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   Table of Contents - Current issue
July-September 2021
Volume 12 | Issue 3
Page Nos. 113-182

Online since Friday, July 30, 2021

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The future role of augmented reality and virtual reality simulation in clinical skills assessment Highly accessed article p. 113
Neha Bapatla, Lauren Fine, Vijay Rajput
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Dyslipidemia in children Highly accessed article p. 116
Arti Uniyal, Manish Narang
Dyslipidemia is a condition characterized by abnormal levels of one or more plasma lipids or lipoproteins. It is a major cause of cardiovascular diseases (CVDs) around the world. Pediatric dyslipidemias can lead to atherosclerosis and extrapolate to premature CVDs. Atherosclerotic lesions begin during childhood and act as the major risk factor for atherosclerotic CVD (ASCVD). Dyslipidemias can be caused by primary genetic disorders or by secondary causes, the most common of which is obesity. In order to diagnose and manage dyslipidemias early, it is important to know the screening guidelines, lifestyle changes, and treatment for childhood dyslipidemias. The appropriate identification and management of dyslipidemia in childhood can lead to decreased risk factors for future CVDs. One of the best ways to manage childhood dyslipidemias is through appropriate lifestyle changes where parents play a vital role, through healthy home environment. Pharmacological interventions include statins and fibrates that play a major role. This article reviews pediatric dyslipidemia and reemphasizes on the importance of lifestyle changes modeled by parents as well as appropriate selection of treatment by health-care providers. The aim of this review article is to draw attention toward the importance of screening, identification, and timely management of dyslipidemias in children which can prevent future risks and complications that may even be life threatening.
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Interplay between Periodontal Disease and diabetes mellitus Highly accessed article p. 122
Garima Asthana, Shivjot Chhina
Progress in the management of diabetes mellitus is turning attention toward comorbidities and conditions such as periodontal diseases. This article aims to present the evidence linking diabetes and periodontal disease. The potential effects of modifying factors of inflammatory origin on diabetic control are also discussed. Increased prevalence, extent, and severity of gingivitis and periodontitis are correlated with diabetes. Moreover, many plausible mechanisms have been exemplified to explain the effect of diabetes on the periodontium. While inflammation plays an important role in periodontal diseases, evidence in the medical literature also supports the role of inflammation as an important component in the pathogenesis of diabetes and its complications. Research suggests that periodontal disease has a large amount of inflammatory components that can negatively affect the metabolic control of diabetes. Conversely, treatment of periodontal disease and decrease in oral inflammation have a positive effect on the diabetic control. Diabetic patients who have periodontal disease have two chronic conditions - diabetes and periodontal disease, each of which can impact the other and require regular professional evaluations, patient education, and consistent educational reinforcement by healthcare providers both medical and dental.
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Prevalence of undernutrition among preschool children (3–6 years) attending anganwadi centers in urban Mysuru p. 127
Preetha Susan George, M R Narayana Murthy
Introduction: For balanced growth and childhood development, adequate nutrition is very necessary. The health and nutritional status of children is an indicator of the health and nutrition of the community and the nutritional profile of the entire country. Undernutrition is not only a significant cause of childhood morbidity and mortality, but it jeopardizes physical as well as mental development of children. The Public Distribution Scheme's bias toward calories and subsidies continued on rice and wheat and did not include more diverse and nutritious foods. Aims and Objectives: This study aims to determine the prevalence of undernutrition among preschool children (3–6 years) attending Anganwadi in Urban Mysuru. Materials and Methods: This community-based cross-sectional study was carried out in the field practice area of Bannimantap Urban Primary Health Centre for a period of 1 year. A total of 365 children (3–6 years) were included in the study. Required total sample size of 365 children in the age group of 3–6 years was selected from each Anganwadi as per population proportionate to size sampling technique. A pretested, semi-structured proforma was used to collect data pertaining to sociodemographic variables, maternal-related variables, and child-related variables. Data were coded and entered into MS Excel 2016 and analyzed using SPSS Version 22. Results: Among the total 365 children aged 3–6 years, 54.7% were males and 45.3% were females. Majority (60.8%) of the children hailed from nuclear family and 50% belonged to upper lower socioeconomic class. The prevalence of undernutrition which constitutes underweight, stunting, and wasting was 25.4%, 23.5%, and 10.2%, respectively. Prevalence of severe acute malnutrition was 0.3%. Conclusion: Lack of socioeconomic development along with ignorance of cost-effective nutritional diet intake contributed to undernutrition in our study area.
