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   Table of Contents - Current issue
May-August 2021
Volume 7 | Issue 2
Page Nos. 99-179

Online since Friday, August 27, 2021

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Herpes Zoster Oticus: A Morbid Clinical Entity p. 99
Santosh Kumar Swain, Roshna Rose Paul
The reactivation of varicella zoster virus (VZV) at the geniculate ganglion of the facial nerve results in herpes zoster virus. Patients of herpes zoster oticus (HZO) often present with symptoms related to the cochleovestibular dysfunction along with otalgia and vesicular eruption at the pinna and external auditory canal. Patients of HZO usually present with hearing loss, vertigo, and facial nerve paralysis. When it is associated with facial nerve paralysis, HZO is called Ramsay Hunt syndrome (RHS). In the majority of cases, patients with vertigo have hearing loss, whereas patients without hearing loss have no vertigo. It is a self-limiting viral disease and the morbidity is often caused due to facial nerve paralysis. If HZO is not diagnosed immediately and treated timely often it progress to RHS. Clinician education is vital for detecting the HZO/RHS at an early stage so that facial nerve paralysis can be prevented along with associated morbidity. In this review article, we discuss the current concept and recent advances in the etiopathology, diagnosis, and treatment of HZO.
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Amphotericin B Revisited p. 104
Sahil Kumar, Vandana Roy
Amphotericin B, one of the first systemic antifungal agents, has been in use since the past six decades. In light of the recent outbreak of mucormycosis (black fungus) cases during the second coronavirus disease 2019 wave in India, the relevance of knowing the chief aspects of this drug has been renewed. This drug review attempts to revisit the important details available about this agent, which will be of use to the clinician.
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Efficacy of Single-Dose Ivermectin on Virologic and Clinical Recovery in COVID-19: A Randomized Controlled Trial p. 109
Romit Saxena, Muthu Rajanagam, Urmila Jhamb, Vikas Manchanda, Sonal Saxena, Pallavi
Background: Coronavirus disease 2019 (COVID-19) pandemic mounts an ever increasing challenge on healthcare resources. Ivermectin shows promise in in vitro studies on coronavirus, but there are few prospective trials on currently approved dosage recommendation for the treatment of COVID-19. Aims: To study the virologic and clinical recovery after single-dose ivermectin, given within first 5 days of symptom onset. Settings and design: Prospective, open-labeled, randomized controlled trial. Patients were recruited in between August 30, 2020, and November 6, 2020, at a single referral center for patients with COVID. Materials and methods: The study participants included patients presenting with severe acute respiratory syndrome coronavirus 2 infection. The patients were randomized to receive a single-dose ivermectin, 0.2 mg/kg in the treatment group (TG). Both groups [TG and control group (CG)], continued to receive standard treatment. Results: The recruited cohort was comparable in the two arms of the study, except age and height. There was no statistically significant difference in virologic clearance between the two arms (percentage COVID positive day 7: TG: 34.2% vs. CG: 52.6%, P = 0.165). Conclusion: Our study shows that after administration of single dose of currently approved doses of ivermectin (0.2 mg/kg), there does not exist a significant virologic or clinical recovery in COVID-19 disease.
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Impact of COVID-19 on the Work Performance of Healthcare Workers in Neurosurgery Operation Theater at a Tertiary Care Institute: A Pilot Study p. 115
Katyal Abhishek, Modi Parth, Rai Neeraj, Singh Daljit
Background: The novel corona virus disease 2019 (COVID-19) pandemic had a massive impact on healthcare systems, increasing the risks of psychologic distress in health professionals in response to chronic emotional and interpersonal stressors on the job; especially associated with surgical care. Aims and Objectives: To assess the impact of COVID-19 on the psychologic health and work performance of healthcare workers (HCWs) in operation theaters (OTs). Methodology: A questionnaire-based survey study was conducted among health professionals associated with neurosurgery OT. Results: Sixty-five HCWs (including doctors, nursing staff, and other HCWs) participated in the survey. The fear of spread of COVID-19 infection to family members was found in majority of HCWs especially nursing staff (96%). The fear of COVID-related death was least among the other HCWs (8%). Majority of the HCWs followed COVID protocols at work place. Transportation issues were a major complaint by other HCWs (67%), whereas majority of the HCWs (71%) were of the opinion that donning and doffing practices affected their daily work routine. Conclusion: Fears and stigmas associated with COVID −19 had an impact on the psychosocial health of HCWs in the neurosurgery OT and affected their workplace performance.
