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   Table of Contents - Current issue
September-December 2020
Volume 6 | Issue 3
Page Nos. 149-237

Online since Wednesday, December 16, 2020

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The Journey of MAMCJMS - Looking back with satisfaction! p. 149
Pawanindra Lal
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Responding to the COVID-19 Pandemic: the Experience and the Road Ahead for the Largest Medical College in India’s Capital City p. 151
Nandini Sharma
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COVID 19 Pandemic: Managing One: Preventing Another p. 153
Mohit D Gupta
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Response to COVID-19: Best Practices From the Department of Community Medicine of a Medical College in Delhi p. 156
Nandini Sharma, Bratati Banerjee, Shivani Rao, Amod Laxmikant Borle, Nidhi Bhatnagar, Pragya Sharma, Rajesh Kumar, Mongjam Meghachandra Singh, Panna Lal, Gajendra Singh Meena, Suneela Garg
Public health response and measures are vital to contain an infectious disease outbreak/epidemic. The discipline of Community Medicine, which provides comprehensive primary health care to the entire population at all times, plays a crucial role in times of disease outbreak/epidemic also, being equipped with skills in providing managerial, clinical, and community care, through policy making, surveillance activities, preventive strategies, primary care, capacity building, and awareness generation in addition to generation of evidence-based strategies. The Departments of Community Medicine in Medical Colleges can play a crucial role in this direction and should be involved to share the expertise as well as the best practices adopted, which will go a long way in containing an epidemic at the earliest. The Department of Community Medicine of a leading Medical College in Delhi, along with the clinical departments, is playing a stellar role in response to the pandemic of Corona Virus Disease of 2019 (COVID-19). This article highlights the response to the situation, the challenges faced, and the success stories. Activities have been categorized as Fair, Good, and Best. Activities that are routinely performed are taken to be “Fair” and activities that are beyond routine activities have been labelled “Good”. “Best” practices have been identified to be those that involve representation at the national/State/District level, activities for capacity building, contribution toward evidence generation, and work with risk of exposure. The best practices adopted by the Department of Community Medicine of this institution can be collated for future use in teaching hospitals where Community Medicine departments are equipped with manpower skilled to face such a challenge. It will serve as a blueprint for action, if the need be, for handling similar situations in the future.
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Surgery in Covid 19 Times: A Comprehensive Review Highly accessed article p. 163
Lovenish Bains, Anurag Mishra, Lalit Gupta, Rajdeep Singh, Pawanindra Lal
The problems faced by surgeons are unique during the Covid pandemic. In the absence of concrete information, we have to resort to extreme degrees of precautions during surgery. Precautions have to start from the point patient enters the hospital, to the point he is discharged. Changes in the patient flow and having sanitization protocols can help in this regard. Since the epidemiology of SARS-Cov 2 is still evolving, the consent process has to necessarily include the risks involved. Preoperative testing is not full proof and the increased risk for the COVID positive patient undergoing surgery has to be communicated. The operating room has to be modified with regard to the number of air changes, an aspect which the surgeons were unaware of prior to this pandemic. Changes in the follow-up protocol, such as use of telemedicine, will help minimize patient contact.
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Imaging Appearances of Pediatric Hepatic Masses − A Review p. 176
Shruti Mittal, Sapna Singh, Radhika Batra
In the pediatric population, a wide spectrum of focal liver lesions is seen, which can be categorised into congenital, inflammatory or neoplastic origin. Majority of the patients with focal liver masses present with abdominal pain, abdominal distention or palpable abdominal lump. However, some lesions can be detected incidentally. After physical examination and clinical history, imaging plays a vital role in evaluating pediatric patients with suspected focal liver lesions. Abdominal radiography may provide some imaging findings suggesting the presence of focal hepatic mass such as hepatomegaly, presence of calcification and displacement of bowel loops. Ultrasound is the first line imaging modality as it does not involve ionising radiation. It can detect, characterise and provide the extent of lesion. However, computerised tomography and magnetic resonance imaging are performed subsequently for further characterisation of liver lesions on the basis of morphology, vascularity, enhancement pattern and for detection of associated metastases in malignant neoplasms. In this review article, we aim to describe the imaging appearances of various benign and malignant hepatic mass lesions in the paediatric age group and to provide differential diagnosis for liver lesions in a child on the basis of available imaging and clinical data. Imaging is therefore essential for making prompt and accurate diagnosis which further helps in appropriate treatment and optimal patient management.
