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   Table of Contents - Current issue
January-April 2021
Volume 7 | Issue 1
Page Nos. 1-98

Online since Wednesday, April 28, 2021

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Looking Forward with Hope and Victory Highly accessed article p. 1
Dr. Ritu Arora
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Challenges and Experience of Setting Up a 2000 Bed COVID-19 Care Center on an Urgent Basis at Delhi p. 2
Rajeev K Kotnala, Deepak K Tempe, Prashant Mishra, Siddarth Ramji, Amaresh P Patil
Background: In the city of Delhi, with rapidly increasing number of COVID-19 positive patients, a need for creating a large COVID-19 care center (CCC) for mildly symptomatic patients was badly felt. This paper describes the challenges of setting up a 2000 bed facility and the experience with the first 400 patients treated in the center. Methods: The Indo-Tibetan Border Police was assigned this task, which was completed in a record time of 10 days in collaboration with several other government and nongovernment agencies. Results: All the involved agencies displayed teamwork of the highest order and completed the task. The first 400 mildly symptomatic patients were successfully treated at the center. Patient safety was the priority, and a protocol was devised for early detection of patients worsening further to moderate (oxygen saturation [SpO2] 90%–94% on room air) or severe category (SpO2 < 90% on room air), and arrange timely transfer to a COVID hospital. Twenty-six patients progressed to moderate disease and were managed with oxygen therapy in an area designated as COVID health center (200 beds) having facilities to oxygenate the patients, one patient required bilevel positive airway pressure. Thirteen patients were transferred to a COVID hospital as they worsened to severe category. All patients were discharged home; the mean hospital length of stay was 9 ± 2.3 days. Conclusions: With careful planning and team work, it is possible to commission a large CCC in a short span of time. The patients can be safely managed in such a facility.
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COVID-19 Infection in Children and Young Adults with Chronic Kidney Disease: A Single Center Experience Highly accessed article p. 9
Swarnim Swarnim, Madhavi Bharadwaj, Mukta Mantan, Onkar Singh Bhinder, Urmila Jhamb
Background: Coronavirus has affected millions of people worldwide and its severity is more pronounced in those with comorbidities; there is paucity of literature on its presentation and course in children and young adults suffering from chronic kidney disease (CKD). Aims: The aim of the study was to describe the clinico-epidemiological, biochemical, and radiological profile of children and young adults (up to 25 years of age) having CKD with coronavirus disease 2019 (COVID-19). Methods: This retrospective study was done at a tertiary care “dedicated COVID” hospital between May 1, 2020 and August 30, 2020. Ten children and young adults (up to 25 years of age) with underlying CKD who tested positive by reverse transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 infection and were hospitalized during this period were included; their clinical presentation, outcomes, biochemical, and hematological parameters were recorded and analyzed. Results: All 10 patients (seven males and three females) were in stage 5 of CKD and were undergoing maintenance hemodialysis at admission. Fever and cough were the most common presenting symptoms of COVID-19, while anemia (100%), leukopenia (50%), lymphopenia (30%), and thrombocytopenia (30%) were the hematological findings. Radiological abnormalities on chest radiography were seen in 50% patients with a majority having bilateral lesions. The median (range) duration of hospital stay was 21.5 (10–46) days; five (50%) patients needed intensive care support and one patient required mechanical ventilation who eventually expired. Conclusion: The presenting features of COVID-19 were similar in children and young adults with underlying CKD compared to their healthy counterparts; however, the mortality rate and intensive care requirement were higher and duration of hospital stay too was longer.