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Assessment and Comparison of the Mental Health Status of Patients Seeking Psychiatry Facilities in Pre-lockdown and Post-lockdown Period During COVID-19 Pandemic: A Retrospective Cross-Sectional Study in a Tertiary Care Centre in a Hilly Region of North India p. 120
Devesh Sharma, Sunny Garg, Anchal Sharma, Dinesh Dutt Sharma, Nidhi Sharma, Simran Gupta, Shivam Sharma
Background: The servicing and framework for mental health care accessible to population have been affected during the unprecedented times of coronavirus disease (COVID-19) pandemic. The new and almost exclusive method to maintain a therapeutic alliance with these patients has been the recently evolving telepsychiatry services. Aim and Objectives: The main aim of the study was to assess and compare the mental health status of patients seeking available psychiatry facilities in pre-lockdown and post-lockdown period during COVID-19 pandemic. Methodology: This was a retrospective cross-sectional study that was conducted in a tertiary care hospital in a hilly region of North India. The registered data was analyzed between January 1, 2020 to March 21, 2020 to gather the information of patients about sociodemographic profile and clinical diagnosis on the basis of International Classification of Diseases-10. The retrieved data constituted 499 new consecutive patients during this period. Then in the post-lockdown phase after the resumption of OPD services in the institute (May 3, 2020), the data collection was initiated to collect a similar sample size of new consecutive patients (501). These data were collected over 151 days (May 3, 2020 to September 30, 2020). Results: A total number of 1000 patients were analyzed. Majority of the patients were male (66%) and within 19 to 60 years of age (85–90%). The average number of patients (3.31) seen per day was less and the average age of the patients (39.17 years, standard deviation = 14.37) was significantly higher in the post-lockdown phase. The most common diagnostic group consisted of neurotic/stress-related/somatoform disorders. As compared to the pre-lockdown period, a significantly (P < 0.001) lower number of patients diagnosed with substance use disorders and a significantly (P < 0.001) higher number of patients diagnosed with psychotic disorders along with anxiety disorders availed the available psychiatry services in the period of COVID-19 pandemic. Conclusion: Sudden cessation of the psychiatry services further precipitated the deterioration of mental health of the patients. There is an urgent demand for services to adapt to changing scenarios with emphasis on practical approaches to help the mentally ill people especially in geographically difficult hilly areas.
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The New Normal Anesthesiologist and the Challenging Post-COVID-19 Mucormycosis Patients − Our Experience p. 126
Sonia Wadhawan, Farah Husain, Munisha Agarwal
Rhino-orbital-cerebral mucormycosis (ROCM) is an aggressive, lethal, angioinvasive fungal infection that has presented as an opportunistic infection in the backdrop of a highly infectious and severe second coronavirus disease 2019 (COVID-19) wave in India. The dominant delta strain during the second wave led to an unprecedented rise in hospital admissions with moderate to severe COVID-19 illness. A working staging system is helpful in triaging these patients to prioritize surgical debridement and liposomal amphotericin B induction therapy. The evaluation and optimization of post-COVID-19 sequelae becomes a cornerstone in achieving a favorable perioperative outcome. As anesthesiologists, we share our experience in managing this novel subset of patients. Post-COVID-19 sequelae with a prothrombotic state and multisystem involvement, challenging and shared airway, and amphotericin B-related complications are being the key concerns.
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Experience of Orthopedic Surgeons Managing COVID Patients at the Peak of Second Wave in a COVID-dedicated Hospital: A Guidance for Future Waves p. 136
Sumit Sural, Tarun Suri, Yasim Khan, Pankaj Yadav, Abhay Meena, Rajeev Yadav, Lalit Maini, Vinod Kumar
Introduction: The second wave of the severe acute respiratory syndrome coronavirus-2 pandemic in April 2021 had a sudden deluge of moderate to severe patients getting admitted to the orthopedics block, due to scarcity of beds in the medical wards, high dependency and intensive care areas of the hospital. This study is an analysis of these patients managed in the orthopedics block by orthopedic surgeons, which may be useful to formulate guidelines for the management of patients in future waves of the coronavirus disease 2019 (COVID-19) pandemic. Methods: The data of patients were collected by orthopedic residents from the Google sheet which was uploaded daily as part of the hospital data. The data from Google sheet were downloaded and compiled into an excel workbook and analyzed for patient progress, outcome, comorbidities, treatment given, oxygen management, and death analysis. Results: The data of 319 patients admitted from April 17, 2021 to May 20, 2021 in orthopedic block depicted successful recovery and discharge of 160 patients, worsening and transfer to higher wards for 126 patients and 33 deaths. The average age of these patients was 53.43 years with male preponderance (71% male). At the time of admission, 78.05% were reverse transcription polymerase chain reaction/rapid antigen test positive and 21.9% were COVID suspects. The patient’s disease status on arrival was found to be mild in 21.3%, moderate in 43.8%, and severe in 34.7%. The most common comorbidity was hypertension in 39 patients followed by diabetes in 29 patients. The average number of days of hospital stay was 5.48 days. Conclusion: Medical professionals other than critical care medicine can be frontline care providers who can guide the ancillary departments at the peak of pandemic waves. Adherence to the standard operating protocols and interdepartmental coordination need to be effectively managed. This study can be used to formulate guidelines for further improvement in COVID patient care in case of future waves of this pandemic.
