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   Table of Contents - Current issue
July-December 2022
Volume 24 | Issue 2
Page Nos. 109-213

Online since Sunday, September 25, 2022

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Evolution of Polysomnography p. 109
Priyadarshee Patra, Anuj Singhal, Virendra Singh, Shyam Krishnan
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Outcomes in HIV patients on two different protease inhibitors on second-line antiretroviral therapy: An observational study p. 113
Kuldeep Kumar Ashta, Sumit Arora, Niket Verma
Introduction: There were 38 million people living with HIV in the world in 2019, out of which 5.8 million were living within the Asia-Pacific region. Globally, 67% (25.4 million) and within the Asia-Pacific region, 60% (3.5 million) of the individuals living with HIV were accessing anti-retroviral therapy (ART) respectively. Approximately 4% of the patients on ART are on second-line therapy. The aim of this research was to analyze the difference in efficacy and tolerance of boosted lopinavir and boosted atazanavir as part of second-line ART regimens and factors associated with the difference. Materials and Methods: The observational study was conducted at a referral ART clinic of a tertiary care hospital in North India. This was an ambispective study on patients under evaluation for first-line treatment failure. One hundred and fifteen and sixty patients were recruited to lopinavir and atazanavir study groups, respectively. Efficacy was assessed by adequate suppression of plasma viral loads 12 months after starting therapy with protease inhibitors. Results: Both the regimens are highly effective in reducing viral loads. Regarding adverse drug reactions (ADRs), hyperlipidemia and abnormal liver function test (transaminitis) were the most common ADRs in the lopinavir study group, whereas nausea, fever, and indirect hyperbilirubinemia were the most common ADRs in the atazanavir study group. Conclusions: Lopinavir and atazanavir are both highly effective in reducing viral loads and produced comparable CD4 levels post 1-year follow-up.
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Pattern of anterior cruciate ligament injuries in armed forces p. 118
Munish Sood, Julie Sachdeva, Amresh Ghai, Ajaydeep Sud, Monika Chauhan, Shalendra Singh
Background: Anterior cruciate ligament (ACL) injuries are the commonly seen and potentially devastating injuries in sportsperson and high-demand professionals like military personals. The return to the preinjury status even after the successful ACL reconstruction surgery is not assured. The aim of this study was to assess the pattern and profile of ACL injuries seen in military personnel. Materials and Methods: Five hundred and twenty-four patients who were operated at our center with ACL reconstruction and were meeting the inclusion criteria were included in this study. Patients were evaluated with detailed history and clinical and radiological examination. Results: Five hundred and twenty-four patients were evaluated at a mean of 7.86 months. The mean age was 29.64 years (range: 20–46 years). Five hundred and twenty patients were male and four were female. The mode of injury was sporting activity in 244 (46.6%), military training-related activity in 180 (34.3%), and other activities in 100 (19.1%). Football and basketball were the most common sporting activities in which ACL injuries were sustained, while landing injuries during 9-feet ditch activity (n = 109) were the single most common activity in which ACL injuries were sustained. An isolated ACL tear in 235 patients was the most common type of injury seen, while the meniscus injuries (medial and lateral meniscus) in 149 (28.4%) and 115 (21.9%) patients, respectively, were the most commonly seen associated injuries. Conclusions: ACL injuries are a common occurrence in armed forces. Injury during sports and landing injuries in 9-feet ditch are the common modes by which patients sustained ACL injuries.
