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   Table of Contents - Current issue
Coverpage
April-June 2020
Volume 11 | Issue 2
Page Nos. 59-114

Online since Friday, July 10, 2020

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REVIEW ARTICLES  

Global trends of clinical presentation of COVID-19 p. 59
Ragini Sharma, Mradul K Daga, Govind Mawari, Vijay Kumar Karra, Naresh Kumar, Manish Kumar Jha, Suresh Kumar
DOI:10.4103/INJMS.INJMS_25_20  
Emerging and reemerging diseases pose global challenges for public health. Pneumonia of unknown origin, given the name COVID-19, began in China in December 2019. On March 11, 2020, the WHO declared it to be a pandemic. Currently, the disease is booming rapidly and impacting the well-being of people and the economy of countries globally. Observational studies have somewhat highlighted clinical findings of the disease, but there are still no decisive data about its global trends. The purpose of this review is to bring to light the huge disparities in the clinical presentation of the disease among countries. The data for this review were obtained from studies pertaining to clinical, laboratory, and imaging features obtained from various journals. It was found that occurrence of the most frequently seen features ranged as – fever (98%–35%), cough (88%–25%), dyspnea (88%–4.8%), and sore throat (61%–8%). A definite reason for this is still obscure. This calls for more conclusive studies to investigate the possible causes of these trends. This might go a long way in increasing our understanding of the disease and improve its diagnosis and treatment.
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COVID 19 and immune phenomenon in children p. 65
Anu Maheshwari, Kaveri Pandit, Virendra Kumar, Deonath Mahto
DOI:10.4103/INJMS.INJMS_59_20  
The novel coronavirus, named as severe acute respiratory syndrome (SARS)-CoV-2 has emerged as a global emergency. In December 2019, from a local outbreak in Wuhan, China, it has rapidly progressed to a global pandemic causing high morbidity and mortality exhausting all health-care facilities. COVID-19 is like any other respiratory virus but has more propensity to infect the lower parts of the respiratory system, namely bronchioles and alveoli. The innate and adaptive immune response helps the body to fight the virus. Atypical presentations such as Kawasaki disease, chilblain like lesions and other cutaneous manifestations, systemic inflammatory response syndrome-like illness (Toxic shock syndrome), Guillain–Barre syndrome, and other immune-related disorders have also been reported in various countries. Rapidly increasing cases worldwide have aroused global concerns regarding the need to understand the immunopathogenesis of the virus and possible explanations for various atypical manifestations occurring in children. This review is aimed at providing a complete understanding of the probable immune response in children and might predict future therapeutic target points.
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ORIGINAL ARTICLES Top

Evaluation of clinico–Radiological profile and correlation with ultrasonography of the chest in coronavirus disease 2019 pneumonia p. 70
Sudhir Bhandari, Ajeet Singh, Meenu Bagarhatta, Govind Rankawat, Amitabh Dube, Shivankan Kakkar, Amit Tak
DOI:10.4103/INJMS.INJMS_55_20  
Background: The present study was undertaken to investigate imaging features of emerging coronavirus disease 2019 (COVID-19) pneumonia by chest ultrasound point-of-care ultrasonography (POCUS) and digital radiographs (chest radiograph [CXR]) and their correlation with clinical manifestation and severity of the disease. Methods: The present ongoing single-center study assessed patients admitted from April 20 to May 15, 2020, with laboratory-confirmed COVID-19 pneumonia at SMS Medical College Hospital, Jaipur, India. The clinical features, laboratory investigations, CXR, and POCUS findings were evaluated and compared. Results: Fifty-two patients with a manifestation of COVID-19 pneumonia were studied. Most of the patients were in the fifth and sixth decade of age group with a mean age of 56.57 years. There was an overall male preponderance (80% men and only 20% women). All pneumonitis patients were symptomatic with fever (88.46%), cough (82.69%), and dyspnea (55.77%) being the major symptoms. Thirty-four patients had underlying comorbid conditions. The digital radiograph-chest findings of 55.77% patients exhibited classic COVID-19 pneumonia findings. The ultrasonography of the chest findings revealed pleural and lungs changes in 94% of patients with COVID-19-positive pneumonia. CURB-65 score for the severity of pneumonia had a positive correlation with POCUS severity score and CXR visual score with P = 0.0013 and 0.0018, respectively. The duration of some major symptoms for COVID-19 pneumonia also had a positive correlation with the POCUS severity score and CXR visual score. Conclusion: The spectrum of COVID-19 pneumonia has a predilection for advancing age and male gender. Although both POCUS and CXR are important tools to detect severity of pneumonia, POCUS has higher sensitivity as compared to that of CXR to detect characteristics of COVID-19 pneumonia, especially interstitial involvement or acute respiratory distress syndrome.
