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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 11 | Issue 3
Page Nos. 115-172

Online since Monday, September 14, 2020

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EDITORIAL  

Drug-resistant epilepsy: A challenge, but ought to be overcome! p. 115
Jasmine Parihar, Kirat Grewal
DOI:10.4103/0976-2884.294951  
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REVIEW ARTICLES Top

COVID diagnostics: Do we have sufficient armamentarium for the present and the unforeseen? p. 117
Bineeta Kashyap, Nisha Goyal, Anupam Prakash
DOI:10.4103/INJMS.INJMS_92_20  
The COVID-19 pandemic has taken the world by storm, and nations world over are battling this unprecedented health crisis. Diagnostics play the most important part in the “test, track, and treat” strategy being used in most of the nations to combat COVID-19. Although viral culture is the gold standard, it is not pursued because of the associated biohazard risks. Short of that, nucleic acid amplification tests (NAATs) are the present gold standard and are being used in several ways. Real-time reverse transcriptase-polymerase chain reaction is being widely used, although cartridge-based NAAT and TrueNat™ testing are also in vogue. Serological testing is also being used as an adjunct specially for screening (rapid antigen testing kits), while antibody (specially IgG) testing is being used as a serosurveillance strategy. Radiological investigations, especially computed tomography scan of the thorax, give peculiar peripheral ground-glass opacities which are quite characteristic in the present COVID pandemic and need to be ascertained together with other clinical features and diagnostic tools. Although the present tools have been able to support the diagnosis of COVID to quite an extent, there are limitations, and as the whole spectrum of COVID disease unfolds, the diagnostic armamentarium will also continue to expand, and we will need to use the diagnostic strategies further to be able to contain this pandemic at the earliest.
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Advances in pharmacovigilance in India: Role of mobile application p. 124
Rajpushpa Labh, Sachin Gupta, Rachna Gupta
DOI:10.4103/INJMS.INJMS_10_20  
India is the fourth largest manufacturer and the second largest consumer of pharmaceuticals in the world. Hospitalizations due to adverse drug reactions (ADRs) lead to a considerable burden on the health-care system and economy of the country. Pharmacovigilance in India faces considerable hurdles due to overburdened hospitals, underreporting of ADRs, variations in reporting formats, etc. To augment ADR reporting, many countries are exploring the option of mobile- and web-based solutions. The National Coordination Centre for Pharmacovigilance Program of India, Indian Pharmacopoeia Commission has released a mobile application (app) called “ADR PvPI” to mitigate some of these issues and both standardize and enhance the reporting of ADRs. This is in line with global focus on patient-reported outcomes and real-world data in pharmacovigilance. However, this approach has many implementation challenges including lack of awareness about mobile app, the use of English language in app, low smartphone adoption among the elderly, and in rural areas.
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ORIGINAL ARTICLES Top

