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   Table of Contents - Current issue
Coverpage
January-April 2022
Volume 8 | Issue 1
Page Nos. 1-91

Online since Friday, April 29, 2022

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REVIEW ARTICLES  

COVID-19 in Children: A Review on Our Understanding So Far Highly accessed article p. 1
Siddharth Madan, Srishti
DOI:10.4103/mamcjms.mamcjms_40_21  
Clinical manifestations of SARS-CoV-2 in children are not typical. These range from relatively mild to no symptoms in 90% of patients to a severe Kawasaki like disease compared to adults. The outcome is usually favorable in children. There are relatively few studies related to coronavirus disease (COVID-19) in children, no major clinical trials exist. The experience of this novel disease in adults is being extrapolated to manage pediatric COVID-19 cases. This review summarizes the current understanding of pediatric COVID-19 with regards to the epidemiology, clinical manifestations and management.
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Innovative Strategies in Medical Education for Addressing Gaps in Health-Care Service in Rural India p. 11
Bratati Banerjee
DOI:10.4103/mamcjms.mamcjms_119_21  
At least half of the world’s population still do not have full coverage of essential health services and the available health-care services are also not equitably distributed, the rural areas being the generally underserved ones. Several factors influence attraction and retention of doctors in rural areas which are related to international and national contexts, work-related factors, environmental and living conditions, and individual or personal factors which includes family and social support, in addition to personal aspirations. Innovative strategies have been worked out and implemented to address these problems and fill the gaps in the areas of educational, regulatory, financial and professional and personal support. This review discusses the educational strategies which are targeted at all levels viz. selection of candidates for admission, and subsequent undergraduate, internship, and postgraduate teaching and training that can be oriented toward rural health and health-care services
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ORIGINAL ARTICLES Top

Impact of COVID-19 Pandemic on the Care of Non-COVID Pediatric Patients: A Healthcare Workers’ Survey from India p. 18
Puneet Kaur Sahi, Priyanka Meena, Pallavi , Anirban Mandal, Aashima Dabas
DOI:10.4103/mamcjms.mamcjms_103_21  
<**b**>Background: Coronavirus disease 2019 (COVID-19) pandemic-related refocusing of healthcare along with needs for social distancing, complete or partial lockdowns, and burgeoning economic crisis has created immense barriers to the access of healthcare services by the non-COVID patients. <**b**>Aim: We aimed to assess the perspectives of Indian healthcare workers taking care of pediatric patients on the barriers to healthcare delivery to pediatric non-COVID illnesses. <**b**>Methods: Indian healthcare workers, working in both public and private sectors, taking care of pediatric patients were surveyed using a predesigned pretested online questionnaire over a period of 1 month (May 2020). The impact on healthcare delivery was graded using a Likert scale. <**b**>Results: Of the total of 356 responses obtained, 75.3% reported a significant negative impact of the COVID-19 pandemic on delivery of healthcare to non-COVID pediatric patients. Respondents of government and COVID hospitals reported a significantly worse impact than private (<**i**>P = 0.0002) and non-COVID hospitals (<**i**>P = 0.01), respectively. Significant decline in number of non-COVID patients attending outpatient department (86.2%), admitted in wards (71.6%), number of routine (81.7%) and emergency surgeries (60.5%), number of diagnostic procedures (61.2%), and scheduled therapies (50.2%) was reported by the surveyed healthcare workers. Most important factors for disrupted healthcare delivery were restricted travel (78.3%) and fear of contracting COVID-19 (68.8%). Telemedicine (67.4%) was the commonest alternate strategy deployed for continuing care of patients. <**b**>Conclusion: Several challenges exist to maintain the continuity of healthcare services to pediatric non-COVID patients especially in those with chronic diseases, poor financial background, and follow-up in COVID government hospitals. Use of telemedicine, strategic preplanning, strengthening peripheral healthcare, and optimal resource reallocation may help reduce the broader health impact of the COVID-19 pandemic.