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Emergence of “urban scrub typhus” during Monsoon season in an urban pocket and biodiversity hotspot of New Delhi, India p. 124
Inam Danish Khan, Pradeep Bahal, Bhagwat Singh, Pallawi Priya, Rahul Pandey, Anuradha Makkar, Ashok Kumar Jindal
Introduction: Scrub typhus is an endemic disease transmitted within the “epidemiological tetrad” of rains, rodents, chigger mites, and scrub vegetation prevalent in “Tsutsugamushi Asia-Pacific triangle,” predisposing one billion population at risk and annual incidence of one million. Scrub typhus is difficult to differentiate clinically from coendemic vector-borne acute undifferentiated febrile illness (AUFI). Untreated scrub typhus may cause disseminated vasculitis, serositis, and hemophagocytic syndrome. Outbreaks of scrub typhus have been reported from Thailand, China, Korea, and rural India. Transmission of scrub typhus in urban areas is relatively rare. Three consequent outbreaks in a urban pocket in New Delhi, India, highlight emergence of urban scrub typhus. Materials and Methods: A cross-sectional, clinicoepidemiological, ambispective outcome surveillance study was conducted among all clinicodemographically homogenous patients presenting with AUFI during 2016–2018. Clinically suspected or intuitively investigated scrub typhus was screened by IgM/IgG immunochromatography and confirmed through IgM enzyme-linked immunosorbent assay and real-time polymerase chain reaction. Spatial, temporal, and vector surveillance through epidemiological mapping, line listing, and mite surveillance was done. Results: Scrub typhus outbreaks affected 161 patients during 2016–2018. Mean age was 31.77 ± 17 years. Most common clinical presentation was fever with headache. Eschar was present in 46.88% patients commonly on abdomen, chest, perineum, and extremities. Coinfections and comorbidities were seen in 3.75% and 14.37% patients, respectively. Seventy percent and 14.8% patients were managed in acute care and intensive care. Mean hospital stay was 8.96 ± 3.86 days. Doxycycline and doxycycline-azithromycin combination were given in 92.5% and 7.5% patients, respectively. All-cause mortality was 6.25%. 126/160 (78.75%) patients were geospatially distributed from urban landscape depicted in epidemiological maps. Temporal-seasonal distribution revealed bell-shaped curve from May to November. Mite carriage was seen in 16% rodents. Conclusion: Urban scrub typhus is emerging in microhabitats fulfilling the epidemiological tetrad and chigger mites undergoing transovarian transmission. Geospatial and temporal mapping are required in urban neighborhoods for risk stratification, outbreak management, vector control, and community education. A high index of suspicion in AUFI and early initiation of doxycycline therapy are required.
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Cesarean sections conducted in a tertiary care hospital – An analysis as per robson's ten group classification system p. 131
Shilpa Asthana, PR Lele, Devdatt Pitale, G Sandeep
Background: Over a past few decades, there has been an increase in cesarean section (CS) rates globally. The exponential rise in CS is a major contributory factor in both maternal and fetal morbidities. It is important to assess, analyze, and audit cesarean section rate and its indications, in obstetric care delivery units existing in every health-care system. This study was conducted to audit the rate of CS in our institute with a focus to optimize the indications of CS with an aim to help in reduction in cesarean deliveries in future. Materials and Methods: This retrospective observational study was conducted over a period of 1 year in a large tertiary care hospital. All patients who underwent cesarean section were categorized according to Robson Ten group Classification system. Results: In this study, a total number of deliveries in the given time period were 1062, of which 455 (42.84%) underwent CS. Among the total CS, n = 237 (52.08%) were elective and n = 218 (47.91%) were emergency CS. The highest contribution to the CS, according to Robson's TGCS, was Group 5 and Group 2 in this study. Group 9 had the lowest contribution to CS rate. The most common indication for emergency CS was nonreassuring fetal heart rate (n = 76, 34.86%); however, post-LSCS pregnancy attributed (n = 132, 55.70%) to elective CS. A total number of CS performed at term were 402 (88.35%) and preterm CS conferred to 53 (11.65%). Conclusion: There exists a significant concern toward the overuse of CS. A definitive protocol and optimization of indications for primary CS along with clinical and administrative efforts would aid in minimizing the CS rate. Furthermore, it must be noted that every effort should be made toward provision of CS in women warranting it, rather than achieving specific target goal.
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Cytokine response to antitubercular therapy in patients with human immunodeficiency virus and tuberculosis coinfection with respect to CD4 count and viral load − A pilot study p. 138
Nagesh Venkata Ivaturi, VK Sashindran, Anchit Raj Singh, Vivek Aggarwal
Introduction and Background: Monitoring of efficacy of antitubercular treatment (ATT) in patients with human immunodeficiency virus (HIV) and tuberculosis (TB) coinfection is more often based on clinical judgment. Having an objective biomarker monitor, the treatment response to ATT is urgently required in HIV-TB coinfection. Methodology: Fifty patients of diagnosed HIV infection with TB as opportunistic infection were enrolled. Baseline CD4 and HIV viral load were done. Serum cytokine levels of IFN γ, IL-10, IL-2, and interferon gamma-inducible protein-10 (IP-10) were assessed at baseline and after 2 months of initiation of ATT. Results: Out of fifty patients, 43 (86%) were male and 7 (14%) were female. The mean age of the patients was 39 years. The median CD4 count was 342 cells/uL, and the mean plasma HIV viral load was 3,05,093 copies/ml. Sputum for AFB was positive in 15 (30%) patients. The levels of interferon-gamma (INF γ), interleukin (IL)-4, and IL-10 have shown a statistically significant decline over 2 months [Table 1] with a P = 0.005, <0.001, and 0.023, respectively. There was a significant correlation between IP-10 and CD4 count in male patients as assessed by Pearson correlation coefficient (P = 0.048). Conclusion: The levels of INF γ, IL-4, and IL-10 have shown a statistically significant decline over 2 months [Table 1] with a P = 0.005, <0.001, and 0.023, respectively. There was a significant correlation between IP-10 and CD4 count in male patients.