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Perceived Stress Among Medical Students and Doctors in India During COVID-19 Pandemic Highly accessed article p. 14
Nishtha Agrawal, Hitakshi Sharma, Aashima Dabas, Anurag Mishra
Objective: The present study was undertaken to assess the perceived stress levels in medical students and doctors in India during coronavirus disease (COVID-19) pandemic. Various studies have been done to assess the perceived stress levels among medical professionals and other associated health care workers, but no significant study has been done among medical students. This study is done with a special emphasis on the latter. Methods: A semi-validated online questionnaire was used to collect stress scores among medical students and doctors using Perceived Stress Scale. The aggravating and relieving factors of stress were also recorded and analyzed. Results: A total of 346 responses were analyzed from across various medical schools of country. The mean cumulative stress score among participants was 18.2 ± 6.8 indicating moderate stress with 34 (9.8%) respondents reporting high stress scores. Female gender was identified as a risk factor (OR 2.76, 95% CI: 1.58, 4.78; P < 0.001). Stress scores were higher among those not directly involved in COVID-19 care (OR 1.08, 95% CI: 0.57, 2.05; P = 0.47). Education and health of the family were major concerns recorded in 39% and 38% participants, respectively. The main stress aggravating factors were found to be news/media (39%) and unsafe work environment (16%). Among the stress relieving factors, hobbies (31%), family support (25%), and meditation (23%) were common. Conclusions: A moderate to high stress was reported in medical students and doctors. Educational concerns should be equally addressed as health care delivery and personal safety.
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Public Sector Resident Doctors’ Knowledge and Practices Amidst COVID-19: A Cross-Sectional Analysis p. 21
Saket Prakash, Raj Kumar, Sonam Patel, Mohit Kumar Patralekh, Lalit Maini
Background and Purpose: COVID-19 was declared as a pandemic on March 11, 2020 by World Health Organization. Resident doctors, including interns, are the frontline of health care workers, have always been at risk of infectious diseases, and the spread of the novel severe acute respiratory syndrome (SARS)-CoV-2 virus. The purpose of this survey was to gather opinions about personal safety, general knowledge, preventive behaviors, attitude, risk perception on COVID-19, and institutional approach toward this pandemic. Methods: This cross-sectional, online survey-based study was conducted from April 18, 2020 to April 21, 2020 in India. Data was collected from health care professionals, mainly frontline doctors, that is, residents and interns. Questionnaire consisted of 41 questions, statistical analysis was done using SPSS software version 26 (IBM Corp). Chi-square test was used to investigate the level of association among variables at the significance level of P < 0.05. Results: About 332 doctors completed the survey. Most of the junior resident (academic), from category A, B, and C received training for donning and doffing, and we found they were aware of donning and doffing (P-value < 0.05). It was also found that N95 was the most common personal protective equipment (PPE) stock missing in the institution. Survey also revealed that most of the surgeons had stopped planned surgery (P-value < 0.05) and also there was a significant decrease in emergency surgery and consultations (P-value < 0.05). Conclusion: We have restricted access to essential PPE. Protecting health care workers had been a governmental health priority. Institutions and government should urgently implement policies to support health care workers in the time of the COVID-19 pandemic.
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A Cross-Sectional Study on Lung Function Status of Adults in Delhi p. 31
Suneela Garg, Bratati Banerjee, Gajendra Singh Meena, Nandini Sharma, Mongjam Meghachandra Singh
Introduction: Air pollution is a major determinant of several lung diseases. With air pollution being a cause of concern in Delhi, present study aimed to assess proportion of individuals with impairment of lung function and factors associated with it. Methodology: A community-based cross-sectional study was conducted among adult population of Delhi. Data were collected by interview of subjects, with spirometry done on all subjects using portable spirometer. Statistical Analysis: Categorical variables were presented as percentages and compared using chi‐square test. Logistic regression analysis was done for independent predictors of lung function impairment. Significance was considered at P ≤ 0.05. Results: Total 3019 individuals were screened and 34.35% had lung function impairment, majority having restrictive disorder. Univariate analysis showed impairment was slightly higher in women, though not significant. Significantly more proportion of subjects with impairment were in higher age group, with lower levels of education, in working population and in those living in Delhi for longer duration. Students had lower risk of impairment when compared to those doing office job. Most of the findings were substantiated by multivariate analysis. Conclusion: Though spirometry is not an ideal screening test, this study does reflect that more than one-third of study subjects had impaired lung function, with those in higher age group having higher odds for lung function impairment, probably indicating the cumulative effect of air pollution. Measures for curbing air pollution are hence need of the hour and other broader determinants of health should be addressed through evidence-informed public policies and actions across all sectors.
