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   Table of Contents - Current issue
September-October 2022
Volume 12 | Issue 5
Page Nos. 195-246

Online since Monday, October 31, 2022

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Busting the myth: Has there been desensitising corporatisation of the Indian private health-care sector? Highly accessed article p. 195
Ashish Kakar, Sumanyu Kakar, Shikhar Tripathi
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Gastroesophageal reflux disease – Current perspective p. 197
Ashish Dey, Vinod K Malik
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Discrepancy between admission diagnosis in emergency and final diagnosis in ward and its correlation with length of hospital stay and mortality p. 199
Umer Un Nabi, Asma Rafi, Muzaffar Maqbool, Parvaiz Ahmad Shah
Background: Inception of emergency medicine as a specialty in India is on a rise. Data on the accuracy of diagnosis made in emergency rooms in India is scarce and with varied results with especially no such data available from our part of the country. Aim: The aim of this study was to evaluate the discrepancy between admission diagnosis in emergency and final diagnosis in ward and its correlation with length of hospital stay and outcome. This study was an observational prospective study. Materials and Methods: Patients were categorised as per the International Classification of Diseases – Version 10. A total of 2000 patients were enrolled in the study. The patients were followed from admission to discharge. Data were categorised into two major groups – 'Concordant' diagnosis and 'Discordant' diagnosis. Univariate analysis was performed using SPSS version 20.0. Results: Five hundred and fifty-three (27.65%) patients had a final diagnosis in ward discordant from the initial diagnosis in the medical emergency room. The frequency of discrepancy was highest for the genitourinary system (39%) and relatively low for neoplasm (16%). The average length of hospital stay in the concordant group of patients was 5.15 days, whereas it was 7.05 days in the discordant group (P = 0.003). There was a statistically significant increase in percentage mortality in patients when initial and final diagnoses did not match (P = 0.0005). Conclusions: A diagnostic discrepancy of 27.65% occurred between admission diagnosis in the medical emergency room and final diagnosis in ward. The diagnostic discrepancy resulted in a significant increase in the length of hospital stay and mortality.
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Evaluation of maternal cortisol-to-highly sensitive C-reactive protein ratio and glucocorticoid receptor resistance at 11–14 weeks of pregnancy to predict pre-eclampsia p. 205
K Jhansi, JM Harsoda
Background: Preeclampsia (PE) is a disorder of pregnancy with a worldwide prevalence of about 5-8% and 4.6% in India. It is the second leading cause of direct maternal and foetal adverse outcomes, resulting in about 50,000-60,000 deaths annually worldwide. Cortisol is a stress hormone, that suppresses the immune system and inhibits the production of pro-inflammatory substances to reduce inflammation. During pregnancy cortisol levels raise to three-fold of nonpregnant level by the third trimester, it is due to changes in HPA axis regulation, raised oestrogen levels and raised maternal CRH levels through placental secretion. Aims: The objective of this study is to evaluate the cortisol (CORT)-to-highly sensitive C-reactive protein (HS-CRP) ratio and glucocorticoid receptor resistance (GCR) in early pregnancy to understand the pathophysiology of pre-eclampsia (PE) and to test whether these parameters have a role in the prediction of PE. CO + RT: HS-CRP ratio evaluates the interrelationship between the hypothalamic–pituitary–adrenal axis (HPA-axis) and the inflammatory response system. It is a new concept and an integrated approach to understand the pathophysiology of PE. Materials and Methods: In this prospective case–control study, we recruited 250 healthy pregnant women at 11–14 weeks of pregnancy and followed them. Those who developed PE after the 20th week according to the American College of Obstetricians and Gynecologists guidelines were considered study participants and the remaining served as controls. CORT was estimated through the ELISA method and HS-CRP was measured by autoanalyser through the turbidimetric method. The CORT-to-HS-CRP ratio was calculated manually. GCR was measured indirectly through leucocytes subsets, neutrophil-to-lymphocyte ratio (NLR) and neutrophil-to-monocyte ratio (NMR); individual leucocytes were obtained from complete blood counts. Data were analysed using the SPSS version 20, Pearson's correlation test was used to correlate the results and receiver operator characteristic (ROC) was used to test the predictive capacity of parameters. Results: Low CORT: HS-CRP was associated with PE, having a significance of P < 0.00, but it did not show any specificity and sensitivity under ROC. NLR and NMR were elevated in cases who developed PE, especially NMR with P < 0.008. NMR showed good specificity and sensitivity under ROC with the area under curve 0.74, cutoff value is 23. Conclusion: Low CORT: HS-CRP ratio has an association with PE, the uncontrolled inflammation during early pregnancy in pregnant women who were destined to develop PE. This is due to low-CORT secretion due to dysregulation of the HPA-axis. GCR also has an association with PE, but it was not fully clarified. HS-CRP and NMR can be used to screen in early pregnancy for the prediction of PE.
