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   Table of Contents - Current issue
Coverpage
April-June 2021
Volume 12 | Issue 2
Page Nos. 51-111

Online since Friday, April 2, 2021

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EDITORIAL COMMENTARY  

Antecedents of positioning medical tourism in India Highly accessed article p. 51
Sheetal Kapoor
DOI:10.4103/injms.injms_10_21  
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REVIEW ARTICLE Top

Circadian rhythm of blood pressure: Implications for antihypertensive management Highly accessed article p. 53
Barun Kumar, Omna Chawla, Manasi Bhattacharjee, Anupam Singh
DOI:10.4103/injms.injms_4_21  
Circadian rhythms synchronize human physiological changes with the day and night cycle. However, with the invention of artificial lighting, the consequences of disrupted rhythm also started showing in various areas of human health including vital parameters such as blood pressure. It is one of the strictly regulated variables in the cardiovascular system and thus understanding its variability is significant. The normal circadian variation in blood pressure is characterized by a 10%–20% reduction in the night recordings and the individuals with this decrease in the night-time blood pressure are termed “dippers,” a blunted decline in night-time blood pressure is seen in “nondippers.” Evidence suggests a relatively increased risk of cardiac and extracardiac morbidity in individuals with nondipping blood pressure patterns. The purpose of this review was to summarize the literature regarding various factors contributing to circadian variations in blood pressure and explore the role of chronotherapy in hypertension. We found that there is conflicting evidence to suggest the role of night time administration of antihypertensive drugs, but the understanding of these mechanisms can be utilized for strategic management of hypertension and suggests that if drugs are aligned with the circadian rhythm then may be useful in not only controlling hypertension but also improving cardiovascular outcomes.
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ORIGINAL ARTICLES Top