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Acute Hepatitis B or Chronic Hepatitis B with Acute Exacerbation: Differentiating Clinical, Biochemical, Immunonological, and Virological Parameters p. 186
Ravi Kant Thakur, Sunit Kumar Shukla, Vinod Kumar Dixit, Dawesh Yadav, Piyush Thakur, Tuhin Mitra
Background and Aims: Acute hepatitis B virus (HBV) infection and chronic HBV infection presenting as acute illness have differing prognosis. Differentiation between acute viral hepatitis B (AVH-B) and chronic hepatitis B with an acute exacerbation (CHB-AE) is difficult if prior hepatitis B surface antigen (HBsAg) status is unknown. This prospective study was undertaken to screen various factors that could help with this differentiation. Methods: All consecutive patients presenting with AVH-B like illness were enrolled in this study and were evaluated as per predefined study protocol. Patients were divided into AVH-B and CHB-AE groups based on HBsAg status at the end of 6 months. Results: Significant differences in clinical and laboratory parameters were found between AVH-B and CHB-AE. No statistically significant difference in prodromal symptoms and jaundice was seen. Ascites (40%) and hepatic encephalopathy (10%) were seen only in patients with CHB-AE (P = 0.002 and 0.244, respectively). Anti-hepatitis B virus core antigen immunoglobulin M (IgM anti-HBc) levels ≥10.15 signal-cutoff-ratio (S/CO) had positive predictive value (PPV) and negative predictive value (NPV) of 90% for diagnosis of AVH-B. Hepatitis B virus deoxyriboNucleic acid (HBV DNA) levels ≥25032 IU/mLhas 62.5% PPV and 69% NPV for diagnosis of CHB-AE. Alpha-feto protein (AFP) at >22.5 ng/mLmL for diagnosing CHB-AE has PPV and NPV of 83% and 62%, respectively. All six mortalities were seen in CHB-AE group with median survival of 2 months. Conclusions: Differentiation of AVH-B and CHB-AE is important as management and prognosis differ. Low IgM anti-HBc levels (<10.15 S/CO), high HBV DNA levels (≥25032 IU/mLmL), and high AFP (>22.5 ng/mL) favor CHB-AE over AVH-B.
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Methods to Handle Incomplete Data p. 194
Vinny Johny, Mariamma Philip, Swathi Augustine
Context: The major question for data analysis is determining the appropriate analytic approach in the presence of incomplete observations. The most common solution to handle missing data in a data set is imputation, where missing values are estimated and filled in. An important problem of imputation is to maintain the statistical significance of the data set. Aim: To compare different imputation techniques − complete case analysis, last observation carried forward (LOCF), mean imputation, hot deck Imputation, regression imputation, and multiple imputation (MI). Settings and Design: The data for the study were collected from a prospective study to find out the predictors of early response to treatment in drug naïve schizophrenia patients from a tertiary care centre, India. Methods and Material: The present study tries to compare four imputation methods: complete case analysis, LOCF, mean imputation, hot deck Imputation, regression imputation and MI, in filling up the missing values of the outcome variable. Statistical analysis used: Paired t test was used to compare the imputation methods. Results: At the fourth week, the positive and negative syndrome scale scores were missing for about a minority of the subjects (41%). Mean imputation differed significantly from LOCF (P = 0.001), regression imputation (P = 0.010) and MI (P = 0.002). LOCF differed significantly from all these methods − regression imputation (P = 0.001), hot deck imputation (P = 0.011) and MI (P = 0.001). Conclusions: LOCF and mean imputation methods are different from other imputation methods, and there is no difference between hot deck imputation, MI, and regression imputation.