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Ossicular chain reconstruction in austin-kartush type A and B defects using titanium prosthesis: Audiological and anatomical outcomes p. 142
Tarun Malhotra, Sujay Nadiger, Vaidehi Thakur, Deep Kamal
Introduction: Ossicular chain reconstruction (OCR) augments the hearing mechanism in various ossicular pathologies. Titanium allograft with superior properties was evaluated in the study. Materials and Methods: To assess the audiological and anatomical outcomes following titanium OCR, a retrospective review was performed for 47 cases who underwent OCR from January 2015 to December 2018 at a tertiary care center. The ossiculoplasty was carried out in a single stage tympanoplasty. The partial ossicular replacement prostheses (PORP) and total ossicular replacement prostheses (TORP) were used in 28 and 19 patients, respectively, with a follow up for 12 months. The pre and postoperative air conduction pure tone averages and air bone gaps(ABG) were analyzed. The operative success was defined as a postoperative ABG of ≤20 dB. Fisher's test, analysis of variance (ANOVA), and t test were used depending on data compared. Results: Postoperatively, the mean ABG was 15.4 ± 2.8 dB; about 80. 85% of cases achieved operative success. ABG values showed significant improvement compared with preoperative values (P = 0.001, t test). Successful OCR was achieved 85.7% of PORP and 73.6% TORP cases. Discussion: The mean postoperative ABG was 13.75 ± 5.4 dB for the PORP group and 17.84 ± 2.5 dB for the TORP group. No variation in audiological outcomes was observed when comparing PORPs to TORPs. There was no significant difference in postoperative ABG on comparison of different etiologies (P = 0.508, ANOVA), procedures undertaken (P = 0.226, ANOVA), and primary/ revision surgery (P = 0.172, t test). The extrusion and displacement rates were 2% each. These findings highlight that Titanium OCR gives stable hearing gains with low extrusion rates.
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Spare the rod and spoil the child? Child disciplining practices adopted by mothers in Urban Maharashtra, India p. 149
Sreeni V Nair, Arun Kumar Yadav, Reema Mukherjee
Background: Very little is known about child disciplining practices adopted by parents in India. Few studies carried out in India have shown a high prevalence of violent disciplining practices. Aims: We carried out this study to assess the nature and severity of violent disciplinary practices (VDPs) adopted by mothers in urban Maharashtra and identify possible social and demographic factors associated with them. Materials and Methods: This descriptive cross-sectional study was carried out in a hospital attached to a medical college in Western Maharashtra, India. One hundred mothers were included in our study, and written informed consent was taken from all participants. The UNICEF/WHO Child Discipline Module questionnaire was used as the data collection tool. Ethical clearance was also obtained from the Institutional Ethical Committee before the conduct of the research. Statistical Analysis: Contingencies tables were made to find out factors associated with discipline behavior. Bivariate logistic regression was done, and factors found statistically significant were taken into multivariable logistic regression. Results: Seventy-one percent of mothers used VDP against their children. The older age of a child's mother and father and female gender significantly increased the child's risk of facing VDP. Conclusion: There is a need to sensitize parents on the ill effects of VDP on the physical and mental health of children.