Clinical and laboratory profile of COVID-19 patients admitted at a tertiary care center in New Delhi and assessment of factors predicting disease severity p. 59
Piyush Jain, Nitin Sinha, M K Hari Prasad, Vaibhav Padole
DOI:10.4103/injms.injms_158_20  
Background: This study was conducted in nonintensive care unit COVID-19 patients admitted in a tertiary care center, to assess the clinical profile and find surrogate markers to predict the severity of COVID-19 at the time of admission. Methodology: It is a cross-sectional observational study. Clinical and laboratory data were compiled of patients admitted in COVID wards in a tertiary care center. Patients were stratified clinically according to the severity of COVID pneumonia. The admission clinical and laboratory parameters were compared between the severe and nonsevere COVID patients. Results: The study included 63 patients of which 46 were males, with a mean age of 47 years. Patients were classified into mild (32%), moderate (19%), and severe (49%) categories according to national guidelines. Fever (81%), cough (67%), and dyspnea (67%) were the most commonly observed symptoms. In comparative analysis, mean C-reactive protein (CRP), serum ferritin, and neutrophil–lymphocyte ratio (NLR) were significantly higher in severe COVID-19 patients and the admission PaCO2 significantly lower compared to nonsevere patients. Conclusion: The study shows that raised NLR, CRP, serum ferritin, and low PaCO2 levels at the time of admission are important predictors of disease severity.
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Feasibility of direct observation and consumption method for hand hygiene compliance in an intensive care unit of a Tertiary Care Hospital p. 64
Bineeta Kashyap, Rajat Jhamb, Rituparna Saha, Pratima Prasad, NP Singh
DOI:10.4103/injms.injms_165_20  
Background: Emerging pandemics, rampant multidrug resistance, and diversity of healthcare-associated infections entail hand hygiene (HH) compliance, surveillance, and documentation as the cornerstone of infection control practices. Methods: HH adherence rates (HHARs) were determined by the WHO's “Direct Observation” technique and compared with the “Indirect Hand-Rub Consumption” method, in the main intensive care unit of a tertiary care hospital over a period of 15 days, encompassing 3000 HH opportunities. HHARs were also compared over the study duration and among doctors and nurses. Results: The overall HHAR estimated by direct observation as per the WHO criteria was 28.5% and by “indirect hand-rub consumption” method was 12.12%. Healthcare workers adhered maximally to the WHO HH moment 3 (64.6%) followed by 5 (31.6%), 4 (27%), and 2 (27%). Conclusion: The direct observation technique for monitoring HH, though conventionally deemed as the gold standard, mandates skilled personnel and devoted time which may deter daily surveillance in resource-limited settings. The time constraints in addition to the observation biases often confound or may even push HH surveillance to the backburners. The indirect “hand-rub consumption” technique, on the other hand, might prove to be an attractive alternative in resource-limited settings, which, in addition to providing an overall glimpse of existing HH culture, is also devoid of observation biases.
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Patterns of utilization of maternal and child health care among tribals of H D Kote Taluk Mysore p. 69
Kavita Yadav, MR Narayana Murthy, Manohar Prasad, Praveen Kulkarni
DOI:10.4103/injms.injms_139_20  
Background: Maternal and child health (MCH) care services utilization is an important issue in the tribal area. It is very important to understand the pattern of utilization so as enable the policymakers to take initiatives to make the service provision more acceptable to the tribal population of India. Methodology: A community-based study was conducted in the tribal area of H D Kote taluk Mysore. Of 16 Primary Health Centers, five centers which cover nearly 50% of the population were chosen for the study. All the mothers who resided in those areas and delivered during January 2013 to December 2013, were chosen for study, which came to 215. Those who had migrated to areas outside our study area and those who were not found in home during data collection home visit were left out. Hence, the final sample size came to be 165. Results: Majority of mothers (74.5%) had antenatal registration done in the first trimester. Nearly 36.4% of mothers had <3 antenatal check-up visits, 26.7% had 3–5 visits, and 32.7% of mothers had >5 visits. About 95.2% of mothers had received two Tetanus toxoid injections, 3% had one injection, and 1.8% had no injections. About 42.4% of mothers had consumed >100 iron and folic acid (IFA) tablets, 27.3% had 75–100 tablets, 13.3% had 50–75 tablets, and 14.5% had <50 tablets, whereas 2.4% did not consume the IFA tablets. Conclusion: MCH care services utilization in the chosen tribal area was found to be satisfactory. It is a good sign as this reflects on the success of the reach of the government programs aimed at improving the mother and child health conditions in the tribal population.
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Audit of drug wastage and its financial cost: A study in the orthopedic discipline p. 73
Veena Reshma Dísouza, Nikku Mathew Geevergese, Princy Louis Palatty, Naveen Joseph Mathai, Manjeshwar Shrinath Baliga
DOI:10.4103/injms.injms_150_20  
Background: Drug wastage is a major concern in healthcare and more so in an orthopedic setup where musculoskeletal ailments form a major proportion. The principal objective of this study was to ascertain the extent of drug wastage and its financial costs in orthopedics. Materials and Methods: This was a prospective pilot study and was conducted to ascertain the quantity of drug wastage in the orthopedic unit of a tertiary care hospital. The study was conducted in the outpatient facilities where the list of drugs prescribed and the wastage was recorded by telephoning the patients after a week of consultancy. The cost evaluation for the actual use and wastage was undertaken and audit was done to understand which drug generated the maximum wastage. Results: The highest drug wastage was observed in paracetamol (80%), diclofenac (38.36%) glucosamine + diacerein (53.33%), methylcobalamin + folic acid + alpha-lipoic acid (53.33%), methylcobalamin + folic acid (28.57%), and rabeprazole + domperidone (12.5%). Highest cost for wastage of drug was observed for diclofenac (INR434.1) and accounted for 44.72% of the drug cost. Conclusion: As far as the authors are aware, this is the first study addressing the financial impact of drug wastage in orthopedics. Attempts should be directed at minimizing wastage and at cost saving.
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Audit of infection and antimicrobial drug resistance pattern in bacterial infections in road traffic accident survivors p. 78
Nikku Mathew Geevarughese, Siddhant Suresh, Ramakrishna Jakribettu Pai, Jeffy Mary Mathew, Sucharita Suresh, Manjeshwar Shrinath Baliga
DOI:10.4103/injms.injms_169_20  
Background: In countries like India, road traffic accident (RTA) associated morbidity and mortality is rising in alarming rate and is major concern of public health. Around 80% of the late deaths in trauma patients are due to infection. This study was undertaken to study the profile of infection and drug resistance pattern of bacterial infection in RTA survivors. Materials and Methods: This was a retrospective study and was conducted at a tertiary care hospital with documented evidence of infection from the hospital records. The demographic details of the patient, details of injury and the pathogens causing infections with drug resistance patterns were studied. Results: A total of 163 patients were accrued and the majority of the patients were male (140, 85%) and around 66% belonged to the working age group, i e., 20–50 years. Most of the patient's were treated by orthopedics and surgery departments, 72% and 20%, respectively. The majority of the patients had wound infection followed by Urinary tract infection. Among the Gram-negative pathogens, Escherichia coli and Citrobacter species were the common pathogens; and among Gram-positive organisms, Enterococcus species and Staphylococcus aureus. Most of the pathogens were resistant to commonly used presurgical prophylactic antibiotics such as ampicillin, cefuroxime, and ciprofloxacin. Conclusion: The bacterial profile of the pathogens causing infection in RTA survivors may vary among different institutions. Therefore the antibiogram of these pathogens needs to be studied and analyzed by each medical facility attending to RTA survivors to formulate policy for presurgical antibiotic prophylaxis.
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Drug prescribing trends and safety profile in pediatric care: Observations from a tertiary care center p. 82
Farangipet Fathima, Princy Louis Palatty, Jayachandran Mamatha, Chennakeshava Thunga, Nizam Mithotti, Faizan Kalekhan, Manjeshwar Shrinath Baliga
DOI:10.4103/injms.injms_149_20  
Background: Globally, pharmacovigilance, rationality of drug prescription studies, and adverse drug reaction (ADR) in children affected with ailments are an understudied topic. Children are a vulnerable age group and reports suggest that over 10% of hospitalized have adverse reactions to therapy and up to 2.9% of all hospital admissions are the consequence of ADRs. In lieu of these observations, the present study was undertaken in a tertiary care hospital to ascertain the bad prescribing habits and ADR in children. Methodology: This was a prospective study and was carried out in the department of pediatrics at a tertiary care hospital for 6 months. The prescription orders of the children on medical treatment for various common ailments were analyzed. The drug prescribing pattern, safety profile of the drug/s alone and in combination was analyzed in accordance with the standard pharmacovigilance method. Results: In the study, a total number of 212 drugs were prescribed for 646 study participants. Most of the study participants were male child, and respiratory infection was the prevalent ailment affecting the children during the study period. With regard to the drug prescription, the average number of drugs per prescription was 3.96. Drugs prescribed by generic name were 6.9%, while 97.21% of the drugs prescribed were observed to be essential for the medical condition. Among the classes of drugs prescribed, antipyretics and antibiotics were the major classes of drugs administered in children admitted in inpatients facility, while among the outpatients (OPs), respiratory drugs and antipyretics were the most common prescribed drugs. Most importantly, polypharmacy was common in inpatients compared to OPs and also that 5.1% had some form of ADR. Conclusion: The present study showed rational prescribing pattern but poor standard pharmacovigilance technique.
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CASE REPORTS Top