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Enteric Transmitted Hepatitis Viruses in Delhi: Experience from a Tertiary Care Hospital p. 39
Sanchi Kashyap, Lavanya Pongiyannan, Shilpee Kumar
Objective: To estimate the seroprevalence of enteric transmitted hepatitis A virus (HAV) and hepatitis E virus (HEV) in patients presented with acute viral hepatitis in a tertiary care hospital, Delhi. Methods: It was a retrospective study from February 2019 to December 2020 conducted in a tertiary care hospital, Delhi. Serum samples from clinically suspected hepatitis patients sent for HAV and HEV testing were included in the study. The samples were tested for HAV and HEV Immunoglobulin (Ig)M antibody by enzyme-linked immunosorbent assay. Data collected in Excel sheet were analyzed using SPSS software version 21. Chi-square and Fischer exact test were used wherever necessary. Results: Viral etiology (HAV or HEV) was found in 122 (18%) patients. IgM HAV was detected in 75 (11%) patients whereas IgM HEV in 47 (7%) patients. The coinfection of HAV and HEV was not observed. HAV infection was significantly more common in pediatric age group 32.8% (59/180; P < 0.001) whereas HEV was significantly more common in adolescent and adult age group 8.6% (42/491; P < 0.001). Conclusions: Periodic surveillance of enteric transmitted viruses causing hepatitis needs to be conducted at hospital as well as community level to ascertain the true burden of the disease and changing epidemiology.
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Utility of Bone Marrow Examination in the Diagnosis of Splenomegaly: Experience from a Tertiary Care Center p. 43
Vijay Kumar, Preeti Singh, Sunayana Misra, Sadhna Marwah, Garima Baweja
Introduction: Establishing the diagnosis of splenomegaly is a clinical and pathological conundrum. The present study aimed to evaluate the clinicohematological findings and the significance of bone marrow examination in establishing the etiology of splenomegaly. Materials and Methods: This study was a retrospective analysis of patients with splenomegaly who had indications for bone marrow examination. The study was conducted over a period of 2 years. Detailed hematological and serological investigations were analyzed in those patients. Results: There were 96 males and 60 females. Most of the patients presented with fever. A mild degree of splenomegaly was found in 56.4% of the patients, followed by moderate (39.7%), and massive (3.9%) degree of splenomegaly. Pancytopenia was noted in 15.4% of the patients. Anemia was observed in 96.2% of the cases. Erythroid hyperplasia was the most common bone marrow finding (37.2%). Etiologies of splenomegaly were documented by the clinico-laboratory evaluation in 45.5% of the patients. Bone marrow examination along with peripheral blood examination alone established etiologies in 15.4% of the patients. Conclusion: Anemia and hematological malignancies formed a major part of the etiologies of splenomegaly. Bone marrow examination was an inevitable investigation in these situations. Serological investigations were useful in the diagnosis of nutrition deficiency anemia and infectious etiology. The grade of splenomegaly assessed clinically at the time of presentation provided an important clue for the etiology. Bone marrow examination proved to be an important diagnostic tool in the workup of patients with splenomegaly.
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Comparison of Dinoprostone Controlled Release Vaginal Pessary with Dinoprostone Intracervical Gel for Preinduction Cervical Ripening and Induction of Labor at Term p. 52
Anjali Tempe, Sonia Sindher, Niharika Dhiman, Devender Kumar, Pushpa Mishra
Context: There is limited experience of use of dinoprostone controlled release vaginal pessary in Indian scenario. Hence, we aim to find its efficacy for induction of labor (IOL). Aims: To compare two formulations of dinoprostone: intracervical gel and controlled release vaginal pessary for IOL. Settings and Design: Randomized controlled study in a tertiary care center. Methods: A double-blinded randomized controlled study was done on 106 women with singleton pregnancy, 37 to 41 weeks with vertex presentation, no obvious fetal compromise, and planned for IOL. They were randomly divided into equal groups to receive either dinoprostone intracervical gel (Group A) or dinoprostone controlled release vaginal pessary (Group B). The main outcome measures: change in Bishop score (using simplified Bishop score) at 0 to 6 hours and 6 to 12 hours after application and success to initiate active labor. The secondary outcome measures: maternal adverse effect, induction to delivery time, requirement of oxytocin infusion, cesarean section rate, APGAR score, and neonatal intensive care unit admission. Statistical Analysis: Statistical Package for Social Sciences (SPSS) version 17.0. Results: Increase in Bishop score and women achieving active labor were more in Group B (90.6% vs. 41.5%; P < 0.01). Mean time from induction to delivery was higher in Group A (19.72 hours vs. 12.53 hours; P < 0.01). Requirement of oxytocin was lesser in Group B (35.8% vs. 75.5%; P < 0.001). No adverse maternal or fetal outcome was noted in either of the groups. Conclusions: Dinoprostone controlled release vaginal pessary has significantly better outcomes than intracervical gel for IOL.