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COVID-19 breakthrough infections amongst ChAdOx1 nCoV-19 (Covishield) vaccinated health-care workers and its clinical manifestations: A prospective observational study p. 154
Deep Kamal, Vaidehi Thakur, Anurag S Chauhan
Introduction: Second wave of the COVID -19 pandemic had a significant impact on India with large number of populations getting affected by it. Pan -India COVID -19 vaccination was started on 16 January 2021. All the hospital Health Care Workers (HCWs) started receiving Covishield vaccine. By March 2021, all the HCWs received 02 dosages of the vaccine. It was the time when the second wave of COVID-19 started in India. This study was conducted to investigate the occurrence and severity of breakthrough COVID -19 infection (BCI) amongst fully vaccinated HCWs. Materials and Methods: This prospective observational study was conducted at a single multispecialty COVID-19 dedicated hospital on fully vaccinated HCWs who developed BCI. A total of 981 HCWs were enrolled and observed them for six months from March -September 2021 for occurrence of BCI. The outcome measures included percentage of fully vaccinated HCWs developing BCI. The BCI according to various demographic variables was studied. Clinical profile, duration between last dose of vaccine and BCI and requirement of mechanical ventilation were analysed. Results: Out of 981 fully vaccinated HCWs, 97 developed BCI. Amongst one -fifth of them were asymptomatic. Fever and cough were the prominent symptoms. Two HCWs developed COVID -19 pneumonia. None required oxygen supplementation or mechanical ventilation. There was no death observed amongst these COVID -19 infected HCWs. Discussion: BCI occurred in 9.88% fully vaccinated HCWs. They were primarily minor and did not lead to severe disease. Overall, Covishield prevented severe infection in HCWs, leading to decreased ICU admission and deaths.
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Outcome of percutaneous cardiac lead extraction in chronically implanted leads with tight rail rotating lead locking device p. 159
Prabhat Sharma, Naveen Agarwal, Balwinder Singh
Aims: Despite advances in lead extraction tools, percutaneous lead extraction is a complex procedure associated with morbidity and mortality. No standards or directives exist to guide the choice of extraction tool or approach, and all operators tend to have their preferred method. The data on removing chronically implanted cardiac leads are scarce in India; reporting outcomes with emerging extraction technology is therefore encouraged. This is the first data submitted for the chronic difficult to explant cardiac leads from India. Materials and Methods: Thirteen lead extraction procedures using the Spectranetics tight rail rotating dilator sheath at the tertiary care center over two years are described here. Results: All patients had chronically implanted leads (mean duration 10.4 years), and the pre-procedure venogram showed occluded left subclavian and brachiocephalic veins with extensive collateralization. All leads were extracted successfully using the rotating dilator sheath, and this kit also retained vascular access by venous recanalization. There were no other procedure-related complications, and all patients remained well with suitable lead parameters at 1-year follow-up. Conclusions: The tight rail rotating extraction tool is safe and effective in chronically implanted leads. Moreover, it helps preserve vascular access by recanalizing long tortuous occlusions. Its use across various centers and a larger number of patients will be required to confirm our results.
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Comparison of USG-Guided gastric volume at 1 h and 2 h of giving clear fluids for elective pediatric surgeries and its effect on postoperative nausea and vomiting p. 164
N Vineela Reddy, Sandhya Ghodke, Ravishekar N Hiremath, Smita M Nimbannavar, Mahesh Krishna Kulkarni
Background: Preoperative fasting is a universally followed principle in patients undergoing elective surgeries to minimize the risk of pulmonary aspiration. Objectives: The main objective is to compare ultrasound (US)-guided gastric volume after encouraging clear fluids till 1 h and 2 h preoperatively. Methodology: We carried out a prospective observational study in a multispecialty children's hospital, wherein pediatric patients of American Society of Anesthesiologists (ASA) I and ASA II physical status undergoing elective surgeries and between the age group of 2 and 10 years were enrolled in the study on sample size of 60. The study tool used was US Mindray machine with a linear probe of frequency 10–12 hertz. The study was approved by hospital ethical committee. Those patients who could take clear fluids 3 ml/kg 2 h prior to surgery as per standard guidelines were placed in Group A and those who received 3 ml/kg of clear fluids till 1 h before surgery placed in Group B. US assessment of gastric volume was done in the preoperative area. Results: There is no significant difference in gastric volumes and antral cross-sectional area in both the groups. There is no significant increase in incidence of postoperative nausea and vomiting in Group B where clear fluids were encouraged till 1 h prior to surgery. Conclusion: According to the study, we can conclude that clear fluids can be encouraged till 1 h preoperatively in pediatric patients undergoing elective surgeries.