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Evaluation of Safety and Efficacy of Postpartum Intrauterine Contraceptive Devices (PPIUCD) in Vaginal and Caesarean Section Deliveries: A Hospital Based Study p. 199
Radha Agarwal, Shubhra Singh
Background: Immediate postpartum intrauterine contraceptive device (PPIUCD) is a lucrative postpartum family planning method which provide an effective reversible contraception for women in delivery settings. PPIUCD can be inserted post-placental, intra-caesarean and within 48 hours postpartum. We conducted this study to determine the outcome, satisfaction rate and continuation rate of PPIUCD. Materials and Method: This was a prospective observational study conducted in a tertiary care teaching institute. CuT 380A was inserted within 10 minutes of placental delivery in accepters who fulfilled the Medical Eligibility Criteria and had no contraindications for PPIUCD. They were then followed up for 3 months. A Cohort of 260 vaginal and caesarean deliveries with PPIUCD in situ were studied over seven months period and follow-up results were compared between Vaginal and Caesarean groups. Result: Overall expulsion rate was 8.47%, removal rate was 14.83% and continuation rate was 76.7%. There was no significant difference in removal rate of two groups. Spontaneous expulsion occurred in 8.47% cases and were significantly higher in vaginal insertion group (p value 0.0017). Overall complication rate was low. No case of perforation or accidental pregnancy was reported. Conclusion: PPIUCD is a safe, highly effective, long acting, cost effective method of postpartum contraception, which can be used during institutional delivery visit and eliminates the need for a return visit to start contraception. PPIUCD is a strong weapon in the family planning armory and should be encouraged in both vaginal and caesarean deliveries.
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Patients Knowledge of Prescribed Medications and Factors Affecting it in a Tertiary Care, Public, Teaching Hospital in New Delhi, India p. 204
Vandana Roy, Vandana Tayal, Anirudh Kansal
Objectives: To study patients’ knowledge about their prescribed medication and factors affecting it. Patients and Methods: An observational, cross-sectional study was conducted in 500 outpatients in the Medicine department of a tertiary care teaching hospital. The patients were interviewed about prescribed medicines using a structured questionnaire. The average consultation time and average dispensing time was also recorded for 100 interactions each. Results: Among 500 patients interviewed, 55% were females. Hindi was the primary language in 99.6% of the patients and majority of the patients 75.2% could not read English. The mean total score for patients’ medication knowledge was 38.87 ± 10.42 (maximum 60). 95% of participants had ‘Adequate to Good Knowledge’, and 5% had ‘Poor Knowledge’. Only 1.8% of the patients surveyed had complete knowledge of their prescribed medications. Various factors like age > 60 years, female gender, illiteracy, inability to read English, the doctor informing the patient only in writing and the pharmacist not explaining the medication information were associated with lower scores. The average consultation time was 284.6 ± 172.87 seconds and the average dispensing time was 60.45 ± 22.3 seconds. Conclusion: Overall the patients appear to have an adequate basic knowledge of their prescribed medications despite inability to understand the language and less time given for doctor patient pharmacist interaction. Interventions are required to improve health care providers understanding of what is required to educate the patients about the same. This is especially so for patients with risk factors contributing to their low knowledge about prescribed treatment.
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A Study of Indices in Smear Positive Leprosy in Post-Elimination Era: Experience at a Teaching Tertiary Care Centre p. 211
Ashwini S Patil, Meena Mishra, Pooja Taiwade, Sunanda Shrikhande
Background: Leprosy is an oldest chronic infectious disease known to mankind that predominantly affects the skin and peripheral nerves. Objective: To evaluate the bacteriological and morphological indices in smear positive cases. Materials and Method: Retrospective observational study was undertaken for one year duration on suspected cases of leprosy. Smears were prepared from one from each of the ear lobes by slit and scrap method and one from the site of lesion. Smears were stained with modified Ziehl-Neelsen stain and bacteriological/morphological indices were calculated. Results: Among 345 clinically suspected cases, 160 (46.38%) were multibacillary with male to female ratio 1.9:1 and most of cases from rural area of lower/middle class of third and fourth decade. All the three sites smears were positive in 112 (70%) cases. 66 (41.25%) cases had bacteriological index of 1+ while more than 1000 bacilli, on average, in 1each oil-immersion field (BI 6+) was observed in 1 (0.62%) cases. In 70 (43.75%) cases morphological index was less than 25 while in 14(8.75%) cases it was more than 50. Conclusion: Bacteriological and morphological index is one of the most important tools for diagnosis, classification, monitoring of treatment and disease severity.