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Monkeypox virus infection – Evolution, molecular biology, epidemiology, clinical features and management aspects p. 211
Dinesh Kaul, Kavita Yadav, Akanksha Bansal
Monkeypox virus (MPXV) infection has lately emerged as a new public health problem across 100 countries. Surging cases of MPXV infection in non-endemic countries prompted the World Health Organization to declare it a public health emergency in July 2022. The virological and clinical resemblance to eradicated smallpox disease has generated new scientific interest. This DNA orthopoxvirus primarily harbouring in squirrels, rats and non-human primates has led to infection in the human population. A recent surge of cases has been seen across 16 countries, with a clustering of cases in bisexual/homosexual men. The virus spreads through close contact with infected individuals with prodromal symptoms of fever and myalgia. A rash appears after 1–3 days of fever. There is presence of vesicular rash over the face, hands, feet and genital areas, and associated lymphadenopathy. Although no specific antiviral drugs directed against MPXV are available, tecovirimat developed against smallpox infection can be used and is effective. A synthetic analogue drug of cidofovir, i.e., brincidofovir has been evaluated for MPX patients in United Kingdom. A preventive strategy in close contacts may be offered through smallpox vaccines such as ACAM2000 and JYNNEOS. Epidemiological data from Africa suggest that smallpox vaccines provide 85% efficacy in preventing MPXV cases. Vaccinia immunoglobulin intravenous (VIGIV) has been used in immunocompromised patients with T-cell defects as prophylaxis where the use of vaccines is contraindicated. VIGIV can be used as a treatment modality for smallpox or non-variola infections like monkeypox in an outbreak, although the efficacy data are lacking.
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The laboratory and hypertension - Novel approach for diagnosis and management p. 217
Seema Bhargava, Anjali Manocha, Mamta Kankra, Parul Singla, Anisha Sharma, Rashmi Rasi Datta
Hypertension remains one of the most significant causes of mortality, affecting more than 1 billion people worldwide. It is a significant public health concern and a major risk factor for renal disease, heart failure, stroke, coronary artery disease and peripheral vascular disease. In more than 90% of hypertensive patients, the cause of blood pressure elevation is unknown. Therefore, early diagnosis and timely interventions are crucial to prevent complications. Over the last four decades, various blood biomarkers have been identified, which can help in understanding the cause of the underlying processes involved in the onset, development and progression of hypertension (HT). It is our attempt, in this review, to suggest a more robust use of circulating biomarkers that may prove to be beneficial in better elucidating the pathophysiology, development, progression and therapeutic efficacy in the management of HT.