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A Mixed-Method Study on Recurrent Unintentional Injuries in Children and Adolescents in a Rural Area of Delhi p. 144
Bratati Banerjee, Priyanka Yadav
Introduction: Unintentional injuries are largely preventable causes of death and disability in children. Understanding the extent of the problem and its contributing factors will help us in addressing them and thus prevent their occurrence to a great extent. Methodology: It is a mixed-method study, which is a part of a funded research project on unintentional childhood injuries, conducted in two villages of Delhi, on 397 children and adolescents. Quantitative data for occurrence of injuries was collected over 16 months during the period 1st September 2017-31st December 2018. Outcome variables included incidence of unintentional childhood injuries, knowledge of subjects regarding injuries and their prevention, family practices for injury prevention and treatment seeking behavior as reported by subjects, safety score regarding domestic and peridomestic environment, and danger signs within the house. Subjects with three or more incidents of unintentional injuries during the entire period of data collection were considered to have recurrent injuries and were classified as belonging to high-risk group. The qualitative part of the study included in-depth interview of subjects who suffered from recurrent injuries and their guardians in their families. Total 13 children were identified as high-risk group, of which three were below 10 years of age and hence were not interviewed. Purpose of interview was to assess the perception of each adolescent subject and his/her guardian in the family, regarding possible reasons for occurrence of recurrent injuries and the ways in which injuries can be prevented in these subjects. Results: Recurrent injuries occurred in 3.28% of total population, significantly more in male subjects. Mean age of the recurrently injured subjects and mean age of their guardians were lower than the corresponding uninjured group. Rate ratio and rate difference indicated greater vulnerability of the high-risk group of subjects. KAP scores of mothers and practice of families were significantly lower in the high-risk group than the other group. The main reasons for injury occurrence mentioned by both subjects and their guardians were that children are careless, naughty, fight with other children, and since parents do not stay at home there is no one to monitor them. Work-related injuries were also stated. Other than preventing the reasons for recurrent injuries stated by both the groups, some more measures were suggested. These were to keep the community clean as one major injury had occurred due to unclean surroundings, take help from close neighbors, particularly by working mothers of nuclear families, and elder siblings to take care of their younger siblings. Conclusion: Deeper understanding of the factors associated with unintentional injuries in specific cases provides a scope for targeted interventions. Educational programs and training of the people in the community and counseling members of the concerned families, will significantly help in prevention of injuries.
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Extrapulmonary Tuberculosis and Its Association with HIV in Patients Hospitalized in a Tertiary Care Center: A Cross-Sectional Study p. 149
Nitin Yashas Murthy, Soumya Umesh, Gherard D Ravindran
Context: Extrapulmonary tuberculosis (EPTB) presentation can be unusual, and the diagnosis may often be challenging when associated with HIV. Aims: This study was conducted to find out the pattern of newly diagnosed EPTB in hospitalized patients, the diagnostic modalities used to arrive at the diagnosis, frequency of HIV positivity among them, and its association with CD4 counts. Settings and Design: All patients newly diagnosed to have EPTB admitted in a tertiary care medical college hospital in various departments over 1 year were included. Methods and Materials: Clinical presentation, comorbidities, and investigations done to arrive at diagnosis of EPTB were recorded. They were classified based on the affected site. HIV was tested for all patients, and CD4 counts in positive patients. Results: A total of 230 patients were newly diagnosed to have EPTB. The median age was 35 years (IQR 29–45), and the proportion of males was 127 (55%). Imaging was used alone in 47 (20%) patients and in combination with cytology or biopsy in 133 (57.8%) patients to establish the diagnosis. Pleural effusion, 50 (21.7%) patients, peripheral lymph node TB (LNTB), 44 (19.1%) patients, and CNS TB, 37 (16.1%) patients, were the most common forms. HIV was associated in 61 (26.5%) patients and diabetes in 27 (11.5%) patients. Both diseases influenced the presentation of EPTB. There was an association between HIV positivity and type of EPTB with peripheral LNTB being the most common in HIV patients. High CD4 counts were associated with pleural effusion and low counts with disseminated forms. Statistical Analysis Used: chi-square, ANOVA, and Student t test. Conclusion: The pattern of EPTB changes with HIV and vigilance is required to detect severe and disseminated forms of EPTB with lower CD4 counts.
