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   Table of Contents - Current issue
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January-March 2021
Volume 12 | Issue 1
Page Nos. 1-49

Online since Tuesday, January 12, 2021

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EDITORIAL  

Conundrum of COVID-19: The road ahead Highly accessed article p. 1
Anupam Prakash
DOI:10.4103/injms.injms_160_20  
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REVIEW ARTICLES Top

Tele-medicine, tele-rounds, and tele-intensive care unit in the COVID-19 pandemic p. 4
Pradeep Rangappa, Karthik Rao, Thrilok Chandra, Sunil Karanth, Jose Chacko
DOI:10.4103/injms.injms_100_20  
The COVID-19 pandemic has caused a worldwide health crisis, laying stress on existing health-care systems and causing an unprecedented financial crisis. In this situation, provision of homogenized, evidence-based care by all levels of health-care providers, including those in a low-resource setting, is of paramount importance. As a specialized offshoot of Tele-medicine, Tele-intensive care unit (Tele-ICU) offers an innovative solution in the care of critically ill COVID-19 patients, by off-site clinicians, using audio, video, electronic, and tele-communication links to leverage technical, informational, and clinical resources. Tele-ICU also helps overcome the shortage of expertise like intensivists in these settings and helps to take the clinical expert to the patient bedside by remote monitoring and supervision. Telemedicine applications can be classified into four basic types, according to the mode of communication, timing of the information transmitted, the purpose of the consultation, and the interaction between the individuals involved-be it doctor-to patient/caregiver or doctor to doctor. The benefits and concerns of tele-medicine have been described in detail.
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Hematological profile in COVID-19, whether it matters in children p. 11
Purnima Margekar, Ashok Kumar, Venu Gopal Margekar, Shubha Laxmi Margekar
DOI:10.4103/injms.injms_141_20  
Coronavirus disease 2019 (COVID-19) is an acute respiratory and systemic illness, and is a public health emergency which has involved all the continents. Though limited data is available for infection in pediatric population, infection seen in children is of milder form. During this pandemic, documentation of laboratory predictors to discriminate between mild and severe forms of this infection would be helpful. Various hematological parameter alterations in the pediatric COVID-19 cases show anemia, thrombocytopenia, eosinopenia, and inconsistent leukocyte indices. It may be too early to say right now as to what extent will these alterations help us in outlining the severity of disease or transmission of disease. However, it will be pertinent to understand these abnormalities, and keep track of them, so as to understand the disease, as the pandemic unfolds.
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ORIGINAL ARTICLES Top