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A Cross-sectional survey on workplace-related difficulties among glaucomatous personnel in aviation maintenance tasks p. 171
S Patyal, Atul Kotwal, Sapna Raina, Bharathi Mahapatra, Arun Kumar Yadav
Introduction: Quality of life and work are affected in glaucoma patients due to their disease or treatment. Many papers have identified factors that may affect the life of glaucoma patients. There is no assessment of personnel employed in aviation maintenance tasks suffering from glaucoma at the workplace to the best of our knowledge. Methods: A total of 63 personnel working in aviation maintenance tasks diagnosed with glaucoma were requested to fill a pro forma consisting of 20 questions about their vision-related duties. The questionnaire was designed using a standard technique. The data were entered into an excel sheet and statistically analyzed. Results: About 15.9% had visual problems mainly at night, 4.8% had difficulties walking on uneven ground, 7.9% had difficulty viewing objects in the periphery, 1.6% in crossing roads, 6.3% in climbing stairs, none had any problems in color differentiation, and 1.6% had problems while working on aircraft parts. Conclusions: In the present study, the glaucomatous patient might not have any difficulty in carrying out task in aviation industry; however, regular follow-up and close monitoring of the cohort is required to confirm the findings of the study.
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Profile of acute coronary syndromes in serving personnel presenting to a field cardiology center without cath lab facilities p. 176
A Jayachandra, Rajat Datta, Ajay Swamy, Neel Kanth Issar, Saikat Sarkar, Vivek Aggarwal
Introduction: Acute coronary syndrome (ACS) is common in serving personnel and requires prompt diagnosis and treatment. This retrospective study was done to see the profile of ACS in serving personnel presenting to a tertiary hospital without cardiac catheterization laboratory (CCL) facilities. Methods: ACS was diagnosed based on an electrocardiogram (ECG), clinical features, and cardiac biomarkers. History of comorbidities, risk factors, and preceding exertion was taken. Immediate medical management was done as per the standard guidelines, and follow-up angiography was done at a dependent cardiology center with CCL. Results: A total of 75 personnel reported with ACS. The mean age of personnel was 42.01 ± 8.59 years. Acute ST-elevation myocardial infarction (STEMI) was noted in 48% (36/75) of the patients, 32% (24/75) had non-STEMI, and 20% (15/75) had unstable angina (UA). Low ejection fraction was more common in patients with STEMI (P ≤ 0.001). History of preceding exertion was noted in 55 personnel. Eighteen patients with STEMI were thrombolysed. Angiographically significant lesions were noted only in 30.6% (23/75) individuals with ACS. Conclusion: ACS is common in deployed serving personnel. The most common precipitators were immediate preceding exertion and smoking. Morbidity and mortality due to ACS can be decreased by digital transmission of ECG, prehospital thrombolysis, graded physical exertion, and counseling about a healthy diet.
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Evaluation of stress level and its association with personality traits among trainees at an armed forces training establishment p. 180
Saurabh Bobdey, Ilankumaran Mookkiah, Shankar Narayan, AA Pawar
Introduction: Stress cannot be considered a simple “stimulus-response reaction,” but it is a complex interaction between an individual and the environment, comprising subjective perception and evaluation of stressors and then responding in a highly personalized manner. The present study was conducted to assess the personality traits of trainees and explore their association with levels of perceived stress. Materials and Methods: A cross-sectional, questionnaire-based study was conducted on 911 trainees. For data collection, two instruments were used – Perceived Stress Score by Cohen for assessing stress among the subjects and Revised Neuroticism–Extraversion–Openness Personality Inventory for personality assessment. Results: Overall, the total mean Perceived Stress Score was 12.60 ± 5.62 indicating less than average stress. Only 10.98% of those tested had a score of 20 or more indicating perception of very high stress. Trainees with high perception of stress had significantly higher scores of neuroticism (57.82 ± 9.02, P < 0.05) including all the subfacets. In contrast, trainees with low or average stress perception had significantly higher scores of extraversion (53.57 ± 8.03, P < 0.05) and conscientiousness (54.25 ± 10.30, P < 0.05). Conclusion: The present study is the first of its kind which tries to not only assess the stress levels among trainees but also explore and compare their personality characteristics. The study brings out that majority of the trainees had average stress and provides definitive evidence of association between high neuroticism, low extraversion, and perception of high stress, and offers a window of opportunity to explore options for remedial action such as incorporation of stress coping-up techniques in Armed Forces training curriculum.