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Ultrasonographic prediction of difficult laryngoscopy in obese patients p. 76
Amit Sharma, Swaran Bhalla
DOI:10.4103/INJMS.INJMS_128_19  
Introduction: Anticipation of difficulties in airway management is of prime importance in avoiding potential catastrophies. Obese patients form part of a population that is believed to have difficult airway. Ultrasound imaging has recently come forth as a simple, portable, noninvasive adjunct for bedside assessment. We hypothesized that there is an association between ultrasonographic measurements of the anterior neck soft-tissue thickness at level of vocal cords (VCs) and hyoid bone (HB) in predicting difficult laryngoscopy in the obese patients and evaluated the feasibility of ultrasound in predicting difficult laryngoscopy in Indian population. Materials and Methods: A total of 70 obese patients with body mass index >30 kg/m2 and American Society of Anesthesiologists Grade I and II undergoing elective surgeries and receiving general anesthesia were enrolled in the study. Ultrasound quantification of the anterior neck soft tissue was performed using a high-frequency (13–6 MHz) linear transducer. The distance from the skin to the anterior aspect of the trachea was measured at two levels: VCs and HB. Results: The incidence of difficult laryngoscopy (III and IV) in our study population was 24.3% (17 of 70 cases). The sonographic measurements of the skin thickness of the anterior neck were greater at the level of VCs in the difficult laryngoscopy group at 13.5 ± 1.5 mm as compared to the easy laryngoscopy group at 10.2 ± 1.6 mm, with the difference being statistically significant, P < 0.001. The soft-tissue thickness at the level of HB was also greater in the difficult laryngoscopy group in contrast to the easy laryngoscopy group (16.4 ± 1.9 mm vs. 12.4 ± 2.0 mm; P < 0.001). Conclusions: Ultrasonographically measured skin thickness at the level of HB and VCs has got a good correlation with difficult intubation.
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Prediscussion and Postdiscussion Assessment Scores in a Self-directed learning module implemented in the department of biochemistry: A comparative study p. 81
Poonam Agrawal, Niket Verma
DOI:10.4103/INJMS.INJMS_153_19  
Background: Self-directed learning (SDL) is an important tool for transforming medical students into lifelong learners so that they are competent to identify their learning needs, allocate resources, and evaluate the learning process throughout their career. Recently, the Medical Council of India has introduced SDL as an essential component of the competency-based medical education curriculum and has allocated fixed hours for SDL in all undergraduate MBBS students. Regarding the role of facilitators in SDL program, there are controversial reports and there are even studies which have shown that the role of a facilitator is not important. Aim: The proposed study aimed to assess students' performance before and after discussion in an SDL module in small-group teaching–learning method and compare the performance scores. Methodology: A total of 117 students responded and were included in the study. Batch A had 59 students and Batch B had 58 students. The topic selected for the SDL module was “Heme degradation and Jaundice.” The module was conducted over two contact sessions, Session 1 and Session 2, which were conducted 5 days apart. The prediscussion and postdiscussion assessment questionnaire was also prepared. Session 1 was conducted during a 1-h SDL slot. A gap of 4 days was given to students for doing self-study and to learn the topic. The prediscussion questionnaire consisting of five multiple-choice questions related to the topic was shared with the students a day before the second contact session. Session 2 was conducted during the 2-h tutorial slot (over 2 consecutive days for two batches of the class, Batch A and Batch B, respectively). Fishbowl method of small-group teaching–learning was done followed by postdiscussion questionnaire. Results: The questionnaire was analyzed, and it was observed that the overall mean performance of students improved considerably (78.3%–87.7%) in the questions related to core concept (Q1, Q2, and Q3). Similarly, in the questions related to clinical aspects of the topic, the mean performance of students showed considerable improvement from prediscussion to postdiscussion assessment (86%–93.5%). Conclusion: We conclude that the SDL module should be meticulously planned keeping in mind the topic selected and the availability of infrastructure and workforce. Peer discussion is a very important aspect of the SDL module, and it shows improvement in learning outcomes in an SDL module.