Protective antibody levels against hepatitis B among serodiagnosed syphilis cases: Need to integrate national control programs with immunization guidelines? p. 15
Bineeta Kashyap, Rituparna Saha, Narendra Pal Singh, Krishna Singha
DOI:10.4103/injms.injms_103_20  
Background: The intersecting routes of transmission in conjunction with hepatocyte injury caused by hepatotropic viruses and Treponema pallidum independently add to the importance of hepatitis B virus (HBV) seroprotection in syphilis. Furthermore, the deficit in the clinical suspicion and stigma associated could at least be partially responsible for the underdiagnosis of syphilitic hepatitis, which is caused by the effect of T. pallidum on hepatocytes. Materials and Methods: Sera from eighty patients, serologically confirmed for syphilis by conventional algorithm, were included in the study. Levels of anti-HBs antibody were determined by ELISA for all serologically confirmed cases of syphilis. Results: Majority of the patients who tested positive for syphilis as per conventional algorithm, hailed from antiretroviral therapy (ART) and sexually transmitted infection (STI) clinics. Levels of anti-HBs antibody of all the patients were found to be below 10 mIU/ml. Conclusion: The absence of protective levels of anti-HBs antibody among all the patients in the study group, despite the inclusion of HBV vaccination in the national immunization program and proximity to tertiary health-care facilities, underscores the pressing need to reinforce and revise our approach to immunization. High-risk groups, such as ART and STI clinic attendees, solicit further enforcement of accelerated immunization strategies in excess to existing dosing schedules.
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Initial data on clinical use of generic romiplostim for second-line and subsequent therapy of immune thrombocytopenia in India p. 19
Suvir Singh, Komalpreet Kaur
DOI:10.4103/injms.injms_105_20  
Introduction: Over 50% of adults with immune thrombocytopenia (ITP) require second-line therapy after steroids, but these options are plagued by low rates of response, which are often delayed by 2–3 months. Romiplostim is a thrombopoietin receptor agonist (TPO-RA) that has shown significant efficacy in this setting and is now available in a generic formulation. No data on the efficacy and safety of the same are available in the India context. Methodology: This study was conducted from August 2019 to July 2020. Romiplostim was used for patients with ITP that was (a) steroid or intravenous immunoglobulin (IvIg) refractory or (b) not responding to other second-line agents. Results: A total of 11 patients were included in the analysis (M:F = 6:5) with a median age of 44 years (range, 18–67). Initial therapy was corticosteroids for all patients of which nine (81%) had an initial response. Second-line therapy included azathioprine for six patients (54%) and IvIg for four (36%) patients. All patients were refractory to the second-line therapy and initiated on romiplostim at a median dose of 3.68 μg/kg/week (range, 2.7–6.2). A sustained response was observed in 10 patients (90.9%) after a median duration of 13 days (range, 2–32). At a median follow-up of 5.5 months, nine patients (81%) had stable platelet counts. Conclusion: Initial data suggest that generic romiplostim is an effective and safe second-line medication for ITP and can potentially avoid splenectomy in steroid and IvIg refractory patients. Prospective follow-up of more patients will provide a better perspective on efficacy and cost-effectiveness of TPO-RAs.
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Estimating serum vitamin D levels and assessing its influencing factors among antenatal women in a South Indian town-Kumbakonam urban rural epidemiological study: KURES-5 p. 22
MR Suchitra, TS Shanthi, S Balachandar, S Parthasarathy
DOI:10.4103/injms.injms_107_20  
Background: Adequate antenatal Vitamin D intake is essential for maternal and fetal health during pregnancy and avoidance of adverse outcomes. The normal and abnormal concentrations are not well established in the different parts of the world with varying customs in life. We intended to estimate the normal random serum Vitamin D levels among antenatal mothers in the first trimester and whether factors such as age, weight, and religion have any influence on the same. Materials and Methods: In this epidemiological study of 644 parturients, we collected the blood samples from asymptomatic antenatal mothers in the first trimester. A simple convenient sample of mothers on no other supplements except folate was selected. The present study was done from April 2019 to March 2020 after individual informed consent and ethical clearance. The factors such as age, weight, type of diet, occupation, and religion were noted. The estimation of Vitamin D3 levels was done by the well described chemiluminescent technique. A value of <20 ng/ml was defined as deficient. Student t-tests, analysis of variance, and correlation tests were done accordingly to find out the influence of the above factors on the level. Results: 83.7% of all women were deficient in Vitamin D3, if the level of 20 ng/ml was taken as cutoff. The mean Vitamin D3 level was 14.57 ± 6.73 ng/ml. Religion wise, the mean Vitamin D3 was 16.63 ng/ml in Hindus (sample – 402/644), 10.55 ng/ml in Muslims (sample – 207/644), 14.27 ng/ml in Christians (sample – 16/644), and 15.08 ng/ml in others (sample – 19/644). There was a significant reduction in the levels of Vitamin D in Muslim women. There is no influence of age, weight, or dietary pattern. Conclusion: A majority of Indian pregnant women were deficient in Vitamin D3, worse among Muslims. We conclude that lifestyle changes with more exposure to sunlight should be suggested to all women in the reproductive age group to circumvent the problem. Health education on these lines should be imparted to them.
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A study on the prevalence of accidents among under-five children in an Urban field practice area of Mysuru p. 25
KV Krishnamurthy, M R Narayana Murthy, Praveen Kulkarni, Amogha Shree, Arun Gopi
DOI:10.4103/injms.injms_125_20  
Background: The World Health Organization defines “Accidents as an unexpected and an unintended event causing physical and mental injuries.” In many developing countries, injuries due to accidents are one of the major causes of deaths among under-five children. In India, 15%–20% deaths among children are due to injury according to the National Crime Bureau. Objectives: To determine the frequency and prevalence of accidents among the under-five children and to identify the risk factors associated with accidents. Methodology: A cross-sectional study was conducted using probability proportionate to size sampling technique in the urban field practice area of JSS Medical College, Mysuru. Based on the reported prevalence of 46.3% of childhood injuries, a total sample size of 438 was obtained. Data related to sociodemographic characteristics, risk factors, and injury profile were collected by interviewing parents who had children less than 5 years. Analysis was done using SPSS V.25. Results: Majority (60.8%) of the caretakers had male children. The prevalence of accidents among under-five was 22.1%. Fall (68%) was the common type of accident. 55.7% of the under-five children received the treatment from allopathic system of medicine. Education level and stress among the caretakers showed statistically significant association with the occurrence of accidents. Conclusion: This study revealed the prevalence of domestic accidents among under-five as 22.1%. Caretakers are failing their responsibility of caring their children due to lack of education among them.
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CASE REPORTS Top