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How Do Residency Match Applicants Fight Battle Against COVID-19 Storm? p. 156
Vaibhav Aggarwal
Every year thousands of domestic and international medical graduates apply for a residency spot in the United States. This communication is an effort to qualitatively measure and describe the impact of the coronavirus disease 2019 (COVID-19) pandemic on the United States residency match application process. This communication tries to perceive a medical graduate who faces the challenges of being a health worker and an examinee at the same time. It is meant for international United States Medical Licensing Examination (USMLE) aspirants to apprise them of the changes that have taken place in the USMLE examinations as a result of the COVID-19 pandemic and advise on how to overcome the difficulties.
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Genome Sequencing of SARS-CoV-2: Outcomes, Predictions, and Their Effects on Therapeutic Options p. 159
Shashank M Patil, Ramith Ramu
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A Rare Case of COVID-19 Infection Presenting as Massive Pericardial Effusion in Young Adult p. 162
Sharad Joshi, Nitesh Tayal, Ankit Bhatia
Novel coronavirus disease 2019 (COVID-19) has emerged as a rapidly spreading viral illness throughout the world. Majority of patients develop pulmonary manifestations. Involvement of extrapulmonary site is rare. We here present a rare case of massive pericardial effusion as a presenting feature of COVID-19 infection.
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Kikuchi Disease: Masquerading as Tubercular Cervical Lymphadenopathy p. 165
Ankur Garg, Prashant Choudhary, Mithilesh Chandra, Devendra Kumar Singh
Kikuchi–Fujimoto disease, also known as “histiocytic necrotizing lymphadenitis,” is a rare, benign disease that commonly affects young females. Patient usually presents with swollen lymph nodes in neck (cervical lymphadenopathy), fever, night sweats, weight loss, nausea, and vomiting. Due to the similar symptomatology, the disease is often confused with tuberculosis and lymphomas. The exact cause remains unknown with no evidence of inheritance. The diagnosis is confirmed by histopathologic examination of lymph node biopsy, which reveals necrosis (that varies considerably from one case to another), histiocytes (contains phagocytosed debris), crescentic nuclei, karyorrhexis, and plasmacytoid monocytes. The disease is self-remitting within 1 to 4 months. However, nonsteroidal anti-inflammatory drugs (NSAIDs), oral corticosteroids, and hydroxychloroquine may be used for symptomatic relief.
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Pseudoaneurysm of Mitral-Aortic Intervalvular Fibrosa – A Case Report p. 168
C.H. Praveen, Shaikh Mohammed Husain Chhotu, Arindam Roy, Neelam Bipinchandra Desai
Pseudoaneurysm of mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare, well-known entity with few cases reported in the literature. We here present a case report of repair of large P-MAIVF that was successfully managed. Postoperatively patient had an uneventful course and patient was asymptomatic at 3rd month follow-up. The cause of P-MAIVF could be an atheromatous ulcer at interleaflet trigone with severely calcified aortic valve as in our case. Even if the imaging and diagnostic modalities are inconclusive, a strong suspicion should be made preoperatively in the presence of abovementioned combination for better preparedness to improve the outcome of surgery.
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Kienbock’s Disease with Volar Intercalated Segment Instability: A Therapeutic Dilemma p. 171
Sumit Arora, Ajeesh Sankaran, Anil Dhal
The etiology of avascular necrosis of the lunate (Kienbock disease) remains unclear despite long clinical experience. Very rarely, it may be associated with carpal instability. We describe a case of 45-year-old female who had Kienbock disease with associated volar intercalated segment instability, detailing how the radiographic features can often cause a dilemma in the staging and management of this enigmatic problem.
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Covid: Seen Through Prism of A Doctor Patient p. 175
Kirti Singh
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Mental Health Tool-Kit for Healthcare Professionals Highly accessed article p. 177
Shreya Sood, Arpita Gupta
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Lung Function Status of Delhi: Points to Ponder p. 179
Pranav Ish
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