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An audit of prescription forms of patients from obstetrics and gynecology clinics in tertiary care hospitals: An exploratory study p. 85
Nilanchali Singh, Neha Varun, Meghna Garg
DOI:10.4103/INJMS.INJMS_157_19  
Objective: The main aim is to analyze the prescription forms to evaluate the completeness of these forms, and we also aim to bring to light the factors which need to be emphasized on while writing a prescription. Materials and Methods: This is a prospective cross-sectional study. Prescriptions of 200 patients visiting the gynecology and antenatal outpatient department (OPD) were evaluated using a specially designed questionnaire containing specific questions pertaining about OPD prescriptions, and a score of 0, 1, or 2 was allotted to each question. Results: In an audit of 200 OPD prescription papers, complete name, age, date of consultation, sex, and OPD registration number of the client were present in 100% prescriptions as it was preprinted. Legible handwriting was seen in 93%. Essential medicines advised were available in the hospital dispensary in 77%. Dosage schedule/doses were clearly written in 85%. Prescription duly signed and the name is written (legibly)/stamped in 87%. The highest score for a prescription was found to be 17/17 and the lowest score for a prescription form was 8/13. Conclusion: Many areas are lagging in prescription writing, especially writing presumptive diagnosis and salient features of clinical examination. Physicians need to improve their prescription writing skills for the benefit of patients.
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Worldwide incidence and mortality of bladder cancer and human development index: An ecological study Highly accessed article p. 88
Elham Goodarzi, Malihe Sohrabivafa, Ali Hasanpour Dehkordi, Zaher Khazaei
DOI:10.4103/INJMS.INJMS_108_19  
Background and Objective: Bladder cancer (BC) is the most common cancer of the urinary and genital tract. Many factors, including environmental and socioeconomic factors, also affect the incidence and mortality of BC. The aim of this study was to evaluate the epidemiology of BC incidence and mortality worldwide based on the data extracted in 2018. Materials and Methods: The present study is a descriptive-analytic study that extracts the incidence and mortality rates of cancer from the World Bank in 2018. The incidence and mortality rates and BC distribution maps were drawn for world countries. To analyze data, correlation test and regression tests were used to evaluate the correlation between the incidence and mortality with the Human Development Index (HDI). The statistical analysis was carried out by Stata-14 and the significance level was estimated at the level of 0.05. Results: The results showed a positive and statistically significant correlation between the incidence (r = 0.587, P < 0.0001) and mortality (r = 0.271, P < 0.001) of BC with the HDI index. The results showed that there was a positive correlation between the incidence of BC with Gross national income per 1000 capita (GNI) (r = 0.405, P < 0.001), mean years of schooling (MYS) (r = 0.525, P < 0.001), life expectancy at birth (LEB) (r = 0.566, P < 0.001), and expected years of schooling (EYS) (r = 0.574, P < 0.001). In addition, there was a positive and statistically significant correlation between mortality rate with GNI/1000 capita (r = 0.186, P < 0.01), MYS (r = 0.227, P < 0.01), LEB (r = 0.305, P < 0.01), and EYS (r = 0.250, P < 0.01). Conclusion: Given that the incidence and mortality of BC in high-HDI countries is higher, more research in these countries is needed to identify the factors affecting the incidence of disease in these countries. We can perform prophylactic actions to prevent the incidence and mortality of this cancer by identifying the risk factors of the aforementioned disease.