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Comparison of Ketamine, Lignocaine, and Fentanyl on Dose Requirement of Propofol in Patients Undergoing ERCP: A Randomized Controlled Trial p. 58
Preeti Dhahiya, Neha Garg, Mahesh Arora, Deepak Tempe
Introduction: Propofol is the most common drug used for providing sedation due to its short duration of action and early recovery. However, it may be associated with hypotension, desaturations, and bradycardia and does not provide analgesia, due to which various adjuncts are used along with it. Lignocaine decreases the doses of propofol and inhalational agent when used for visceral surgeries. Thus, we conducted a study to compare the dose of propofol along with lignocaine, ketamine, and fentanyl for sedation in endoscopic retrograde cholangiopancreatography (ERCP) procedure. Methods: A total of 105 patients were randomized into three groups. Sedation was provided by intravenous bolus injection of propofol 1 mg/kg in all patients followed by infusion of 0.5 mg/kg/hour. In group K bolus dose of intravenous ketamine was 0.5 mg/kg followed by infusion of 0.3 mg/kg/hour, in group L patients were given intravenous bolus of lignocaine 1.5 mg/kg followed by a infusion of 2 mg/kg/hour, in group F the matched volume of saline and 1 μ/kg fentanyl were administered. Intermittent boluses of propofol were given in all three groups in response to patients’ discomfort evidenced by grimaces, movement, or increase in heart rate or mean arterial pressure by >20% of baseline. The total dose of propofol consumed in the three groups was noted. Results: The total dose of propofol consumed and post-procedure abdominal pain was significantly higher in the fentanyl group but was comparable in lignocaine and ketamine groups. Conclusion: Lignocaine and ketamine were equally effective in deceasing propofol requirement and in preventing post-ERCP abdominal pain.
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Early Functional Outcome of Osteoporotic Intertrochantric Fractures in Elderly Managed with Proximal Femoral Nail and Proximal Femoral Nail Antirotation: A Comparative Study p. 63
Ankit Mittal, Simrat P.S Gill, Dinesh Kumar, Jasveer Singh, Harish Kumar, Ajay Rajput
Introduction: The choice of an implant in the management of intertrochanteric fractures of the femur has evolved from extramedullary devices to intramedullary ones. The proximal femoral nail antirotation (PFNA) that employs a helical blade is a recent and promising advancement but there is a paucity of data in the literature to prove its superiority over its predecessor nails in terms of functional gains. Aim: To compare the functional outcome of PFNA with proximal femoral nail (PFN). Materials and Methods: In this prospective randomized control study in osteoporotic elderly patients, 32 patients managed with PFNA were compared with a similar number treated with PFN and compared in terms of demography, intraoperative variables (duration of surgery, fluoroscopy time, and blood loss), time to union, and functional outcome utilizing Harris hip scores (HHS) at 6 and 12 months follow-up. Results: Both the groups were comparable in terms of age, gender, type of fracture, and Singh’s osteoporosis index. Although the duration of surgery and fluoroscopy time was significantly less in the PFNA group, it did not translate into any functional gains to the patients as the time to union and the HHS, at 6 and 12 months did not reveal any significant difference. Implant-related complications were significantly more in the PFN group with five patients having varus collapse, one having screw cut-out, two having screw pull-out, and one having Z-effect. Conclusion: Although there was no significant difference in terms of functional aspect, with lesser implant-related complication and shorter operative time, PFNA can prove to be a better substitute for the management of these fractures in osteoporotic elderly debilitated patients.