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A proposed five-step simplified algorithm for the management of hepatocellular carcinoma in India p. 224
Anil Arora, Ashwani K Singal, Praveen Sharma, Ashish Kumar
Hepatocellular carcinoma (HCC) is the eighth-most frequent cause of cancer mortality in India. The staging system most often used for treatment decisions in India is the Barcelona clinic liver cancer (BCLC) system. However, this staging system is often criticised for several reasons, such as heterogeneity of patient prognosis in each BCLC stage, limited guidance on expanding the role of liver transplantation (LT), no recommendation on combination therapies, no guidance on downstaging and limited treatment options for late presenters (stages C or D). Hence, we propose a simplified five-step algorithm for making treatment decisions for HCC patients in India. This algorithm incorporates evidence-based treatment allocations based on the step-by-step assessment of major prognostic and treatment-related parameters. The five steps of the algorithm are – Step 1: assessment of performance status, Step 2: assessment of extrahepatic spread and macrovascular invasion, Step 3: assessment for living donor LT, Step 4: assessment for the eligibility of liver resection and Step 5: assessment for appropriate locoregional therapy. Each of these steps does not require any separate investigations, and the initial workup for the diagnosis of HCC (dynamic computed tomography/magnetic resonance imaging and routine laboratory tests) would suffice in this five-step algorithm. We hope that this algorithm will not only simplify the management approach to HCC patients in India, but also it will bring uniformity in the treatment protocol for HCC in India.
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Solitary neurofibroma of the psoas muscle: An unusual location p. 232
Chandrashekher Chaturvedi, Himani-Tiwari Chaturvedi
Neurofibroma is a benign peripheral nerve sheath tumour usually present on superficial tissues of the head and trunk. Retroperitoneal location is extremely rare for neurofibroma and comprises only 1% of all retroperitoneal tumours. It can be solitary or associated with the genetic disorder, von Recklinghausen's disease or neurofibromatosis type-1. Magnetic resonance imaging (MRI) is the gold standard modality for imaging retroperitoneal tumours because it provides a better definition and specificity in the evaluation of the location, extension, and composition of the lesion. Here, we report the case of a 30-year-old man affected by retroperitoneal solitary neurofibroma of the psoas muscle, but not associated with von Recklinghausen's disease. MRI showed a well-defined lobulated retroperitoneal lesion noted within the right psoas muscle. Complete surgical excision of the tumour was performed, and the diagnosis of neurofibroma was made through histological and immunohistochemical examination.
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Childhood-onset systemic lupus erythematosus, probably triggered by severe acute respiratory syndrome coronavirus 2 infection, presenting with autoimmune haemolytic anaemia p. 235
Abdul Rauf, Shinto Francis Thekkudan, Neena Mampilly, Ajay Vijayan
Systemic lupus erythematosus (SLE) is a multisystemic and chronic autoimmune disease with varying clinical manifestations. The role of various infectious agents in triggering the disease onset in genetically predisposed patients has been implicated in the pathogenesis of SLE. The severe acute respiratory syndrome coronavirus 2 has been reported to trigger various autoimmune diseases including SLE in few adults. Herein, we report the case of a previously well 12-year-old girl who presented with warm antibody Coombs-positive autoimmune haemolytic anaemia, 3 weeks after testing positive for COVID-19. COVID IgG antibody test was positive. During the hospital stay, she developed multisystem involvement in the form of neurological manifestations and arthritis. She was managed with steroids, intravenous (IV) immunoglobulins and supportive measures. Her anti-nuclear antibody and anti-dsDNA antibodies were positive and complement levels were low, confirming a diagnosis of SLE. Her clinical condition improved rapidly and remained neurologically normal, and serial haemoglobin showed an improving trend. IV steroids were changed to oral form, and hydroxychloroquine was also added. She remained well on 3-week follow-up.
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Teleconsultation for anaesthesiologists - Update and limitations p. 238
Anju Romina Bhalotra
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Detection dogs cases about their sniffing applications in medical and future application for COVID-19 pandemic p. 244
Shashi Bahl, Ashok Kumar Bagha, Abid Haleem, Mohd Javaid
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Granulomatosis with polyangiitis presenting with strawberry gingivitis p. 246
Atul Kakar, Sumanyu Kakar, Shikhar Tripathi
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