Post-COVID-19 guillain-barre syndrome: A distinct neurological entity p. 31
Ritika Sud, Jyoti Verma, Shubham Goswami, Niharika Aggarwal, Anil Gurtoo
DOI:10.4103/injms.injms_142_20  
SARS-CoV-2, the causative agent for COVID-19, originated in China in the fall of 2019 and soon became a pandemic engulfing the entire world, presenting with a myriad of presentations from asymptomatic to severe disease with acute respiratory distress syndrome and multiple organ dysfunction and severe inflammatory response. Little is understood about the new virus and its pathogenesis, and it is too early to ascertain its long-term sequelae at this point in time. New associations and clinical problems keep appearing with the new virus and thus we also got to encounter three cases of acute inflammatory demyelinating polyneuropathy (AIDP) in patients following COVID-19 infection. This case series aims to convey clinicians that AIDP can be seen in patients with COVID-19, particularly during the recovery phase, and thus not to miss it as postviral fatigue and malaise.
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Guillain-barre syndrome and posterior reversible encephalopathy syndrome associated with COVID-19: Expanding horizon of the novel disease p. 34
Sunil Chaudhary, Mithu Bhowmick, Ashok Kumawat, Gaurav Singh
DOI:10.4103/injms.injms_126_20  
On late December 2019, an epidemic of cases with unexplained pneumonia was first detected in Wuhan, China. Subsequently, the etiological agent was attributed to a novel coronavirus SARS-CoV-2, also designated as COVID-19. The disease primarily affects the respiratory tract, but involvement of the cardiovascular system, neurological system, gastrointestinal system, and renal system had been reported. Here, we report the case of a 60-year-old female who presented with progressive ascending pattern weakness of both lower limbs associated with the symptoms of severe headache and blurring of vision, which progressed to such an extent that she could only perceive light. Two weeks prior to hospitalization, she had fever, sore throat, dry cough, and myalgia. Subsequently, she tested positive for COVID-19 by? reverse transcription-polymerase chain reaction and imaging, and electrodiagnostic study was performed which was suggestive of Guillain–Barré syndrome (GBS) and posterior reversible encephalopathy syndrome (PRES). She was treated with intravenous immunoglobulin and antihypertensive medications, which resulted in a dramatic improvement of her symptoms. There had been reported cases of GBS and PRES associated with COVID-19 separately. However, this may be the first case report of concurrent occurrence of both the syndromes in a patient with the novel disease.
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Guillain–Barré syndrome unmasking asymptomatic peripheral spondyloarthritis p. 37
Harleen Kaur, Gaurav Kumar Mittal, Jennifer Singhdev
DOI:10.4103/injms.injms_116_20  
Guillain–Barré syndrome (GBS) is an immune-mediated disease characterized by evolving ascending limb weakness, sensory loss, and areflexia. While moderate and severe back or extremity pain is frequent in patients with GBS due to polyradiculopathy, the literature does not reveal any association of acute demyelinating disorders and asymptomatic sacroiliitis, which becomes symptomatic during the episode of the demyelinating illness. We present the case of a young male patient with acute-onset quadriparesis diagnosed as GBS based on clinical evidence and electrophysiological criteria, who developed acute low backache 7 days after the onset of acute demyelinating illness. Subsequently, a diagnosis of peripheral spondyloarthritis (SpA) was confirmed based on clinical outline (past history of bilateral heel pain and acute low backache), along with magnetic resonance imaging (MRI) and computed tomography findings of focal erosions with surrounding sclerosis on iliac para-articular surface bilaterally. The patient responded well to the therapy (intravenous immunoglobulin, hydroxychloroquine, and symptomatic treatment) thereafter. It is crucial to consider the possibility of SpA when patients with GBS complain of low backache. Timely diagnosis will not only aid in the institution of early therapy but also prevent any long-term sequelae. MRI can visualize active inflammation at sacroiliac joints and spine in recent-onset disease.
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LETTERS TO THE EDITOR Top

Neurosarcoidosis presenting as recurrent polyneuritis cranialis p. 40
Abhishek Juneja, Kuljeet Singh Anand, Rakesh Kumar Mahajan
DOI:10.4103/injms.injms_128_20  
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Chilblain lupus and discoid rashes in systematic lupus erythematosus p. 42
Prakash Gupta, Latika Gupta
DOI:10.4103/INJMS.INJMS_124_20  
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Dyslipidemia in adult thalassemia patients p. 44
Shubha Laxmi Margekar, Ritika Sud, Ramesh Aggarwal
DOI:10.4103/injms.injms_129_20  
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Neurobrucellosis presenting as guillain–Barre syndrome p. 46
Abhishek Juneja, Kuljeet Singh Anand, Ritu Yadav, Jyoti Garg
DOI:10.4103/injms.injms_120_20  
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The impact of COVID-19 preventive measures on the spread of influenza viruses and influenza-like illnesses p. 48
Chidiebere Emmanuel Okechukwu
DOI:10.4103/injms.injms_148_20  
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