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CASE REPORTS Top

Steroid-sparing effect of omalizumab in stage IV (corticosteroid dependent) allergic bronchopulmonary aspergillosis p. 98
PC Kathuria, Manisha Rai, Neelam Kathuria
DOI:10.4103/INJMS.INJMS_149_19  
Allergic bronchopulmonary aspergillosis (ABPA) consists of five stages ranging from the acute stage (pulmonary infiltrate, eosinophilia, and increased total Immunoglobulin-E [IgE]) to pulmonary fibrosis. Our patients were diagnosed as Stage IV (corticosteroid dependent) ABPA, in which treatment with systemic corticosteroids cannot be discontinued as symptoms worsen after discontinuation of oral corticosteroids. Omalizumab is a humanized recombinant, monoclonal antibody that selectively binds to IgE to inhibit the immune response to an allergen. It forms immune complexes which not only lower the level of free IgE antibody, but also serve as an allergen buffer, even in cases of markedly high serum IgE >1000 IU/ml in ABPA. In this article, we report three cases of (Stage IV) corticosteroid-dependent ABPA with poor clinical response even after effective treatment with antifungal therapy and courses of corticosteroids (>3 exacerbations/year). After the start of injection omalizumab, the three patients have experienced significant and sustained clinical improvement and improved quality of life with low-dose prednisolone 5 mg every alternate day. The dose of systemic corticosteroids was reduced by 50% in the 1st year and by 70% in the 2nd year although lung function failed to improve.
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Achromobacter xylosoxidans infection in a patient with acute leukemia: characteristics and options for antibiotic therapy for a rare highly virulent gram-negative bacterium p. 102
Suvir Singh, Deepinder Kaur
DOI:10.4103/INJMS.INJMS_37_20  
Gram-negative infections are a common cause of induction mortality in acute leukemia. Multidrug-resistant (MDR) Gram-negative bacilli are common culprits, contributing to over 40% of deaths in some centers in India. A 20-year-old male with B-cell acute lymphoblastic leukemia, after 5 days of initiation on steroids at another hospital, developed rapid onset dyspnea, with signs of bilateral pneumonia and Type 1 respiratory failure. High-resolution computed tomography of the thorax showed bilateral nodular opacities with ground glassing. Galactomannan was negative, and blood culture isolated MDR Achromobacter xylosoxidans. Antibiotic sensitivity by VITEK2 indicated sensitivity only to ciprofloxacin, levofloxacin, and minocycline. Antibiotics were tailored according to sensitivity, but he had a rapidly worsening downhill course with death from respiratory failure within 72 h. This is only the third case of this organism being described in a patient with malignancy from India. MDR organisms should be suspected whenever a patient with acute leukemia has a history of being in contact with another hospital. In such patients who present with signs of sepsis, it may be reasonable to consider a “de-escalation” approach, with addition of carbapenems upfront and stepping down once cultures are available.
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LETTERS TO THE EDITOR Top

Acute appendicitis in a patient with appendiceal duplication p. 105
Andrés Lorenzo Mestril, Fernando Karel Fonseca Sosa, Anival Ernesto Ramos Socarrás, Francisco Antonio Vargas La O
DOI:10.4103/INJMS.INJMS_12_20  
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Is it rheumatoid arthritis or something else? p. 107
Abhishek Juneja, Kuljeet S Anand, Irteqa Ali
DOI:10.4103/INJMS.INJMS_21_20  
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Owl's eye sign: A rare neuroimaging finding p. 109
Abhishek Juneja, Kuljeet Singh Anand, Arpit Agrawal
DOI:10.4103/INJMS.INJMS_16_20  
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Immunomodulatory effect of amphotericin B enhances antiviral activity p. 111
Falah Hasan Obayes AL-Khikani
DOI:10.4103/INJMS.INJMS_34_20  
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Systemic effects of SARS-CoV: A brief insight p. 113
Atin Singhai, Parul Jain
DOI:10.4103/INJMS.INJMS_18_20  
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