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   Table of Contents - Current issue
January-March 2021
Volume 9 | Issue 1
Page Nos. 1-66

Online since Wednesday, February 3, 2021

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Editorial p. 1
Manjunath Premanath
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Changing profile of COVID-19 p. 2
Prabha M. R. Adhikari
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Impact of coronavirus disease-2019 pandemic on Hemodialysis care delivery pattern in Karnataka, India: A Cross-sectional, questionnaire-based survey Highly accessed article p. 4
YJ Anupama, Arvind Conjeevaram, A Ravindra Prabhu, Manjunath Doshetty, Sanjay Srinivasa, Venkatesh Moger
Background: The coronavirus disease-2019 (COVID-19) pandemic has disrupted health-care delivery globally. Patients on in-center hemodialysis (HD) are particularly affected due to their multiple hospital visits and the need for uninterrupted care for their well-being and survival. We studied the impact of the pandemic and the national policy for pandemic control on the HD care delivery in Karnataka state in India in April 2020, when the first and second national lockdown were in place. Materials and Methods: An online, questionnaire-based survey of dialysis facilities was conducted, and the responses analyzed. The questions were pertaining to the key areas such as changes in a number of dialysis treatments, frequency, duration, expenses, transportation to and from dialysis units, impact on the availability of consumables, the effect on dialysis personnel, and on machine maintenance. Results: Sixty-two centers participated. Median of dialysis treatments for the months of March and April 2020 was 695.5 and 650, respectively. Reduction in dialysis treatments was noted in 29 (46.8%) facilities, decreased frequency reported by sixty centers. In at least 35 (56.5%) centers, dialysis patients had to bear increased expenses. Cost and availability of dialysis consumables were affected in 40 (64.5%) and 55 (88.7%) centers, respectively. Problems with transportation and movement restriction were the two key factors affecting both patients and dialysis facilities. Conclusions: This survey documents the collateral impact of COVID-19 on the vulnerable group of patients on HD, even when not affected by COVID. It identifies the key areas of challenges faced by the patients and the facilities and implores the care providers for finding newer avenues for mitigation of the problems.
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Study of serum uric acid and homocysteine levels in acute ischemic stroke p. 10
Srinith B Patil, Basawaraj Belli, Sangram Biradar, Anil Patil
Introduction: Worldwide, stroke is the third most common cause of death after coronary heart disease and all cancer deaths. All the physicians have a role to play in the prevention of stroke by encouraging the reduction in risk factors. Ischemic stroke accounts for >80% of total stroke events. There is growing evidence that high serum uric acid and homocysteine levels contribute to the pathogenesis of ischemic stroke, and early identification of individuals at risk could be of help in primary prevention strategies. Aims: The aim was to study the association between levels of serum uric acid and homocysteine and acute ischemic stroke and to compare them with control subjects. Materials and Methods: A case–control study was carried out among 100 subjects, which included 50 cases of first-time ischemic stroke and 50 healthy controls attending the outpatient department and casualty, in whom serum uric acid levels, serum homcysteine, and other associated risk factors were evaluated. Results: The overall mean age of the case population was 55.84 ± 15.57 years and control was 59.92 ± 11.62 years. Among the 50 cases of first-time ischemic stroke and 50 controls, males constituted 32 (64%) and 30 (60%), respectively. The mean uric acid level in case population was 5.32 ± 1.09 mg/dl and in controls was 3.21 ± 1.01 (P = 0.001). The mean homocysteine level in case population was 20.85 ± 10.85 μmol/l and in controls was 8.10 ± 3.54 (P = 0.001). Among the case population, 28 (56%) were found to have hypertension, followed by smoking 19 (38%), diabetes mellitus 18 (36%), and alcoholism 13 (26%). Conclusion: Significant elevation of both uric acid and homocysteine in a cohort of stroke patients when compared to the control group was found. Thus, it is concluded from the present study that an elevated uric acid and homocysteine level appears to be an important risk factor for stroke. Hypertension was found to be the most common modifiable risk factor.
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Prognostic significance of thyroid dysfunction in acute stroke p. 14
Shivashankara Kaniyoor Nagri, Chandrasekhar Udayavara Kudru, Sampath Kumar Amaravadi, Laxmi Prasad
Background: Cerebrovascular accidents (CVAs) are the leading cause of morbidity and mortality. Several comorbidities have been associated with increased mortality in acute stroke patients. Conditions such as hypertension, dyslipidemia, diabetes mellitus, and thyroid dysfunction are identified as risk factors in the etiology of stroke. Methods: This is a prospective study involving 40 patients admitted with acute stroke between October 2010 and July 2012 in Kasturba Hospital, Manipal, under the Departments of Medicine and Neurology. Results: Thyroid dysfunction has been associated with CVAs and is an area of active research in the present times. Conclusion: Low T3 level was associated with unfavorable outcome and with posterior circulation stroke as accessed using the National Institutes of Health Stroke Scale.