Etiological spectrum of drug-resistant epilepsy – A glimpse from North East India p. 127
Baiakmenlang Synmon, Shri Ram Sharma, Musharraf Hussain, Yasmeen Hyniewta
DOI:10.4103/INJMS.INJMS_78_20  
Introduction: Drug-resistant epilepsy (DRE) occurs in 20%–30% of all epilepsy patients. This group of patients is a clinical challenge and needs a multidisciplinary approach to achieve the etiological diagnosis and also guide their treatment protocol.Materials and Methods: A retrospective study was conducted at North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS) in the Northeastern region of India, where patients fulfilling the definition of DRE were followed up to establish an etiological diagnosis. Clinical and drug history was taken for these patients. Electroencephalogram and neuroimaging were done in all patients. An attempt to evaluate the various etiologies causing DRE was made.Results: Thirty-three patients were included in the study after the exclusion of pseudo-resistance. Seventeen males and 16 females were included with the age range of 2–57 years. The most common clinical semiology was focal seizure with dyscognitive features seen in 16 patients. The most common etiology documented was medial temporal lobe epilepsy seen in ten patients.Conclusion: DRE is a common entity seen in this part of the country where epilepsy surgery is still out of reach. Etiology needs to be established in these groups of patients as other modes of therapy can be offered which include surgical and other interventions other than optimal drug therapy.
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Evaluation of interleukin-6 and its association with the severity of disease in COVID-19 patients Highly accessed article p. 132
Sudhir Bhandari, Govind Rankawat, Ajeet Singh, Dileep Wadhwani, Bhoopendra Patel
DOI:10.4103/INJMS.INJMS_63_20  
Background: The present study was undertaken to determine the levels of interleukin-6 (IL-6) and evaluate its association with clinical presentation, severity, radiological imaging, management, and outcome in coronavirus disease (COVID-19) infection. Methods: The present study included 132 admitted COVID-19 patients, categorized into three groups. Group 1 had IL-6 within the normal reference range, Group 2 had IL-6 raised up to ten times the upper normal limit (UNL), and Group 3 had IL-6 level raised > ten times the UNL. The patient's data concerning medical history, clinical manifestations, laboratory findings, radiological imaging, management, and outcome were extracted from their medical records for subsequent evaluation, interpretation, and association among the groups. Results: COVID-19 patients with raised IL-6 levels exhibited frequent symptomatic presentations, severity, and critical illness, especially with extremely high IL-6 levels (P < 0.001). Radiological findings in terms of a digital chest radiograph and high-resolution computed tomography (CT) chest indicated severe lung involvement in patients with extremely high IL-6 levels (P < 0.05). The majority of patients with extremely raised IL-6 levels were associated with the classic COVID-19 CT images (P = 0.014). Patients with extremely raised IL-6 levels required intensive treatment as compared to normal IL-6 group in terms of tocilizumab therapy (P = 0.008), noninvasive ventilation (P < 0.001), and intensive care unit care (P = 0.009) associated with higher mortality (P = 0.046). Conclusion: Raised IL-6 levels in COVID-19 patients should be considered a risk factor for the severity of the disease, inflammatory storm, and rapid pulmonary invasion. There is an urgent need for establishing a treatment protocol in patients with extremely raised IL-6 levels.
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Comparison of efficacy, safety, and humanistic outcomes of iron-chelation therapy in pediatrics suffering from transfusion-dependent β-thalassemia major p. 137
Narayana Goruntla, P Stephen Azarya, Mahitha Chalagundla, Dasaratha Ramaiah Jinka, Pradeepkumar Bhupalam, Vishnuvandana Bandaru
DOI:10.4103/INJMS.INJMS_23_20  
Introduction: Beta-thalassemia major (β-TM) is a severe form of genetic disorder that affects the patient's quality of life. Iron-chelation therapy (ICT) is recommended in these patients to reduce the complications (iron overload) associated with repeated blood transfusion. Objective: The present study aims to compare the efficacy, safety, and Pediatric Quality of Life (PedsQL) of the single and combinational ICT regimens in β-TM. Materials and Methods: This prospective, comparative study was conducted in the outpatient department of a daycare pediatric hospital located in South India. Patients diagnosed with β-TM, ages between 2 and 12 years, under ICT regimens were recruited. A suitable data collection form and PedsQL questionnaire was used to obtain demographics, blood transfusion, serum ferritin, hematological, biochemical, and PedsQL data of the study participants. One-way ANOVA and Chi-square test were used to compare the