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Acute kidney injury in intensive care unit: A clinical and outcome study p. 132
Narinder Pal Singh, Danish Kathuria, Neeru P Aggarwal, Anish Kumar Gupta, Gurleen Kaur
Background: Acute kidney injury (AKI) has both short term as well as long-term consequences in critically ill patients. The present study is an attempt to study its etiological profile in intensive care units (ICUs) which has been only scarcely done in India. Methods: One hundred and twenty patients admitted with or developing AKI during their ICU stay were included in the prospective study and were defined as well as staged according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Patients were followed up at discharge and at 3 months to determine the outcome as either favorable (renal recovery) or adverse (residual renal dysfunction, dialysis dependence, or death). Various known risk factors, as laid down by KDIGO, were identified and analyzed with respect to their association with the outcome. Results: Out of total of 120 subjects, almost half of the subjects (47.5%) had Stage I AKI, 27.5% had Stage II AKI and the remaining quarter of subjects had Stage III AKI. One fourth had pre-existing chronic kidney disease and three-fourth subjects had developed de novo AKI of which more than half of patients had community-acquired AKI. Anemia and sepsis were the most prevalent risk factors. The highest rate of renal recovery was demonstrated in Stage I AKI. Overall mortality was 28%, highest in Stage III AKI. Conclusion: The study demonstrated increasing prevalence of the adverse outcome in a linear fashion with an increase in the severity of AKI. Sepsis was not only the most prevalent risk factor but was also strongly associated with an adverse outcome. The epidemiology of AKI in critical care in India has started to resemble high-income group countries, in terms of both age distribution as well as etiology.
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Altered oral intake during hematopoietic stem cell transplantation: Patterns and countermeasures p. 137
Suvir Singh, Kanwarpal Singh, Jagdeep Singh, Davinder Paul, Kunal Jain
Introduction: Hospitalization for stem cell transplantation leads to reduced oral intake, often requiring parenteral nutrition (PN). Preserving enteral nutrition sustains gut mucosa and microbiota and potentially reduces long-term complications. We provide a short report on patterns of altered dietary intake in stem cell transplant recipients and simple measures that can be taken to mitigate the same. Methods: Patients undergoing autologous and allogeneic stem cell transplantation over an 11 month period were included. Baseline calorie and protein intake was calculated according to the National Institute of Nutrition (India) guidelines. Steps to maintain oral intake included: patient education pretransplant, allowance of home food and packaged food (cookies/chocolates), shift to semisolid or liquid diet, and symptomatic local analgesia for all patients with mucositis. Results: A total of 16 patients were included in the analysis, (male:female = 10:6), with a median age of 43 years (range, 6–67). Median body mass index at baseline was 22.5 kg/m2 (range, 11.9–31.8 kg/m2). Median calorie intake at baseline was 26.8 kcal/kg/day (range, 18–51) and protein intake was 0.47 g/kg/day (range 0.19–0.87). During the course of treatment, maximum grade of mucositis was grade III in 9 and grade II in seven patients. The median caloric deficit from baseline at lowest intake was -79% (range, +11 to − 96%), with the nadir occurring by median day 6.5 (range,-1–12). At the time of discharge, the median oral intake was 70% of baseline (range, −1.2% to + 175%). Most patients had a median of − 4.3% (range, −15% to + 0.4%) of weight loss at discharge. No patient required PN during admission. One patient died as a result of regimen-related toxicity. Conclusions: Patients undergoing stem cell transplantation demonstrated significantly low oral intake at admission which further significantly reduced over the course of hospitalization. Pretransplant optimization of calorie intake, patient education, dietary modification, and in-hospital symptomatic control along with daily monitoring of calorie intake is essential so that reduction can be picked up early and corrective actions are taken.
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A study of prothrombotic factors in human immunodeficiency virus-infected patients p. 142
Meena Lanjiwar, Pushpa Kumari, Jitendra Mohan Khunger, Narender Singh Negi
Introduction: Human immunodeficiency virus (HIV) infection has been described as a hypercoagulable state. Some studies suggest that thrombotic events may be 2–10 times more prevalent in this group than in the general population. Subjects and Methods: This was a single-center, cross-sectional case–control study. Thirty confirmed HIV cases of age group 20–60 years were enrolled. A similar number of age- and sex-matched healthy volunteers were taken as controls. CD4 cell count, protein C, protein S, antithrombin III (AT III), anticardiolipin antibody, and highly sensitivity C-reactive protein (hs-CRP) estimation was done and correlated with the CD4 counts. Results: Among HIV cases, 40% were protein C deficient, while 10% were deficient in control group (P = 0.015). One-third (33%) were AT III deficient in HIV-infected group, while none were observed AT III deficient in control group (P < 0.001). Protein C and antithrombin levels did not correlate with CD4 count. Protein S levels were normal in all the HIV-infected cases. Anticardiolipin antibody was not detected in any patient among HIV group. Mean hs-CRP levels in cases and controls were 20.18 ± 12 mg/dl and 3.32 ± 5.13 mg/dl, respectively (P < 0.0005). Conclusion: Protein C deficiency and AT III deficiency were found to be significantly associated with HIV infection. The hs-CRP levels were significantly elevated in HIV-infected patients' protein C deficiency, increased level of hs-CRP, and AT III deficiency did not correlate with CD4 cell count.