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Neurological manifestations in scrub typhus from a case series in Southern India p. 19
Vasantha Kamath, Shreyashi Ganguly, B Himabindu
Scrub typhus is an acute febrile illness caused by Orientia tsutsugamashi. CNS is the most crucial target in other rickettsial diseases and historically, the neurological disease burden was considered low in scrub typhus. However, there is growing evidence in literature that O. tsutsugamushi does invade the CSF and CNS invasion may be seen in 2–5 % cases of tsutsugamushi disease. O. tsutsugamushi parasitises endothelial cells both in the periphery as well as in the brain. The disease is characterized by focal or disseminated vasculitis and perivasculitis. Scrub typhus has protean manifestations. CNS involvement is rare but it should be considered as an important differential in the setting of known areas of scrub typhus outbreak. Meningoencephalitis with or without focal neurological deficits is the commonest clinical picture. However, the neurological manifestations can be highly variable. In our case series out of 81 patients who were diagnosed with scrub typhus, only 5 patients had neurological manifestations. All patients presented with altered sensorium. GCS was decreased in all patients. It was <10 in 60% cases. Neck rigidity and signs of meningeal irritation was present in 80% cases. There was no sign of papilloedema, cranial nerve involvement, focal neurological deficits. 2 of the patients had seizure which was GTCS in semiology. CSF in all cases showed lymphocytic predominance (between 150 and 400 cells/ mm3) with high protein and low to normal CSF sugar levels. NCCT brain was normal. MRI brain showed meningeal enhancement in 60% cases. Additionally, hyperintense signal on T2 was observed in 60% cases. Confirmation of the case requires serological evidence. CSF and neuroimaging picture are not pathognomonic. In the setting of acute fever, headache along with eschar or macular rash, scrub typhus must be ruled as a cause of neurological manifestations, such as altered sensorium, and seizure.
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Laboratory accreditation and customer satisfaction p. 25
D Abhijith, KS Kusuma, MN Suma
Laboratory accreditation is a process by which an authoritative body gives formal recognition of technical competence for specific tests or measurements usually following international standards such as ISO/IEC 15189/17025. The process checks on inaccuracy or imprecision that may crop up during the preanalytical, analytical, or postanalytical phases, which could have an impact on the patient's reports and thereby the treatment aspects. The process itself helps the personnel of the laboratory to be alert, be quality conscious, and provide the best to the customers, namely patients and health-care providers, thereby helping the health-care providers to give the best of their services to the patients. This enhances the quality of the health-care services on the whole due to quality management system being in place in laboratories. The accreditation agency which takes interest in the laboratories of India and ensures quality in them is National Accreditation Board for Testing and Calibration Laboratories. The developed countries already have the system in place, and it is mandatory for every lab to be accredited before releasing patient reports. We are not far behind in this process, and shortly it may be considered to be mandatory for all labs to obtain the accreditation to run the tests. However, there are several challenges one needs to address in the process of accreditation, with the most important being the finances, team work, and planning.
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What's new in COVID-19? Highly accessed article p. 29
Umar M M A Shareef, Vinod Kumar, Vasantha Kamath
COVID-19 has affected over 57,410,025 people and killed more than 1,368,848 of those affected in 220 countries as on November 20, 2020. Community-acquired coronaviruses are ubiquitous with a male preponderance. Unlike Western nations, majority of the cases in India are in the age group of 31–50 years, and the mortality rate is around 1.46%. The possible modes of transmission for severe acute respiratory syndrome coronavirus 2 include droplet, airborne, fomite, fecal-oral, bloodborne, mother-to-child, and animal-to-human transmission as per the World Health Organization. Apart from the known symptoms of influenza-like illness, COVID also presents with cutaneous, hematological, gastrointestinal, and neurological manifestations. In the absence of dedicated cures, until there is a hope of appropriate and effective vaccine development, the novel coronavirus will be a challenge to the existence of humanity.
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Dysfunctional kidney due to dysfunctional thyroid! p. 38
S Rashmi, AC Nirmala
Hypothyroidism can have various musculoskeletal manifestations such as myalgia, myopathy, or myositis. However, hypothyroidism causing rhabdomyolysis is rare. Moreover, the occurrence of acute kidney injury due to rhabdomyolysis precipitated by hypothyroidism is a rare, life-threatening yet reversible cause for renal dysfunction. Here, we report a case of an 18-year-old girl who presented with renal dysfunction following acute gastroenteritis, and on evaluation for worsening renal functions, she was found to have rhabdomyolysis due to hypothyroidism.
