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   Table of Contents - Current issue
July-September 2020
Volume 16 | Issue 3
Page Nos. 101-141

Online since Friday, October 9, 2020

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Killer secretions: Organophosphorus poisoning: Practice eessentials and protocols p. 101
KP Amrithachandra, TP Sreekrishnan, KP Gireesh Kumar
Organophosphorus pesticide self-poisoning is an important clinical problem in rural regions of the developing world and kills an estimated 200,000 people every year. Unintentional poisoning kills far fewer people but is a problem in places where highly toxic organophosphorus pesticides are available. Medical management is difficult, with case fatality generally more than 15%. However, consensus suggests that early resuscitation with atropine, oxygen, respiratory support, and fluids is needed to improve oxygen delivery to tissues. The role of oximes is not completely clear.
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Prediction of outcomes in stroke patients from radiological findings – A hospital-based retrospective cohort study from a comprehensive stroke care center in Kerala, India p. 105
Remya Sudevan, Vivek Nambiar, Padma Priyaa Arumugam Premalatha, Sridhar Suresh Babu, Anu Vasudevan
Introduction: Functional outcome after stroke can be improved by early and accurate diagnosis with the help of imaging techniques such as computed tomography (CT) and magnetic resonance imaging. Alberta Stroke Program Early CT Score (ASPECTS) calculated from the CT image infarct areas of middle cerebral artery (MCA) circulation is supposed to be a reliable outcome predictor. Methodology: A retrospective cohort study was conducted in the Comprehensive Stroke Care Center for a period of 6 months. All adult patients (18–90 years) who had visited the hospital from January 2014 to December 2017 were enrolled for the study. Patients with MCA strokes were only included in the study since the ASPECTS is defined for this territory. The data were gathered from the electronic format of the patient information system in the institution and were entered in a structured proforma specifically designed for the study. ASPECTS was calculated from the CT findings of the patient. The modified Rankin Scale (mRS) scores were calculated for every patient at four different time points. The collected data were compiled in a Microsoft Excel sheet and were analyzed using IBM Statistical Package for Social Sciences (SPSS version 21). The summary statistics for categorical variables were reported using frequency and percentage and continuous variables as mean (standard deviation). We reported the association of the ASPECTS with mRS at different time points using the Chi-Square test. Results: A total of 132 adult patients were enrolled in the study. The mean age of the study population was 60.72 (±13.99) years, and among them, 93 (70.45%) were males. Majority of the patients were nonvegetarians (99.92%). The most prevalent risk factor found was hypertension (62.1%). The most common symptom presented by the patients was facial palsy (28%). When the ASPECTS was calculated for 132 patients, 62 patients fell in the high ASPECTS category (8–10), 45 patients had a moderate ASPECTS (5–7), and 25 had low ASPECTS (0–4). mRS scores calculated for four different time points showed a decline in disability in most of the patients. ASPECT and mRS had a negative association signifying, as the ASPECTS increases the number of functional disability decreases. Conclusions: Our study results show that ASPECTS can be a definite outcome predictor in MCA stroke patients.
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Building evidence for information surveillance of nutrition rehabilitation center to assess risk factors for severe acute malnutrition in a tertiary hospital of the northern state of India p. 110
Suresh Kumar, Dinesh Kumar, Sunil Kumar Raina, Milap Sharma
Background: As community-based surveys require energy and time, information surveillance of nutrition rehabilitation centers (NRCs) can be used to assess the nature and degree of risk factors for children with severe acute malnutrition (SAM). Therefore, the current study was planned to assess the degree of association of known risk factors for SAM among children admitted in NRC of a tertiary hospital from the northern state of India. Materials and Methods: Case–control study design was adopted where 50 children with SAM (cases) were recruited from NRC and 50 without SAM (controls) were from an immunization clinic of a tertiary center. A pretested structured interviewer-administered questionnaire was used to collect data from cases and controls. Results: Type of house, status of water and sanitation, simple exponential smoothing, method of birth, birth order, initiation and frequency of breastfeeding, colostrum intake, and profile of diarrhea and acute respiratory infection were statistically similar among cases and controls. Logistic regression analysis observed SAM had significantly high odds for risk factors like mean age of mother at birth (1.4, 1.0–1.9), low birth weight (LBW) (8.7, 2.1–35.3), and bottle feeding (6.3, 1.2–14.2), whereas exclusive breastfeeding (0.2, 0.4–0.4) and fully immunization (0.07, 0.5–0.001) had significantly low odds. Conclusion: Advancing age of mother at the time of delivery, LBW, poor rate of exclusive breastfeeding, and high rate of bottle feeding are significant associated factors for SAM in the study area. Reasons for LBW and reasons for bottle feeding need to be targeted in the study area to reduce SAM among children <5 years of age.