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Is There A Need to Supplement Transfusion-Dependent Thalassemics with Vitamin B12? p. 72
Anu Sharma, Shilpa K. Arora, Alok Hemal, Vijay Kumar
Purpose: The aim of this study was to compare the levels of serum vitamin B12 of transfusion-dependent thalassemic (TDT) children with that of healthy controls. The other objectives were to compare the occurrence of vitamin B12 deficiency in cases and controls and to find out any correlation between serum vitamin B12 of cases with their clinical, hematological, and laboratory parameters. This study was proposed as routine supplementation with folic acid is advised in TDT, but there are no guidelines for screening and supplementation of vitamin B12 for these patients. Methods: Thirty TDT children under 18 years and an equal number of age- and sex-matched controls were evaluated. Results: The mean levels of vitamin B12 in TDT group (260.17 ± 86.26 pg/mL) were lower than that of controls (337 ± 213 pg/mL) (P = 0.57). Correlation analysis of serum vitamin B12 levels with several parameters did not reveal any significant result. Conclusions: Similar large-scale multicentric studies are warranted before formulating guidelines for vitamin B12 screening and supplementation in thalassemics. Till then it may be prudent that TDT must be regularly screened for deficiency if the resources permit or else they must be routinely supplemented.
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High-Resolution 3-Tesla MRI in the Evaluation of Ankle and Hindfoot Pain: A Pictorial Review p. 77
Elvis Raja Kachari, Sapna Singh, Surabhi Gupta, Jyoti Kumar
Ankle joint is affected by a large gamut of pathologies ranging from traumatic to nontraumatic in origin. Although ankle radiographs continue to serve as the initial investigation of choice, magnetic resonance imaging (MRI), owing to its superior soft tissue resolution and noninvasive nature is the most important investigative tool to evaluate ankle and hindfoot pain. MRI allows excellent assessment of soft tissue structures like ligaments, tendons, fascia, neurovascular bundle, and cartilage. MRI can also be used in detection of osseous injuries like bone contusions, stress and insufficiency fractures, osteonecrosis, osteochondral defects, and transient bone marrow edema. In this pictorial essay, we aim to study the normal anatomy of ankle joint as well as demonstrate a spectrum of common pathologies affecting the ankle joint with their salient imaging features on MRI.
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Acute Intermittent Porphyria (AIP): A Difficult Diagnosis p. 86
Shailata Prisi, Parama Banerjee, Tarun Kumar Mishra
Acute intermittent porphyria (AIP) is a rare autosomal dominant disorder of heme biosynthesis but usually carry a good prognosis, if the condition is picked up early. Nonspecific nature of symptoms make it difficult to diagnose as a cause of acute neurovisceral attacks; thus demands high level of suspicion and early screening with necessary investigation to rule in the diagnosis. Here, we present a case of acute abdominal pain accompanied by weakness which rapidly progressed to seizure and quadriplegia and was associated with altered mental status. With the history of gastrointestinal symptoms correlating with presenting complaints was earlier misdiagnosed as Guillain–Barre syndrome. Later, MRI brain was suggestive of posterior reversible encephalopathy syndrome. On further evaluation, darkening of urine was observed leading to suspicion of AIP. Ehrlich test and Watson–Schwartz test was done which helped in coming to the right diagnosis and hence appropriate management.
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An innovative fixation technique for pediatric bi-epicondylar avulsion fracture of humerus p. 90
Manish Kumar, Ajeet Kumar, Lokesh Goyal, Sumit Arora, V. K Gautam
Bi-epicondylar avulsion fracture of the distal humerus is a rare injury and poses challenges for treating orthopaedic surgeons. We present a case of 11-year-old boy who presented with bi-epicondylar avulsion fractures of the distal humerus that was managed with innovative ‘synergistic tension band analogue technique’ and resulted in good clinical outcome.
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Ensuring Effective Clinical Supervision of Medical Students and Residents During Their Training Period p. 95
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
In order to accomplish the vision to produce a competent medical graduate, a number of strategies have been proposed. In that regard, effective clinical supervision of the teachers is an exclusive requirement, which plays an important role in the learning and the professional growth of the students. In broad terms, the act of clinical supervision helps to ensure patient safety, educate the student, sustain the set standards of quality of care, identify the problems encountered by the student, support them to accomplish learning outcomes, and by doing all this monitor the learning progression. In conclusion, clinical supervision of students and residents during medical training is an effective approach to ensure attainment of the learning outcomes. However, clinical supervision has been more often than not ignored, and thus there is an indispensable need to establish a supervision framework in each of the medical colleges for the benefit of the students and the society at large.
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A case of COVID-19 with pulmonary sequelae p. 97
Baljeet Singh Virk, Nitesh Gupta, Nipun Malhotra, Pranav Ish
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