (ED) should be attempted. Materials and Methods: This was a single-center, retrospective, cohort study analyzing patients with a history of ingestion of agrochemicals and significant methemoglobinemia in a period of 4 years that presented to our ED. Results: The total number of patients presenting to the ED following ingestion of agrochemicals with a motive of deliberate self-harm was 2491 during the 4-year study period, among which 24 patients had significant levels of methemoglobin. Majority of the patients presented following ingestion of nitrobenzene compounds (37%), followed by organic herbicides and larvicidal compounds (17%). The most common clinical features were that of low oxygen saturation on pulse oximetry not improving with oxygen therapy and central cyanosis. Most of these patients, i.e., 91.6%, were treated with intravenous (IV) methylene blue, to which 81.8% patients responded favorably and had methemoglobin <20% at 1-h interval from administering. Among the total study population, most (83.3%) patients required admission in the ward or intensive care for further stabilization and management, whereas the rest (16.7%) opted for discharge against medical advice. There was no mortality in the ED. Conclusions: Methemoglobinemia can be caused by a wide variety of agrochemicals that are potentially life-threatening. The most common clinical signs in the ED are those relating to hypoxemia. Use of IV methylene blue resulted in a significant reduction of methemoglobinemia. With this characterization, we hope to guide protocols in the future for the management of agrochemical poisoning.

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Objectives: Stroke is one of the major causes of death and disability in India, as evident from the Global Burden of Disease Study, causing 7.3% deaths. An effort was made to correlate stroke mortality with tobacco use, alcohol use, use of clean fuel, and economic condition. Study Design: This was an ecological study. Methods: Data were taken from nationally representative reports – National Family Health Survey 4, Global Adult Tobacco Survey 2: India 2016–2017, and India: Health of the Nation's States. Spearman correlation coefficient, scatter plot, and multivariate linear regression were used for state-wise analysis. Results: Clean fuel and smokeless tobacco (SLT) were significantly associated with mortality due to stroke (r = –0.423 and 0.445, respectively). Delhi, Goa, and Tamil Nadu, states with the highest proportion of population using clean fuel, recorded less deaths due to stroke, in comparison to rest of the country. On multivariate regression, use of SLT and secondhand smoking at work were found as independent predictors for stroke mortality. Conclusion: For preventing deaths from stroke, wide use of clean fuel should be encouraged and work place should be kept free from smoking.

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Endometriosis is said to have a low incidence in women with African descent. However, recent studies have shown otherwise. Thoracic involvement is rare; thoracic endometriosis syndrome mostly affects nulliparous women within the ages of 25–35 years. The diagnosis is usually missed or delayed by clinicians. We report the case of a 26-year-old female with catamenial hemothorax secondary to thoracic endometriosis. A high index of suspicion for this condition should be maintained in women of the reproductive age group presenting with dyspnea/chest pain, severe dysmenorrhea, and background history of chronic pelvic pain. A multidisciplinary approach involving the radiographers, gynecologists, pulmonologists, and the thoracic surgeons coupled with hormonal therapy and surgical treatment will go a long way in improving this disease condition and preventing reoccurrences.

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Background: Alcohol intoxication plays a major role in the causation of road traffic accidents (RTAs) and assault. On April 1, 2017, the honorable Supreme Court of India banned liquor shops on all national and state highways to a distance of 500 m from them. Out of 231 liquor shops, 178 were closed in Vellore district after the ban. This, we assumed, would have reduced the number of drunken drivers and pedestrians, resulting in the fall in the number and severity of the accidents. Materials and Methods: This is a retrospective observational study done in a tertiary hospital in South India. All RTA patients presented to the emergency department (ED) 1 month before the liquor shop ban (March 2017) were included in the preban group and who presented to the ED 1 month after the liquor shop ban (April 2017) were included in the postban group; their incidence and severity of trauma were assessed and compared. A bivariate analysis was done to identify the relationship between these variables and potential determinants, and their 95% confidence interval (CI) was calculated. For all tests, a two-sided P < 0.05 was considered statistically significant. Results: The study cohort included 438 patients, in which 194 were in preban group and 244 in the postban group. Both groups showed male predominance, with a mean age of 37.57 and 35.12 years, respectively. Majority of the RTAs in both groups involved two-wheelers (75.3% vs. 77.9% [odds ratio (OR): 0.87, 95% CI: 0.55–1.35, P = 0.52]). There was no decrease in the incidence of RTA victims under the influence of alcohol (45.2% vs. 45%, OR: 1.6, 95% CI: 0.89–2.90, P = 0.11). There was no decrease in the incidence of severe head injuries (19.1% vs. 15.6%, OR: 1.28, 95% CI: 0.78–2.10, P = 0.33) or injuries to extremities (42.8% vs. 35.2%, OR: 1.37, 95% CI: 0.93–2.02, P = 0.11). Conclusions: Although three-fourth of the liquor shops in the district were closed, it did not have a significant impact on the incidence and severity of RTAs presenting to the ED.