safety, efficacy, and PedsQL. Results: A total of 97 participants who met the study criteria were enrolled in the study and divided into three groups: Group I (n = 45) Deferasirox alone, Group II (n = 28) Deferasirox + Deferiprone, and Group III (n = 24) deferasirox + deferoxamine. The mean difference of ferritin concentration in Group III (695.3 ± 1252.4) was high compared to Group I (91.31 ± 702.6) and Group II (392.5 ± 1083.5) regimens with a P = 0.0053. In Group III, a significant reduction in physical and school functioning was observed. Conclusion: Oral Deferasirox combined with subcutaneous deferoxamine shows a great significant reduction in ferritin levels, but this combination is associated with a significant rise in hepatic enzymes, and poor physical and school functioning. An oral Deferasirox combined with oral Deferiprone is a safe and effective regimen in the treatment of β-TM, without affecting any domain of the Health-Related Quality of Life.
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The relationship of clinical and laboratory factors with acute isolated vertigo and cerebellar infarction p. 143
Cihan Bedel, Mustafa Korkut
DOI:10.4103/INJMS.INJMS_14_20  
Introduction: The aim of the study was to investigate the relationship between acute cerebrovascular infarction and risk factors in the patients presented to the emergency department (ED) with isolated vertigo symptoms. Materials and Methods: Ninety patients presented with isolated acute vertigo attack and/or dizziness symptoms were retrospectively analyzed. The criteria for inclusion in the study were patients with ≥18 years of age and patients with acute vertigo and/or dizziness and ischemic infarction on diffusion-weighted magnetic resonance imaging or computed tomography. The exclusion criteria were patients with peripheral vertigo, dizziness associated with a systemic disease, and incomplete data. The patients were categorized into two groups as cerebellar and noncerebellar according to the infarct localization. Results: The mean age of the patients was 60.31 ± 15.18 years and 43 patients were male. Of the patients, 34 (37.8) had cerebellar infarction and 56 (62.2) had noncerebellar infarction. There was no statistically significant difference between the two groups except for hyperlipidemia (67.6% in the cerebellar group, 35.7% in the noncerebellar group; P = 0.005). The multivariate logistic regression analysis revealed that hyperlipidemia (odds ratio [OR] = 3.233; 95% confidence interval [CI] = 1.144–9.136; P = 0.027) and imbalance (OR = 4.064; 95% CI = 1.271–12.995; P = 0.018) were the strongest indicators of cerebellar infarction in the patients with isolated vertigo. Conclusion: While the presence of accompanying nausea and vomiting in the ED is indicative of noncerebellar infarction, the risk factors of hyperglycemia and/or hyperlipidemia are strong indicators for the diagnosis of acute cerebellar infarction in isolated vertigo patients.
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Daytime sleepiness and sleep quality among undergraduate medical students in Dammam, Saudi Arabia p. 148
Mubashir Zafar, Eltigani O M Omer, Mohamed Elfatih, Khalid Ansari, Abdul Kareem, Ali fawaz, Reem Fares, Wadha Saad
DOI:10.4103/INJMS.INJMS_54_20  
Introduction: Daytime sleepiness and poor sleep quality are common among medical students. The objective of the study is to determine the prevalence of daytime sleepiness and sleep quality and the associated risk factors among medical students in medical college of Dammam, Saudi Arabia. Materials and Methods: It was a cross-sectional study and 149 medical students were selected through stratified random sampling techniques. The Pittsburgh Sleep Quality Index was used to assess the sleep pattern and Epworth Sleepiness Scale was used to measure daytime sleepiness. Association of sleep quality and daytime sleepiness with its risk factors were determined through regression analysis. Results: Students suffering from severe disorder of sleep quality and daytime sleepiness were 30.9% and 34.9%, respectively. In the multivariate analysis after the adjustment of covariates, males (odd ratio [OR]: 1.43, confidence interval [CI]: 1.16–1.95) (P = 0.035) and students who smoke cigarettes (OR: 1.62, CI: 1.18–2.11) (P = 0.045) were at higher risk of having severe daytime sleepiness. First academic year students were more than five times (OR: 5.34, CI: 1.30–12.58) (P = 0.042) and students who had low academic score (grade point average) were more than three times (OR: 3.13, CI: 1.28–4.87) (P = 0.035) likely associated with severe sleep quality disorder. Conclusion: The majority of students had suffered from poor sleep quality and daytime sleepiness. Male gender, smoking, academic score, and academic years were the major predictors for poor sleep quality and daytime sleepiness. There is a need for awareness and counseling among students to reduce the sleep disorder burden.
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CASE REPORTS Top