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Trends of Blood Pressure and Body Mass Index Among Adolescents and Young Adults of a Government Medical College in India p. 216
Yamini Marimuthu, Panna Lal, Navya Gangadharan, Bharathnag Nagappa
Context: Medical undergraduates are an important health resource for the country in the future. Their health status and risk for the development of non-communicable disease need to be studied. Early diagnosis and management of these physiological risk factors among adolescents and young adults are of utmost importance for a healthy world in the future. Aims: The study was performed to assess the trend of non-communicable disease risk factors among adolescents and young adults of a government medical college in Delhi over 13 years from 2000 to 2013. Subjects and Design: A record-based cross-sectional study was conducted in a medical college in Delhi. The records of the routine health screening of MBBS students from 2000 to 2013 were analyzed. The data related to the student’s age, sex, height, weight, blood pressure, family history of diabetes, family history of hypertension were utilized for the study. Results: Among 1350 study participants 63.5% were males. Female MBBS students were constantly lesser than males with a minimum of 20% in 2006. The trends of obesity among MBBS students were increasing from 11.3% in 2000 to a maximum of 31.7% in 2013. The prevalence of hypertension was 8.1% in the year 2000 which increased to 16.4% in 2001, 10.6% in 2002, 15.3% in 2006, 14.% in 2007 and then it decreased to 1.5% in 2013. Conclusion: Our study has found that there was an alarming increase in the trend of prevalence of obesity among medical undergraduates which indicates the need for urgent interventions to minimize unhealthy behaviours among future doctors. Key Messages: The MBBS undergraduate students are the future doctors of India who are going to manage patients with non-communicable diseases (NCD). But, they themselves are at high risk of having NCDs in future. This study assessed the trend of NCD risk factors over 13 years and found that the prevalence of obesity has increased alarmingly.
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Coronavirus Disease 2019 Pandemic: Urgent Need to Scale up Public Health Emergency Response in the South-East Asia Region p. 223
Saurabh R Shrivastava, Prateek S Shrivastava
The ongoing Coronavirus disease-2019 (COVID-19) outbreak has become a global public health emergency. In the South-East Asia Region (SEAR), as on 6 July, 2020, 8 out of 11 nations have reported cases of this disease. There is a significant need to urgently scale-up the measures such as surveillance, case detection, isolation, infection prevention & control, contact tracing, treatment, risk communication, etc. In conclusion, in the global battle against COVID-19, the South-East Asian Region has to accelerate their preparedness activities and public health emergency response. We can reduce the consequences of the disease only with coordinated, concerted and sustained efforts and it is the time for each one of us to play our part in the effective containment of the disease.
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Is There a Difference in Etiology in the Liver Abscesses in South India?: A Clinical and Microbiological Study p. 225
Tusharindra Lal, R. Ponniah Iyyappan, C. Kaliyappa
Background: Liver abscesses in India are considered to be amoebic in origin. Studies for determining causative organism of liver abscesses in Southern India are limited in number. The present study was conducted to determine the etiology of these abscesses in the Chennai region. Methods: Twenty-three patients with a diagnosis of liver abscess were prospectively studied with full blood profile. Ultrasound-guided pus was aspirated and sent for culture. Amoebic serology was performed. The abscesses were classified as pyogenic, amoebic and indeterminate. Results: Sixteen patients (69.6%) were diagnosed as pyogenic, three (13%) as amoebic and four (17.4%) as indeterminate. Fifteen (5.2%) abscesses were single and 12 (52.3%) affected the right lobe. Escherichia coli (42.85%) and Staphylococcus aureus (35.71%) remained the most common causative organisms grown on pyogenic culture. Conclusion: In this study of a small group of patients from South India, liver abscesses were found to be predominantly single and pyogenic in origin with an equal propensity of gram-positive and gram-negative organisms.
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Shivering Due to Repeat Dose of Tranexamic Acid: A Peculiar Case Series p. 228
Sahil Kumar, Vandana Tayal, Kavita Swachia, Vandana Roy
Tranexamic acid (TXA) is a well-tolerated hemostatic agent that has been in clinical use for nearly 60 years. In this report, we describe for the first time 10 patients who experienced adverse reactions to repeat dose of TXA, which were not seen with the first dose. Shivering was found to be the most common adverse reaction. In half of the cases, shivering was associated with low-grade fever. On dechallenge and subsequent administration of steroids and antihistaminic agents, the reactions were controlled. On assessment with the World Health Organization–Uppsala Monitoring Centre scale, the causality was ascertained to be “Probable”.There is no clear postulated mechanism for shivering with TXA. We have postulated that hypersensitivity, fever, and shivering in these patients may be interlinked. In the light of this report, the physicians should take into account that repeated challenge with TXA may lead to adverse reactions in some patients and withdrawing the drug in such patients may be required.
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Overcrowding in Teaching Hospitals. Time for Policy Makers to Ponder Upon Residents’ Health p. 232
Vaibhav Aggarwal
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An Unusual Cause of Partially Opaque Hemithorax p. 234
Mayank Mishra, Subodh Kumar
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The HCWarrior p. 237
Mayank Mishra
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