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Clinico-radiological progression in COVID-19 patients: Study in a tertiary care hospital p. 147
Akash G Dholakia, Monila N Patel, Ruchir B Dave, Dharita S Shah, Shivam O Poddar, Parita K Trada
Background: Coronavirus disease 19 (COVID-19) caused by a severe acute respiratory syndrome coronavirus-2 belonging to the Coronaviridae family has caused a global pandemic. As it has emerged as a newer disease, there is a lack of information in many aspects of it. Materials and Methods: We tried to study the progression in the COVID-19 patients in terms of their clinical, laboratory, and X-rays as a radiological modality, for that, we did a single-centered retrospective observational study in 159 laboratory-confirmed COVID-19 positive patients with sample size being duration dependent. Results: We found statistically significant correlation between clinical parameters and lung involvement based on chest X-ray (CXR) scoring and also temporal variation as the disease progression occurs. Conclusion: Along with clinical and laboratory parameters, CXRs can be used as a useful bedside, inexpensive, and easily available radiological tool for assessment in resource-poor settings where high-resolution computed tomography scans are not feasible.
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Perceptions and beliefs on vaccination for COVID-19 in Delhi: A cross-sectional study p. 151
Abha Sharma, Anshuman Srivastava
Introduction: It is believed that despite all the measures taken to curb the contagion, a vaccine will be the most effective tool in preventing the spread and complications of coronavirus disease-2019 (COVID-19) and achieving a state of normalcy again. Scientists from worldwide have been successful in developing the vaccine against SARS-CoV-2, but COVID-19 vaccination faces several challenges which may impact its success. Methodology: A cross-sectional study was done to determine the beliefs and perceptions of people on COVID-19 vaccination in Delhi in the month of March–April 2021 with the help of a questionnaire which was distributed online. It contained 22 questions and was finalized after the review through a pilot study and content validation. Statistical analysis was performed using Microsoft Excel 2007. Results: A total of 286 participants were analyzed, of which 55% were female. The mean age was 33.4 years. Intention of people for taking vaccination was analyzed with relation to different age groups, and positive trend was seen in people with advancing age and it was also statistically significant (P = 0.002). It was seen that people with higher education and of higher socioeconomic status were more inclined to get vaccination; however, in our study, 39.1% of the participants were concerned about the safety of the vaccine. Conclusions: Our study demonstrated that despite repeated assurance about the safety of vaccine, people still had doubts and misconceptions which were evident from our study. Hence, this study may help the administrators to understand the community concerns, tweaking current policies, and increasing the awareness campaign so that people gather more knowledge about vaccine benefits and community trust is built.
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Impact of lockdown period on chronic diseases p. 155
Rajashree Khot, Amol H Dube, Bharatsing D Rathod, Prashant P Joshi, Sunita D Kumbhalkar
Objectives: In the wake of COVID-19 pandemic, strict lockdown measures posed many challenges in managing chronic diseases such as hypertension and diabetes. The impact of lockdown on physical and biochemical parameters along with contributing factors was assessed. Design: Cross-sectional analytical study. Materials and Methods: One hundred and fifty consecutive patients with chronic illnesses attending medicine outpatient department during unlock down phase I were enrolled. A 5 point Likert scale was used to determine the effect on diet, exercise, pain, physical and psychological symptoms, and a personal interview to assess the contributing factors. Clinical examination and laboratory investigations were done to compare between pre and post lockdown status and appropriate statistical tests were used. Results: The mean age of the patients was 48.53 ± 6.4 years with a female preponderance. Mean duration of illness was 8.93 ± 2.4 years and majority had hypertension (21%), diabetes (19%) or both (12%), hypothyroidism (18%), and gastroesophageal reflux disease (8%). While physical symptoms and pain did not show a significant change, 41.3% had worsening of psychological symptoms, 53.3% diet, and 70.6% exercise noncompliance. Weight, blood pressure, lipids, serum thyroid-stimulating hormone showed little change. Glycemic control was deranged in 72.5% with HbA1c increasing from 6.47 ± 1.9 to 8.1 ± 2.4 (P = 0.007). Contributing factors, 52.3% reported lack of exercise, 40% financial problems, 36% transport difficulties, and 30% unavailability of medicines. Conclusion: Lockdown negatively affected the management of chronic diseases with significant worsening of psychological symptoms, diet, and exercise adherence. Glycemic control worsened in diabetics. Lack of transport and unavailability of medicines were the significant contributing factors.