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Clinical profile and spectrum of Duodenal biopsy and other investigational abnormalities in NUD patients p. 185
Sarvinder Singh, Naresh Bansal, Sreenivasu Mamidi, Pradeep Kumar Singh, PK Sharma, Rahul Jain, KS Brar
Aim of Study: The study was done to find out the prevalence of rapid urease test (RUT) positivity, IgA-tTG, and spectrum of duodenal abnormalities in nonulcer dyspepsia (NUD) patients. Methods: This descriptive observational study was carried out in the gastroenterology center in GOI research institute from August 2020 to March 2021. Initially, 200 dyspepsia patients were selected. Fifty patients were excluded due to various reasons. Finally, 150 patients who met the Rome 4 criteria for NUD/functional dyspepsia were recruited. The inclusion criteria were patients above 18 years of age, dyspepsia for ≥ Six months, and no evidence of underlying malignancy, pan gastritis, previous gastric ulcers, and pancreatitis. The patients underwent RUT, upper gastrointestinal endoscopy, duodenal biopsy, and serum IgA-tTG antibody. Results: The mean age was 46.3 years ± 14.12 years, of which 49.3% were female and 50.70% were male. The prevalence of epigastric pain syndrome (EPS) was found in 37.3%, postprandial distress syndrome (PDS) in 30.7%, and both EPS + PDS in 32%. Thirty-eight percent of the NUD patients were positive on RUT suggesting Helicobacter pylori infection. 88.7% of the NUD patients were IgA-tTG antibody negative and 11.3% serologically positive. The duodenal biopsy was normal in 48% of the patients, 21.3% had mild inflammation/duodenitis, 8% had chronic duodenitis, and 22.7% had various grades of celiac disease (CeD) (as per Marsh grading). These 22.7% showing evidence of CeD on histopathological examination showed Marsh Grade 1 in 12.7%, Grade 2 in 2%, Grade 3A in 6.7%, and Grade 3B in 1.3%. Only 17.6% of biopsy positive had IgA-tTG antibody positivity, but only 4% of the total cases were positive for both biopsy and IgA-tTG antibody (P = 0.05). Eosinophilic infiltration in the duodenum was common in NUD patients. It was observed that 17.33% (26/150) of the NUD patients had duodenal eosinophilia. Duodenal eosinophilia association with various other Gastrointestinal disorders, It was observed that 33.33%(19/57) of the H. pylori patients had duodenal eosinophilia with p<0.001. It was also observed that 7.52% (7/93) of others, such as normal individuals, chronic duodenitis, and mild inflammation/duodenitis, had duodenal eosinophilia. Conclusion: The prevalence of H. pylori and IgA-tTG antibodies in NUD patients was 38% and 11.3%, respectively. The spectrum of duodenum biopsy abnormalities in NUD patients included mild inflammation/duodenitis, chronic duodenitis, and CeD. 22.7% of the NUD patients had various degrees of CeD morphology on D2 biopsy, and only 17.6% of these biopsy-positive patients were positive for IgA-tTG. Only 4% of the total NUD patients were positive for both biopsy and IgA-tTG antibody labeled as CeD. There is a significant association between H. pylori and duodenal eosinophilia.
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Central Diabetes Insipidus: A Case Series and Literature Review Highly accessed article p. 190
Vikram Singh Shekhawat, Amit Kumar Das, Somnath Pan, MD Sudhan
Central diabetes insipidus (CDI) is a rare disorder of water homeostasis characterized by the excretion of a large volume of hypotonic urine resulting from deficient secretion of arginine vasopressin. It is the most common form of diabetes insipidus and manifests when more than 90% of the vasopresinergic magnocellular neurons have been destroyed. The correct diagnosis is always a challenge as it is not always possible to differentiate the different etiologies of CDI based on clinical, hormonal, and radiological examination alone. Histopathology may have to be resorted to at times to provide a definitive diagnosis. In this case series we describe five patients of CDI with varied aetioogies who presented to our tertiary centre. The case series describes and discusses the clinical presentation, evaluation and management of these patients who presented with diabetes insipidus. The aetiologies discussed are extremely rare and required histopathological examination for the final confirmation of diagnosis.