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An interesting case of subacute hypersensitivity pneumonitis p. 40
Aishhwarrya Umeshchandara Gurugunti, K Ravi
Hypersensitivity pneumonitis (HSP) is the paradigm of lung response to inhaled organic and inorganic substances. It is a relatively rare disease, constituting 2% of cases of interstitial lung diseases. We describe a case of a 55-year-old female with a history of breathlessness, fever, and cough with expectoration for 1 month. She gave a history of similar such episodes on and off for the past 7 years. She was diagnosed with pulmonary tuberculosis 6 years back and was treated, but her breathlessness continued to occur despite treatment. Further workup was suggestive of HSP. The later history of exposure to poultry dust was elicited. She was started on steroid pulse therapy along with maintenance dose, which resulted in symptomatic improvement. She underwent a bronchoscopy and the bronchoalveolar lavage, and a diagnosis of subacute HSP was made. HSP can be mistaken for pulmonary tuberculosis and wrongly treated with antitubercular therapy unless the patient is probed about exposure to various inciting antigens.
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Complex regional pain syndrome (reflex sympathetic dystrophy) after coronary artery bypass graft – An interesting case p. 43
Manjunath Premanath
A 58-year-old male presented himself with swelling, pain, and color change of the left shoulder, arm, and hand of 3 months duration. His problems started a week after he underwent a coronary artery bypass graft for triple-vessel coronary artery disease. The function of the left upper limb was severely restricted. Investigations done to know the cause of his problems were negative. A clinical diagnosis of complex regional pain syndrome was made. Even though this syndrome was observed after myocardial infarction, its occurrence after CABG has been quite rare. This case is presented as CABG is on the rise, and more and more cases may occur which should not be missed.
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A case of noncardiogenic pulmonary edema and pleural effusion following diclofenac administration p. 48
Vinod Kumar, Vasantha Kamath, Shreyashi Ganguly
The acute manifestations of diclofenac allergy vary from mild urticaria or skin rash to severe and life-threatening complications such as ARDS, and anaphylactic shock. Very few cases of diclofenac allergy have been reported in literature especially with respect to pulmonary manifestations. We are reporting a case of a 31-year-old who presented in respiratory distress consequent to diclofenac hypersensitivity. Our patient had non-cardiogenic pulmonary oedema and bilateral minimal pleural effusion 3 days following diclofenac administration. On examination the patient was conscious, alert and oriented, PR- 88 bpm, BP- 150/100 mmHg, RR-22 cpm temperature 98.6°F with oxygen saturation of 95% on room air. Her respiratory system examination revealed a dull note on percussion and decreased vocal fremitus, decreased vocal resonance, diminished air entry in bilateral infra scapular and infra axillary areas with fine inspiratory crepitations. The diagnosis of ARDS was ruled out as the ratio of PaO2 to FiO2 was 410. After treatment with I.V diuretics, antibiotics and inhalational bronchodilators she improved over a period of 5 days. She had complete resolution of her chest symptoms and chest findings both clinically and radiologically. Pulmonary manifestations such as ARDS, eosinophilic pneumonitis, pleural effusion, eosinophilic pneumonia, pulmonary oedema, hemoptysis, pulmonary infiltrates with eosinophilia and asthmatic attacks are rare. The temporal relationship between symptom onset and drug administration is the most important piece of history while making the diagnosis. History of allergic reaction to NSAIDs should be evaluated in detail. It is therefore important that the physician keep this in mind while prescribing.
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Scrub typhus: A case report from Bangladesh p. 52
Shaila Rahman, Tamanna Bahar
Scrub typhus is an acute febrile illness caused by a Gram-negative obligate intracellular bacterium named Orientia tsutsugamushi. Although this zoonotic disease is common in tropical and subtropical regions, it is often underreported in Bangladesh. We present a case of scrub typhus in a 15-years-old male who presented with fever, eschar, hepatitis, and positive serology and got complete recovery with doxycycline.
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ACS complication p. 55
DC Prashanth, Suresh V Sagarad, Mohammed Emad Hussain
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Pleural effusion - A radiological review p. 58
Raghavendra Bhat
Pleural effusion is a collection of fluid in the pleural cavity. Various types of pleural effusions are discussed with illustrations (8 images).
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Obituary p. 62
BV Murali Mohan
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Obituary p. 63
Shrikanth N Hegde, J Sharanappa
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Obituary p. 64
Tekur Ramanath
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Obituary p. 66
MG Usha
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