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Use of Students’ Learning Outcomes as a Tool for Changing Teaching Content and Methodology: Assessment of Impact p. 26
Syed Shariq Naeem, Vandana Roy
DOI:10.4103/mamcjms.mamcjms_116_21  
Objectives: Assessment of student’s learning outcomes in alignment with the teaching goals can be a tool for modification of curriculum and teaching methods. This study was conducted to evaluate the impact of a pharmacology curriculum on students’ learning outcomes and the use of their assessment as a tool for making curriculum changes. Materials and methods: An assessment of the students’ (exiting 2014) knowledge and skills at the end of their fifth semester training in pharmacology was carried out using a questionnaire that was developed to accommodate testing of all areas which are underlined in the Medical Council of India’s goals and objectives of teaching pharmacology to MBBS undergraduates at the time of designing of the study. Areas where lesser than 50% students scored well were identified for educational interventions with the next two batches of students (2015, batch B and 2016, batch C), who were then subjected to the same assessment. Results: Based on the learning outcomes, 15 areas were identified for educational interventions with batch 2015. Improvement in learning outcomes of students was observed in 10, ranging from 10% to 15% in batch 2015, whereas in batch 2016, an improvement of 20% was observed in three questions and >10% was observed in six questions. Overall improvement in the intervention questions was 60% (+9 questions) in batch 2015 and 80% (+12 questions) in batch 2016 when compared with preintervention batch 2014. The preintervention batch 2014 scored better overall than the intervention batches 2015 and 2016. Conclusions: Changing teaching content and method, based on assessment of students’ learning outcomes alone, may not translate into an improvement in students’ learning outcomes. Teachers must look for other factors that can impact students’ learning.
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Internet Gaming Disorder and Its Harmful Health Effects among the Medical Students in a Tertiary Care Teaching Hospital p. 33
Anshu Singh, Tuhina Shree, Prem Kumar
DOI:10.4103/mamcjms.mamcjms_63_21  
Background: Online gaming has gained a lot of popularity due to easy accessibility of Internet-enabled devices. This has given rise to a new phenomenon of gaming addiction. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) published by American Psychiatric Association, in 2013, included the term Internet gaming disorder (IGD). Impact of IGD on physical and psychologic health warrants further exploration. Objectives and methods: A cross-sectional study was carried out among medical students to find out the prevalence of IGD and the associated health effects. The study was conducted from July to September 2019. Data collection was carried out using a semistructured self-administered questionnaire consisting of sociodemographic profile, Pittsburgh sleep quality index, DSM-5 criteria for IGD and examination of participants. Data were entered and analyzed using frequency, percentage, and Chi-square test. Results: Almost three-fourth participants (72.2%) engaged in the online games out of which 30.9% had IGD. A higher proportion of male students were found to be suffering from IGD. Sleeping disorder was also found to be significantly more among those who had IGD. Conclusion: Prevalence of IGD was found to be high among medical students. The majority of gamers also faced various health consequences of which sleeping disorder was the major problem.
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Knowledge and Awareness Regarding Facemasks among Medical Professionals in a COVID-Dedicated Hospital – A Cross-sectional Study p. 40
Sulakshna Aggarwal, Lovenish Bains, Anurag Mishra, Aashima Dabas, Madhav Goel, Aiman Perween Afsar
DOI:10.4103/mamcjms.mamcjms_102_21  
Background: Severe acute respiratory syndrome coronavirus 2 is a severe respiratory infection that spreads through infected droplets. Facemasks have been mandated by the World Health Organization and Centers for Disease Control as the cornerstone for preventing the spread of infection among healthcare workers. However, despite the ubiquitous use of masks, many healthcare professionals are unaware of their properties and proper use. Therefore, the study aims to assess the awareness, practices followed, and problems faced in the use of facemasks among medical professionals in a coronavirus disease (COVID)-dedicated hospital. Methodology: An e-questionnaire-based survey was conducted among medical professionals working in a tertiary care (COVID-dedicated) hospital in North India. The questionnaire tested for the knowledge and awareness on properties of facemasks, problems faced on regular or prolonged use, and removal, storage, and disposal practices among professionals. Results: The survey was sent to 368 medical professionals with a response rate of 45.65%. About 43.3% of the participants were aware of the properties of the N95 facemask, and 26% of the health professionals checked for the proper fit of the mask after putting it on. Discomfort and sweat issues were the most common problems reported by 84% and 69.33% of participants, respectively. About 86% of the participants had the knowledge of appropriate removal of the mask, but only one-third were aware of the proper mask disposal practices. Conclusion: Knowledge about the properties of facemasks, their use, and disposal practices among the North Indian healthcare professionals was found to be significantly lower than in western countries; however, the awareness increased with experience in the participants studied (P < 0.001). As it is the young medical force at the forefront to tackle the menace, regular training and accurate information on facemask usage must be disseminated via institutional training programs to prevent the risk of infection and equip the frontline workers to share this knowledge with the community further.