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Thinking beyond lockdowns and social distancing: Identifying the predictors of spread for COVID-19 pandemic using ecological correlation study p. 115
Sunil Kumar Raina, Mitasha Singh
Background: COVID-19 (SARSCoV2 or 2019 novel coronavirus [nCov]) pandemic has spread to every continent except Antarctica, and cases have been rising daily globally. However, COVID-19 is not just a health crisis. Aim: The present study was aimed to identify the predictors defining spread of the pandemic. Methodology: An ecological correlation study was conducted to identify the factors predicting the spread of COVID-19 (SARSCoV2 or 2019 nCov) pandemic worldwide. For this purpose, countries affected with Covid-19 worldwide from both the northern and southern hemispheres were included using a predefined inclusion criteria. Data from the selected countries were retrieved for the duration extending from January 1, 2020, to March 31, 2020. Results: A significant moderate positive correlation between cumulative Covid-19 cases and number of motor vehicles registered per 100 persons was observed in January 2020 (r = 0.623, P = 0.01) and March 2020 (r = 0.620, P = 0.01). Population density remained positively correlated with the cases of Covid-19. A strong significant correlation was observed in February (r = 0.746, P = 0.001). Increase in the length of highway road in countries was statistically significantly correlated with the increase of cases in the month of March 2020 (r = 0.644, P = 0.007). However, after accounting for all the variables, none of the variables could be identified as an independent predictor of cumulative cases except for time (in form of months). The R2 of the model was 41.4%. Conclusions: Urbanization, urban clustering, and population density may be the important contributors in spread; however, their role as independent predictor may be questionable. Therefore, it is time to think beyond social distancing and lockdowns and strengthen primary care and public health.
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Clinical profile of patients presenting to the emergency department with acute pulmonary edema p. 120
Fathima S Nissar, Manna Maria Theresa, TP Sreekrishnan, BS Dhanasekaran, KP Gireesh Kumar
Objective: The objective is to study the clinical profile of patients presenting to an emergency department with acute pulmonary edema. Materials and Methods: This is a prospective, observational study performed in 100 patients presenting to the Emergency Department of Amrita Institute of Medical Sciences (Kochi) with acute pulmonary edema. Patients were selected according to the inclusion and exclusion criteria. The variables analyzed were age, sex, comorbidities, ABG, cardiac enzymes, NT-prob-type natriuretic peptide, chest X-ray, electrocardiogram, and clinical outcome. Results: Of the 100 patients, 64% were male and 36% were female. Age group affected were between 51 and 70 years (52 patients) and between 71 and 90 years (32 patients). Data analysis revealed that the cause of pulmonary edema in 63 patients was cardiogenic and 37 patients was chronic kidney disease. Conclusion: In this study, the incidence was more in males, nearly twice that of females. The most commonly affected age group was between 51 and 70 years of age (52%). We found that the most common cause of pulmonary edema was congestive heart failure (63%) followed by chronic kidney diseases (37%). Moreover, the most common ABG finding was high anion gap metabolic acidosis, mostly lactic acidosis.
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Posterior reversible encephalopathy syndrome due to autonomic dysreflexia in medullary infarction p. 124
K Vivek Nambiar, Jishnu Narayanan Nair, V Amrutha Ajai, Remya Sudevan
The simultaneous occurrence of cervicocephalic arterial dissection and posterior reversible encephalopathy syndrome (PRES) is a rare entity. A healthy 33-year-old male with no known comorbidities had sudden onset pain in the neck, while he was doing strenuous physical labor. Over the next 2 days, he developed symptoms such as swaying to either side while walking, numbness on the left side of his body, painless progressive bilateral blurring of vision, and drooping of bilateral eyelids. On arrival at the emergency room, he was drowsy with a Glasgow Coma Score of 14 and complained of headache in addition to the preexisting symptoms. He also reported that his entire visual field was clouded and dark. On examination, he was detected to have a blood pressure of 220/120 mmHg with bilateral mild ptosis and nonreactive pupils. He had cortical blindness at the time of admission. He had significant gait and truncal ataxia but no other cerebellar signs. Motor system examination was unremarkable and plantars were flexor. No objective sensory deficit was demonstrable. Magnetic resonance imaging showed acute infarct in the vermis with vertebral artery dissection at V4 extending to the basilar artery. In addition, there were diffuse T2-hyperintensities in the bilateral occipital areas without restricted diffusion suggestive of posterior reversible encephalopathy syndrome [Figure 1]. He was admitted to the intensive care unit; the high blood pressure was treated aggressively with labetalol and hydralazine. Gradually, his vision improved over 48 h and back to normal acuity by 5 days. His magnetic resonance angiography with the neck vessels showed a dissection of the vertebral artery. His symptoms of medullary infarct persisted for a few weeks and then resolved completely. Young brainstem stroke with neck pain points to vertebral artery dissection. Concurrent worsening with autonomic fluctuation can be due to associated PRES and is to be considered as this situation is eminently treatable with good control of blood pressure at the earliest.