Dual infection of the brain, varicella zoster and tuberculosis in an immunocompetent adult: A rare scenario p. 154
Harleen Kaur, Gaurav Kumar Mittal, John Jacob Mathew, Shilpa Sekhar
DOI:10.4103/INJMS.INJMS_24_20  
The spectrum of central nervous system diseases caused by mycobacterium tuberculosis (TB) and herpes virus is broad and overlapping, ranging from self-limiting meningitis to life-threatening encephalitis. In a country like India where TB is a common infection of the brain, antitubercular therapy finds itself as frontline empirical therapy in appropriate clinical scenarios. In this case report, we describe a challenging case of a middle-aged immunocompetent male whose cerebrospinal fluid came positive for herpes zoster which aided us in diagnosing viral meningoencephalitis. However, later on, when the patient deteriorated in spite of 21 days of antiviral therapy, repeat brain imaging revealed another pathology, which was TB. We wish to highlight the fact that both these pathogens can mimic each other in clinical presentation and investigations can be misleading. One should always keep them as early differentials in appropriate clinical scenarios so as not to squander crucial time in treatment.
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Hypertriglyceridemia in a baby with thalassemia major p. 157
Saumya Pandey, Poonam Agrawal, Aditi Rawat, Mrinal Gupta, Pratima Khare
DOI:10.4103/INJMS.INJMS_150_19  
Thalassemia is the most common inherited hemoglobin disorder around the world. It is usually associated with normal serum lipid profile. However, there are a few reports in literature that hypertriglyceridemia has an association with beta-thalassemia major. We report a case of hypertriglyceridemia associated with beta-thalassemia major, in a 9-month-old female baby.
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Anterior ischemic optic neuropathy and branch retinal artery occlusion: An uncommon finding in thalassemia minor p. 161
Soukaina Belfaiza, Adil El Khouya Ali, Imane Jeddou, Taoufik Abdellaoui, Karim Reda, Abdelbar Oubaaz
DOI:10.4103/INJMS.INJMS_8_20  
The minor thalassemia has always been considered as an asymptomatic disease in the majority of cases. However, according to the literature, the poor chronic retinal perfusion related to a minor thalassemia can produce ocular manifestations as venous occlusion and ischemic retinopathy, especially in the presence of other risk factors. This short report describes a rare observation of a patient with an anterior ischemic optic neuropathy and branch retinal artery occlusion revealing a minor beta-thalassemia.
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Severe acute respiratory syndrome coronavirus-2 and tuberculosis coinfection: Double trouble p. 164
Abhijeet Singh, Ayush Gupta, Kamanasish Das
DOI:10.4103/INJMS.INJMS_72_20  
The ongoing pandemic of novel coronavirus disease 2019 (COVID-19) has received worldwide attention by becoming a major global health threat. We encountered one case with COVID-19 and tuberculosis (TB) coinfection, which has not been frequently reported. A 76-year-old female presented with acute respiratory symptoms superimposed on chronic symptoms, suggestive to have pneumonia. Oropharyngeal throat swab sample for COVID-19 was positive as detected by real-time reverse transcriptase–polymerase chain reaction assay. GeneXpert Ultra detected Mycobacterium tuberculosis complex with rifampicin resistance indeterminate. The patient was treated with appropriate management. Clinicians should suspect coinfection with TB during the ongoing pandemic of COVID-19 as therapeutic strategies need to be determined timely to improve outcomes and prevent transmission in the community.
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LETTERS TO THE EDITOR Top

Acute pulmonary embolism in COVID-19: Vigilance is the need of the hour p. 169
Arul J Mahendran, Nitesh Gupta, Sourabh Agstam, Pranav Ish
DOI:10.4103/INJMS.INJMS_83_20  
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Challenges in fungal treatment: A serious public health problem p. 171
Falah Hasan Obayes AL-Khikani
DOI:10.4103/INJMS.INJMS_32_20  
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