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Serum Lipids in COVID-19: A Case–Control Comparative Study from a Tertiary Care Center, New Delhi, India p. 51
Anita Rani, Omkar K. Choudhari, Rohit Kumar, Paarth Bhatia
DOI:10.4103/mamcjms.mamcjms_84_21  
Background: The coronavirus disease 2019 (COVID-19) pandemic still remains as an evolving condition. The available literature suggested that the level of various biochemical parameters was found to be associated with severity of the infection and can be used as markers of severity in patients with COVID-19. However, speculation for association of hypolipidemia with COVID-19 severity was also postulated. Hence, present study is conducted to find association of lipid profile with the severity of the disease. Materials and methods: A case–control study was carried out in the months of August to October 2020 in Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. Cases included 103 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) real-time polymerase chain reaction (RT-PCR)-positive admitted patients (52 with moderate disease and 51 with severe disease), whereas control included 100 SARS-CoV-2 RT-PCR-negative patients visiting outpatient clinic of Department of Respiratory Medicine of the hospital. Total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) values of participants were evaluated and compared among severe COVID-19 cases and controls as well as in moderate and severe COVID-19 diseased. Results: Among 103 patients, 52 patients had moderate disease and 51 had severe COVID-19 on admission. The mean serum total cholesterol level in cases was 145 ± 64.21 and 161.43 ± 43.48 mg/dL in controls (P = 0.035). Mean serum triglyceride level was 167.22 ± 99.04 mg/dL in COVID-19 cases and 141.73 ± 71.76 mg/dL in control (P = 0.037). Mean serum LDL-C level was 93.77 ± 38.68 mg/dL in cases and 110.74 ± 43.11 mg/dL in control (P = 0.004). Mean serum HDL-C level was 29.61 ± 11.71 mg/dL in cases and 42.35 ± 13.87 mg/dL in control population (P < 0.001). Conclusion: Hypolipidemia was found to be significantly associated with COVID-19 infection in the current study. There was no statistically significant difference found in patients with moderate and severe COVID-19 in this small group study.
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Biofilm Formation in Methicillin-Resistant and Methicillin-Sensitive Staphylococcus aureus Strains p. 56
Ankita Singhal, Manisha Jain, Rajni Gaind
DOI:10.4103/mamcjms.mamcjms_10_21  
Background: The combination of methicillin resistance (MR) and the ability of biofilm formation of Staphylococcus aureus (SA) makes treatment difficult. Biofilm is formed by distinct genetic mechanisms in MRSA and methicillin-sensitive SA (MSSA), and hence, there is difference in the prevalence of biofilms in them. This study investigated the biofilm production in SA and analyzed its correlation with MR. Materials and methods: A total of 261 consecutive Staphylococcus aureus isolated from various clinical samples from January to April 2019 were included in the study. Antibiotic sensitivity was carried out as per Clinical and Laboratory Standards Institute guidelines and cefoxitin disk was used for screening for MR. Total of 147 MSSA and 114 MRSA were taken for further processing. Biofilm formation was determined by tube and microtiter plate methods in all the isolates. The data were analyzed for statistical significance using Microsoft excel software. Results: Resistance to erythromycin, clindamycin, gentamicin, cotrimoxazole, and inducible clindamycin resistance was significantly higher in all the MR Staphylococcus strain including biofilm forming MRSA strains. The biofilm formation was significantly higher in MSSA isolates by both the tube (78.2%) and microtiter plate methods (64.9%). Discussion: Although the antimicrobial resistance was higher in MRSA, the ability to form biofilms was significantly higher in MSSA. Biofilms of MSSA are usually less prevalent than MRSA probably because of the distinct genetic mechanisms involved in the formation of biofilms. The higher biofilm forming ability of MSSA in our study highlights the need for determination of other genes involved in biofilm formation and virulence mechanisms in SA.