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Primary pelvic primitive neuroectodermal tumor: A rare tumor in an adult male p. 127
Abhishek Laddha, Pooja Ashok Phalak, MR Bindhu, Appu Thomas, P Ginil Kumar
Primitive neuroectodermal tumor is a rare tumor involving the genitourinary system. Primary pelvic primitive neuroectodermal tumors are extremely rare in an adult male. We report a case of a young adult with large primary pelvic primitive neuroectodermal tumor.
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Infant viral exanthem: Simple sneezes or measles? p. 130
Bharat Pillai, C Jayakumar, Devraj Ramakrishnan, Jay Vishwanath
Measles is a highly infectious viral exanthema very rarely seen in children under 9 months, as well as adults. We describe a case of measles in a 29-day old infant who presented with fever, rash and pneumonia. Treatment commenced with IV antibiotics, IVIG and oral Vitamin A following admission to the ICU. The mother had a similar illness prior to the onset of symptoms in the baby. She had not received MCV as per schedule. The infant and mother recovered fully without any complications. We conclude that administering one dose of MCV to a woman who has not taken at least two doses of MCV- at least three months prior to conception may help in preventing measles in the infant in first nine months of life.
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Management of a case of diffuse sclerosing osteomyelitis p. 133
A Akhila, Salu S Kumar, VP Prabath Singh, S Vijaykumar
Definitively diagnosed disease-directed therapy leads to the rapid resolution of clinical illness and decreases the chances of developing chronic ailments. Appropriate diagnosis is crucial in initiating such therapies which can be made straightforward with the assistance of modern diagnostic aids. Osteomyelitis is an inflammatory disease of the bone and its marrow contents. This disease can have multifarious clinical and histopathologic presentations. Osteomyelitis of the jaws has proved to be a challenging condition to effectively diagnose, treat, and cure. However, there are various diagnostic aids which help in the identification of the condition. The diagnosis is usually based on a thorough evaluation of the patient history and clinical presentation, imaging techniques, culturing, and histologic analysis. Cone-beam computed tomography (CBCT) has proved to emerge as a promising diagnostic aid in relation to osteomyelitis. CBCT offers different views that give a clear insight into the extent of involvement of the disease. Treatment of this condition includes two lines of management – conservative approach and surgical approach. The conservative approach includes the use of antibiotics, hyperbaric oxygen therapy which improves the availability of antibiotics at the localized site, especially with the sclerosing variant. Surgical interventions are usually confined to the extraction of extremely mobile teeth, debridement of fragments of bone, and incision and drainage of fluctuant areas. Additional surgical procedures are considered if the infection persists, and these include sequestrectomy, saucerization, decortication, or resection followed by reconstruction. A case of diffuse sclerosing osteomyelitis arising from nonvital teeth managed using the surgical approach is presented here.
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Anesthetic management of total thyroidectomy and partial sternotomy for a case of retrosternal goiter p. 138
Gokuldas Menon, Pawan Kumar, Ahlam Abdul Rahman, Shalini M Nair, Mathew George, Eldo Issac
The anaesthetic management of retrosternal thyroid swellings has many associated problems. Positioning and induction may cause severe cardiorespiratory decompensation. Intubation may be difficult and may require all the gadgets for difficult intubation procedure. Rarely patients may require cardiopulmonary bypass to save life. Extubation may be difficult in patients with tracheomalacia. Post-operatively patients may require tracheostomy and ventilatory support. This is a case report outlining successful management of a patient with retrosternal goiter who underwent total thyroidectomy following partial sternotomy.
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