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Post-COVID Neurological Complication; A Case Series and Review of the Literature p. 195
Sreenivasu Mamidi, Rahul Soni, Pawan Dhull, Sindhu Singh, J Muthukrishan
Introduction: There are certain post-coronavirus disease (COVID) neurological syndromes which have been reported such as cerebrovascular diseases, cerebral venous thrombosis, peripheral neuropathy, encephalitis, encephalopathy, cerebellar ataxia, facial palsy, and myositis. However, most of these are isolated case reports. In this case series, we discuss the post-COVID neurological complications such as facial palsy, lateral rectus palsy, cerebellar ataxia, peripheral neuropathy, and stroke which occurred within 2 weeks after complete recovery from COVID. Methods: This multicentric case series is from three large tertiary care hospitals in northern and central India. We have reviewed seven patients with recent-onset neurological symptoms who had recovered from COVID infection within 2 weeks. We have retrospectively studied the clinical profile and radiological imaging during COVID infection. Results: Three out of these seven patients had received steroids during COVID treatment. None of our cases had any neurological manifestations during their COVID infection. The likelihood of neurotransmission through the cribriform plate via the olfactory bulb was low, as none of our patients had anosmia. None of the patients in the case series showed features of systemic hyperinflammatory syndrome, making the possibility of macrophage activation syndrome less likely. Conclusion: We hypothesize that antibodies against the coronavirus post recovery from COVID are responsible for these post-COVID neurological complications. Higher likelihood of these complications after rapid tapering off steroids may further corroborate this mechanism, as the antibody levels rise after steroid withdrawal. Titers of antibodies to SARS COV-2 virus in the postinfection period in these cases may have further helped prove our hypotheses which can be considered in future studies on the subject.
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COVID-19-Induced acute pancreatitis – A case series p. 200
Bal Mukund, Amit Kumar, Vivek Bhat, DK Tiwari, RW Thergaonkar
The present pandemic of the COVID-19 virus has caused enormous morbidity and mortality to humankind. Acute pancreatitis (AP) in otherwise healthy patients infected with the COVID-19 virus has been reported only as case reports and series. We report a series of three cases of AP including one adolescent with necrotizing pancreatitis due to COVID-19 infection, out of total 4117 COVID-19 admission (0.07%) in our hospital till February 8, 2022. Detailed investigations for etiological diagnosis of AP were within normal limits thus, the causation was attributed to COVID-19 viral infection as causative agent. One child succumbed to the illness as he also manifested with features of multisystem inflammatory syndrome and had progressive multi-organ dysfunction despite aggressive management. Further studies are required before a clear mechanism of causation due to the COVID-19 virus is proven in AP.
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Heterotaxy: Rare case of isolated duodenojejunal junction malposition p. 204
Ranjit Singh Lahel
Heterotaxy syndrome is an uncommon disease, with an incidence ranging from 1 in 6000 to 1 in 20,000 live births.[1] This syndrome is characterized by major cardiac vascular malformations, congenital asplenia, polysplenia, and abnormal arrangement of the chest and abdominal organs. Radiological investigations such as radiographs, sonography, and computed tomography scan play a pivotal role in ascertaining the correlation between clinical symptoms of the patient and the extent of anatomical aberration in the form of thoracic or visceral “situs” abnormalities. The case in this report is a rare variant of heterotaxy, which cannot be stratified into any of the existing subsets for heterotaxy syndromes. The relevant investigations thereof and their relevant findings have been discussed in detail.
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Scuba Diver Presenting with a Giant Sphenoid Sinus Mucocele p. 208
Santosh Kumar Swain
Isolated sphenoid sinus mucocele is an uncommon clinical entity. Expanding mucocele in the sphenoid sinus may affect vital structures such as the optic nerve, internal carotid artery, and other adjacent structures. Hence, barotrauma causing sphenoid sinus mucocele may result in serious neurological disorders including headache and vision disturbances. The patient urgently requires treatment of endoscopic marsupialization of the sphenoid sinus mucocele. Here, a 35-year-old male diver presented with acute headache and was diagnosed as sphenoid mucocele by computed tomography scan and magnetic resonance imaging. He was treated immediately with oral corticosteroids, nasal decongestants, and antibiotics. Then, he underwent endoscopic transnasal sphenoidotomy and marsupialization of the mucocele. A high index of suspicion is needed to get such a rare clinical entity like sphenoid mucocele when a diver presents with a headache and/or visual problem.
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A Rare and Sinister Presentation of Cutaneous Metastasis over Right Lower Limb in a Case of Ovarian Carcinoma p. 211
Preema Sinha, Parul Kamboj, Anamika Sinha, Juhi Sharma
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