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Stigma and its Associated Factors among People Living with HIV/AIDS (PLHA) Attending ART Centre in a Tertiary Care Institute in Kolkata p. 62
Kaushik Adhikari, Debashis Dutt, Dipak Pal, Suprakas Hazra
DOI:10.4103/mamcjms.mamcjms_87_21  
Background: AIDS stigma exists in a variety of ways, including ostracism, rejection, discrimination, and avoidance of HIV-infected people. Some people are rejected by family and community, whereas others face poor treatment in healthcare and educational settings, erosion of their rights, and psychologic damage. All these limit access to HIV testing, treatment, and other HIV services. Objectives: This study was undertaken to determine the proportion of patients with severe stigma among people living with HIV/AIDS (PLHA) and to identify the factors associated with it. Materials and methods: It was a cross-sectional study conducted among 444 PLHA, attending ART center of a tertiary care institute of Kolkata, chosen by systematic random sampling. Berger scale was used to classify stigma as no, mild, and severe stigma. Logistic regression analyses were performed to identify the risk factors. Results: About 32.7% of PLHA had experienced severe forms of stigma. These were severe forms of personalized stigma (33.8%), negative self-image (25.9%), perceived public attitude (27.5%), and disclosure concerns (30.0%). Overall severe stigma was higher in females (33.3%) than males (31.8%). After binary logistic regression, factors significantly associated with severe stigma included age [adjusted odds ratio (AOR) 1.564 (1.071–2.285), sig: 0.021], socioeconomic status [AOR 0.748 (0.574–0.974), sig: 0.031], HIV status known to the partner [AOR 19.965 (3.3673–78.357), sig: <0.0001], presence of comorbidities [AOR 8.497 (3.541–20.389), sig: <0.0001], and possible mode of transmission not known by the patient [AOR 0.615 (0.380–0.993), sig: 0.047]. Conclusion: Study found that those who were older, who were from lower socioeconomic group, whose partner knew their disease status, who were having comorbidities, and who do not know their mode of infection experienced a higher level of HIV-related stigma.
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CASE REPORTS Top

Moebius Syndrome: A Case Report with Unique Features p. 70
Divya Ramraika, Pradeep Kumar, Bithi Chowdhury
DOI:10.4103/mamcjms.mamcjms_126_21  
We report a case of a 13-year-old female who presented in the medical emergency with seizures and was referred to the ophthalmology department for fundus examination. On examination, she was found to have bilateral asymmetric VIth and VIIth nerve palsy, bilateral horizontal gaze paresis (right > left), tongue atrophy, mask-like face, normal intelligence, prominent lower lip, and history of treated club foot. She was diagnosed to have Moebius syndrome based on the above findings. She also had some atypical features such as head tilt, significant refractive error, anisometric amblyopia, and horizontal nystagmus. Her computed tomography scan of the head revealed neurocysticercosis.
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Anesthetic Management in Pediatric Patient with Moyamoya Disease in Orthopaedic Surgery: “Managing the Precarious Circulation” p. 73
Manisha Manohar, Bharti Wadhwa, Kirti N. Saxena, Divya Gahlot
DOI:10.4103/mamcjms.mamcjms_3_21  
A 12-year-old female, diagnosed case of Down phenotype with Moyamoya disease (MMD) was posted for internal fixation of compound fracture shaft of femur. Preanesthetic evaluation revealed history of acute URI, abnormal body movements, left hemiparesis and mental retardation. Patient was managed under general anesthesia with proseal LMA and caudal epidural was administered for adequate analgesia in the perioperative period. The goal of anaesthetic management in a case of MMD is to maintain the balance between cerebral metabolic oxygen consumption rate (CMRO2) and cerebral blood flow (CBF) in order to prevent any neurologic morbidity. Though there is no ideal anaesthetic agent in MMD, the anaesthetic technique should ensure normotension, normocapnia and normothermia in the perioperative period. To our knowledge regional analgesia has not been used in the pediatric orthopedic surgeries in patients diagnosed with Moya moya. The technique of general anaesthesia supplemented with caudal epidural analgesia ensures that all the anesthetic goals are met adequately and the precarious cerebral circulation in moya moya patient is not compromised.