Idiopathic polyclonal plasmacytosis presenting as fever of unknown origin p. 89
Vivek Pal Singh, Ashutosh Garg
DOI:10.4103/INJMS.INJMS_131_20  
An elderly male, after being flagged to have fever of unknown origin, was found to have plasmacytosis on bone marrow examination. On immunophenotyping, the proliferation was confirmed as polyclonal. No associated underlying condition such as infection or connective tissue disease was found. The importance of polyclonal plasmacytosis is discussed vis-a-vis the usual knee jerk reaction to diagnose multiple myeloma.
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Maxillary anterior implant placement with autogenous guided bone regeneration p. 92
Pratibha Chaudhary, Pravesh Mehra
DOI:10.4103/injms.injms_151_20  
Anterior implant placement is quite a challenge that clinicians face due to ridge deformity as it is an esthetic zone. This case report presents an innovative approach of using autogenous bone graft (ABG) to correct an atrophic ridge in conjunction with implant placement. A 23-year-old male patient lost a maxillary central incisor tooth due to trauma followed by abscess formation. Due to severe and active infection, ridge augmentation was not feasible at the time of tooth extraction, resulting in prominent loss of buccal plate. The guided bone regeneration was performed at the extracted site procuring graft from the parasymphysis region, followed by the implant placement. After 1 year of function, both clinical and radiographic examinations revealed promising and stable treatment outcomes. ABG from the parasymphysis region is a good option for ridge augmentation procedures. The only disadvantage is the second operating site.
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Cerebral infarction following bee sting p. 95
Krishnan Balagopal, Anand Muraleedharan, Ansa Grace Koshy, Jerin Peter Jacob
DOI:10.4103/injms.injms_156_20  
Although bee stings can cause local reactions, neurovascular complications are rare. The venom toxins of honeybee cause anaphylactic allergic reactions and both cerebral infarction and hemorrhage. Diverse pathophysiological mechanisms have been postulated for the occurrence of these strokes. A 50-year-old man developed a focal neurologic deficit 6 h after a bee sting, which was confirmed to be acute cerebral infarction on magnetic resonance imaging scan.
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Acute quadriparesis in dengue – A rare presentation of a common disease Highly accessed article p. 98
Swapan Nagpal, Amar Jeet Singh Nagpal
DOI:10.4103/injms.injms_174_20  
Dengue fever commonly presents with electrolyte abnormalities including hypokalemia. Hypokalemic quadriparesis is a very rare manifestation of this common arboviral infection. We report a case of acute reversible quadriparesis caused by hypokalemia in a patient with dengue. Such a presentation has been reported very few times. Various mechanisms have been proposed to explain hypokalemia in dengue, and it is still not completely known why some patients develop motor weakness and others do not. Most such cases have a very good prognosis and the weakness resolves on potassium supplementation.
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LETTERS TO THE EDITOR Top

Hemosuccus pancreaticus caused by a mucinous cystadenoma of the pancreas p. 100
Fernando Karel Fonseca Sosa, Anival E Ramos SocarrŠs, Pedro R Casado Mťndez, Yudier Montalban Olivera
DOI:10.4103/injms.injms_162_20  
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Bilateral middle cerebellar peduncle infarction p. 102
Abhishek Juneja, Kuljeet Singh Anand, Himank Goyal
DOI:10.4103/injms.injms_1_21  
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Fighting COVID-19 with vaccines – The perspectives of a medical student p. 103
Anuhya Dayal
DOI:10.4103/injms.injms_22_21  
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Relation between hematological derangements and disease outcomes in children with COVID-19 are likely indirect p. 106
Suvir Singh
DOI:10.4103/injms.injms_5_21  
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Hashimoto's encephalopathy presenting with cognitive impairment and vertical supranuclear gaze palsy p. 108
Abhishek Juneja, Kuljeet Singh Anand
DOI:10.4103/injms.injms_3_21  
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BOOK REVIEW Top

Till we win p. 110
Ramesh Aggarwal, Saloni Agarwal
DOI:10.4103/injms.injms_33_21  
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