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Are patients with comorbidities more prone to sequalae in severe COVID-19 p. 161
Mradul Kumar Daga, Govind Mawari, Siddharth Chand, J Aarthi, RV Raghu, Naresh Kumar
Majority hospital admission in COVID-19 is because of pneumonia. Few develop progressive and permanent pulmonary fibrosis. Here, we present three patients of severe COVID-19 pneumonia requiring intensive care unit care. Computed tomography (CT) of the chest of these patients revealed multiple areas of lung involvement at the 4th week of illness. Follow-up CT scan and pulmonary function test were done after 5 months to look for residual changes. Pulmonary fibrosis induced by COVID-19 is being documented. We need long-term follow-up studies to observe the clinical and radiological course of fibrosis. Corticosteroids and antifibrotic agents in such cases are being looked into.
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Dextrocardia: Clinical vignettes p. 165
Ramesh Aggarwal, Shridhar Dwivedi
Dextrocardia is one of the rare cardiac positional anomalies, in which heart is located in the right side of thorax with its base-to-apex axis positioned to the right side. Dextroposition is different than dextrocardia where the heart is displaced to the right secondary to extracardiac causes like eventeration of diaphragm and right lung hypoplasia. The term situs solitus is used when heart and abdominal viscera are normally placed with the cardiac apex, spleen, stomach, and aorta are placed on the left side and inferior vena cava and liver placed on the right side, whereas situs inversus has mirror-image of the organs relative to their position in situs solitus. Dextrocardia, cardiac dextroposition, and situs inversus generally remain asymptomatic and are detected incidentally by imaging studies done for reasons other than cardiovascular system related problems. This article shares our experience of five cases of cardiac malposition that presented with atypical features of common medical problems. It highlights the importance of basic clinical examination in these patients which helps in making a bed side diagnosis of cardiac malposition and also prevents any mishap which can arise if any emergency intervention is done in patients of dextrocardia with or without situs inversus.
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Symmetrical peripheral gangrene: A rare clinical syndrome p. 168
Ashok Kumar, Urvashi Khan, Shivani Bansal
Symmetrical peripheral gangrene (SPG) is a rare syndrome which is defined by the peripheral ischemic lesion of two or more extremities in the absence of major vascular obstructive disease. We hereby describe a case of 63-year-old female, admitted in intensive care unit with a history of shortness of breath with atrial fibrillation since few days, developed cold extremity with acrocyanosis that rapidly progressed to gangrene. Laboratory analysis revealed increased inflammatory parameters, deranged liver enzymes, thrombocytopenia, and prolonged coagulation time. Patient developed septic shock and was started on intravenous vasopressor with clinical benefits. Even though there is no consensus regarding SPG treatment, consequences should be mitigated, particularly when vasopressor are used, in order to avoid major amputation. Most of the sepsis survivors with SPG require amputation of the affected extremities.
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Adult-onset still's disease masquerading as hemophagocytic lymphohistiocytosis p. 171
Pooja Gautam, Navneet Gupta, Aanchal Arora, Kusha Sharma, Atul Goel
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hematological condition caused by the overactivation of macrophages leading to widespread tissue destruction and organ dysfunction. The disease has a clinical overlap with adult-onset still's disease (AOSD) and hence poses a diagnostic challenge. We report the case of a 20-year-old female who presented with prolonged febrile illness, anemia, hepatosplenomegaly, and generalized lymphadenopathy. She was diagnosed with HLH and was readmitted 6 weeks later with recurrent fever, polyarthralgia, and pharyngitis. A diagnosis of AOSD with secondary HLH was made.
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Clinical efficacy and safety of combined house dust mite subcutaneous immunotherapy and omalizumab in five cases of allergic rhinitis and asthma p. 175
PC Kathuria, Manisha Rai
Allergen immunotherapy (AIT) is a well-recognized treatment for altering the natural course of respiratory allergy which builds immune tolerance and prevents progression of allergic diseases. In our five cases of house dust mite (HDM)-driven allergic rhinitis and asthma, combined HDM Subcutaneous Immunotherapy (HDM-SCIT) for 2 years with omalizumab for more than 12 months has achieved disease remission in four cases and disease control in one case along with long-term effect for 3 years after discontinuation of AIT. We hypothesize that combining HDM-SCIT and omalizumab is a promising strategy as it is effective, safe, and synergistic having immune-modifying activity in cases of HDM-driven Allergic Rhinitis and Asthma.
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Traumatic rupture of renal cell carcinoma: Rare pediatric affliction p. 179
Juan Guillermo Bauzá-López, Fernando Karel Fonseca-Sosa, Mirelis Popa Arias, Nadia Blanco Figueredo, Iván Ramón Cutiño-Ocaña
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COVID-19 happy hypoxemia and high-altitude pulmonary edema – Pathophysiological links? p. 181
Harsha Jain, Nitesh Gupta, Pranav Ish
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