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Use of TIVA as an Adjuvant to SAB in a COVID-19-positive Parturient with Morbid Obesity Posted for Emergency Caesarean Section − A Case Report p. 76
Divya Gahlot, Bharti Wadhwa, Kirti Nath Saxena
DOI:10.4103/mamcjms.mamcjms_34_21  
Obstetric patients offer specific anesthesia concerns and associated coronavirus disease 2019 (COVID-19) infection makes the condition more challenging. We describe anesthetic management and difficulties encountered in a parturient with multiple comorbid conditions who came for an emergency caesarean section (CS). A 32-year-old morbid obese COVID-positive female G2P1L1 at 36 weeks gestation with previous LSCS, gestational hypertension, and diabetes presented for emergency CS in view of fetal distress. She had a respiratory rate of 24 to 28/minute maintaining a saturation of 94% to 95% on oxygen at 6 to 8 L/minute. Airway examination revealed mouth opening = 2.5 cm, Mallampati classification III, neck circumference 40 cm, temporomandibular distance 3.5 cm. Surgical duration was unusually prolonged and was successfully managed with total intravenous anesthesia (TIVA) as an adjuvant to subarachnoid block. We successfully managed an emergency CS of a morbidly obese parturient with COVID-19 infection using TIVA as a rescue anesthesia to central neuraxial block, avoiding conversion to general anesthesia, minimizing aerosolization and associated risk.
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A Case Report of Sudden Bradycardia and Impending Cardiac Arrest by Intramyometerial Vassopressin in Laproscopic Myomectomy p. 79
Shubhangi Sharma, Sameer Raj
DOI:10.4103/mamcjms.mamcjms_18_21  
Vasopressin has long been used in myomectomy to decrease blood loss. Its efficacy is beyond doubt. But at the same time, it is known to cause some of the serious cardiovascular side effects. We are here to report a case of severe bradycardia and impending cardiac arrest caused by intramyometerial infiltration of 13 IU of vasopressin.
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Sequential Fracture of Neck of Femur of Both Sides in a Patient with Psychosis: A Diagnostic Dilemma p. 82
Dhananjaya Sabat, Prerna Kukreti
DOI:10.4103/mamcjms.mamcjms_27_21  
The authors describe the case of an adult male patient with psychosis developed fractures of neck femur of both sides sequentially at a year interval following trivial trauma. In addition, the patient was found to have hyperthyroidism. The rare presentation, possible complex etiopathogenesis for the problem and difficulties in treatment are discussed.
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SHORT COMMUNICATION Top

Experiences with Horizontal and Vertical Integration in Competency-based Physiology Education p. 85
Aarti Sood Mahajan, Garima Rakheja, Smita Kaushik, Prerna Arora, Anubhuti Chitkara, Rashmi Verma
DOI:10.4103/mamcjms.mamcjms_112_21  
Integrated teaching is a well-known concept in medical education and has been reintroduced in the competency-based curriculum. The physiology department started the exercise in the topic of hematology in 2019 in the offline mode and again in 2021 in the online mode (due to the pandemic). This article is an attempt to describe what went through in its conceptualization and implementation. The background of integration, types of integration, how the exercise was planned, and the feedback of the faculty are included. This could benefit the phases 2 and 3 faculty members who must be planning similar exercises now. In addition, it would act as a screenshot to others, phase 1 faculty included, to help them do a similar or other exercises in the coming years. Integration in competency-based curriculum is here to stay. We can gradually improve upon it and innovate it.
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