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The novel coronavirus (SARS-COV-2) that causes the disease coronavirus disease-19 (COVID-19) has posed major challenges for health-care workers worldwide. Once the lockdown is relaxed in India, there might be an increase in the number of positive cases. Simple tools and practice guidelines may make clinical tasks faster, easier, and safer. Toward this objective, governments, hospital administrators, medical associations, health-care providers, and policy-makers worldwide have published multiple papers and guidelines. However, there remain several controversies on the pathophysiology of COVID-19, leading to uncertainty on what should and should not be done. It is in such a context that some simple tools and practice guidelines, based on best available evidence, are being shared on this platform. The contents of these tools have been taken from the World Health Organization guidelines and recent publications on COVID-19. The tools have been designed by a senior anaesthesiologist/medical administrator at a NABH-accredited hospital with over three decades of expertise in the private health-care systems. The purpose of these guidelines is to be prepared to deliver safe and standardized care to COVID-19 patients, while maintaining the ease of work environment for hospital staff. It is understood that all the health-care workers will be wearing personal protective equipment as per the guidelines released by the Ministry of Health and Family Welfare, Government of India. There are nine forms, namely patient workflow, screening form, triage form, COVID-19 severity score tool, outpatient management guidelines, advise; COVID-19 inpatient management guidelines, modified early warning signs chart, and oxygen therapy flow chart. These are simple, on-paper tools, and guidelines for use at secondary care hospitals, in compliance with the governmental regulations.

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Vertigo, an illusory movement, arises mostly because of lesions in the peripheral vestibular system (e.g., damage or dysfunction of the labyrinth and vestibular nerve) and occasionally that of central vestibular structures. Patients give various descriptions of vertigo: a head-spinning feeling, swaying, tilting, or an imbalance in walking depending on the location of the lesion. Acute vertigo remains a diagnostic challenge for the physicians due to the wide array of differential diagnosis. It is important to distinguish the central causes of vertigo from its peripheral causes. Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of peripheral vertigo, most commonly attributed to calcium debris within the posterior semicircular canal, known as canalithiasis. Prompt diagnosis by positional testing (e.g., Dix–Hallpike), performing a bedside repositioning maneuver (e.g., Epley) and administering symptomatic therapy helps in providing the quick relief to the highly distressing symptom of vertigo due to BPPV.

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Pain is one of the most common complaints among patients presenting to the emergency department (ED), and almost all conscious trauma patients would experience pain as the most troubling symptom. The acute management should include initial appropriate assessment of severity of pain and various measures to relieve acute pain. Multimodal analgesia which includes multiple analgesic medications (opioid and nonopioid), regional anesthesia, and nonpharmacologic interventions (physical and cognitive strategies) is highly efficient for effective and immediate pain relief. Regional anesthesia, which is gaining popularity in the ED as an integral part of acute pain relief due to trauma, includes peripheral nerve blocks and local neuraxial blockade and significantly alleviates pain and improves patient comfort.

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Chest radiographs are extensively used yet surprisingly complex. Compressing the three dimensions of the patient into the two dimensions of the image, there is a lot of opportunities for overlapping shadows to trip up the unwary and obscure diagnoses. Lobar collapse and lobar consolidation can usually be identified and distinguished as distinct diagnoses. The silhouette sign is king; ask “what can be seen?” and “what cannot seen (that should be seen)?”

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Urinary incontinence, which is the involuntary leakage of urine, is very common in the elderly. Temporally, incontinence can appear suddenly (transient), or be chronic in nature (established). Transient incontinence is usually due to the appearance of a new identifiable problem, the causes are embodied in the mnemonic DIAPPERS: Delirium, Infection, Atrophic vaginitis, Pharmaceuticals, Psychological, Excessive urine, Restricted mobility, Stool impaction. Established Incontinence is one that persists even after correction of precipitating factors, or, lack of identifiable factors. The types are: stress, urge, and overflow, mixed, and functional. Stress incontinence: A weakened pelvic floor in females, leads to prolapsed pelvic organs, causing sphincter dysfunction. The role of pelvic floor exercises (Kegels exercises) and newer surgical interventions is discussed. Urge incontinence: The disturbance in cortical control of the pontine centers of micturition is highlighted. The use of anti-muscarinic agents, sympathetic receptor blockers, and agonists is explained. Overflow incontinence: The role of removing obstruction to urine flow, or catheterization in atonic bladders is discussed.

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