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   Table of Contents - Current issue
November-December 2020
Volume 13 | Issue 6
Page Nos. 575-708

Online since Friday, November 6, 2020

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Pandemic, panic, policies, and the paradox of control Highly accessed article p. 575
Amitav Banerjee
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Commentary on nCovid 19 p. 578
Vishnu Sharma Moleyar
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COVID-19 lockdown: Psychological effects Highly accessed article p. 580
Suprakash Chaudhury, Madhura Samudra
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It is time to invest in health security p. 585
Sunil Kumar Raina
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Palliative care in COVID pandemic: Need of the hour in testing times! p. 586
Kanika Rustagi, Nishkarsh Gupta
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Strategies of India against coronavirus disease-2019: A strengths, weaknesses, opportunities, and threats analysis p. 588
Sitikantha Banerjee, Arvind S Kushwaha, Sujiv Akkilagunta, Kajari Bandyopadhyay, Jaya P Tripathy, S Kalaiselvi, Mubashshera F Khan, Ranjan Solanki, Pradeep R Deshmukh
The coronavirus disease-2019 is a rapidly progressing pandemic that has jeopardized health infrastructure in many countries. India was to some extent successful to slow the rate of spread of disease by implementing multipronged strategies. Unfortunately, despite all efforts, the disease is rapidly progressing in India. The aim of this review is to critically appraise the strategies adopted by the Government of India to tackle this pandemic and to suggest suitable strategies for the current scenario. Strengths, weaknesses, opportunities, and threats analysis was done to assess the current scenario. Delayed and selective implementation of regulation on international travel, self-reporting of symptoms and undue reliance of thermal scanning for screening at the point of entry screening, poorly monitored home quarantine strategy with noncompliance, narrow testing strategy at the beginning with inability to capture asymptomatic case were some of the loopholes identified in the existing strategy. Improvement of inter-sectoral coordination by the development of Multi-disciplinary Epidemic Management board, involvement of AYUSH, judicious use of health manpower, and capacity development for indigenous production of personal protective equipment and other logistics, up-gradation of rural health facility and preparedness for second wave are the key recommendations.
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Institutional quarantine center of North Bengal Medical College: A novel concept p. 595
Nilanjana Ghosh
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Recommendations for affected and unaffected nations amid the successful containment of coronavirus disease-2019 outbreak in China p. 598
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
As the ongoing coronavirus disease-2019 (COVID-19) pandemic continues to expand with each day, a total of 1,511,252 cases have been detected worldwide, of which 83,305 cases (5.4%) have been reported outside the China. However, the biggest change in the recent trends of the disease has been a significant decline in the incidence of coronavirus cases in China and a simultaneous rise in the cases reported from the other affected nations. Despite the success, it has been advocated that China should continue with the emergency management protocols based on the results of risk assessment in different parts of the nation. Further, it is quite obvious that we cannot succeed and sustain the gains accomplished, if we do not receive the support and involvement of the community. In conclusion, the success obtained in the containment of COVID-19 outbreak in China is an encouraging sign in the battle against the disease. However, it is the responsibility of both the affected and unaffected nations to continue to practice nonpharmacological measures and actively engage the members of the community in the containment of the infection.
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Recommendations for containment of COVID-19 p. 601
Viroj Wiwanitkit
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Positive side of human response to the COVID-19 crisis p. 602
Praveen Prakash, Santosh Kumar Sharma, Arpita Joshi, Namrata Sarin, Sompal Singh
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Impact of COVID 19 lockdown on emergency admissions at a large zonal hospital p. 603
Nitul M Bewal, Sukhmeet Minhas, GV Krishna Prasad, Arun Yadav, CM Sreedhar, Dinesh Bhasin, Satish Kumar
Introduction: The COVID-19 pandemic along with the measure to control it like complete lockdown has affected the health-care delivery in multiple ways. Resources in the health setup were earmarked for COVID-19. All routine and nonurgent procedures were deferred. There was an overall decrease in the number of patients visiting the emergency department. However, in India, there was no major study conducted on emergency hospital admission at the time of the ongoing COVID-19 pandemic. Materials and Methods: The study was conducted in a zonal hospital as a before-and-after record-based observational study. The hospital admission data for all causes of emergency 2 months prior (i.e., from January 25, 2020, to March 24, 2020) and 2 months into the lockdown (March 25, 2020–May 24, 2020) were studied. The emergency admission during the last 2-year period in the same period was taken as a control for the study. Results: The number of emergencies reported during the year 2018, 2019 and 2020 in January 25 to March 24 were 92, 101, and 119 respectively and in March 25 to May 24 were 93, 107, and 82 respectively. There was no statistically significant difference among age, sex, and socioeconomic status of persons reported as emergencies during the studied period. There was a significant reduction by 31% in emergency hospital admissions two months before and two months after period of lockdown in the year 2020 and it varied as per subject specialty with highest reduction in emergency hospital admissions was found in orthopedic cases by 93% and no reduction in obstetric and newborn emergencies. Conclusion: The COVID-19 lockdown in India had a significant impact on the frequency as well as types of emergency admission to a large zonal hospital. The provisioning of hospital resources may need to be aligned with changing patient workload in view of COVID-19.
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A comparative study of telemedicine-assisted traditional teaching classes and flipped classroom-assisted self-directed learning sessions during COVID-19 pandemic among first MBBS students in Burdwan Medical College: A pilot study p. 608
Arunima Chaudhuri, Suhrita Paul, Tanushree Mondal, Ayan Goswami
Background: Burdwan Medical College is one of the 212 medical colleges included under National Knowledge Network (NKN), and we use telemedicine platform for imparting medical education. COVID-19 pandemic has brought a sudden change in education across the globe. Medical colleges in India also started online medical teaching since nationwide lockdown from March 24, 2020. Aim: The aim of the study was to compare the impact telemedicine-assisted traditional teaching classes and flipped classroom (FC)-assisted self-directed learning (SDL) sessions among first MBBS students in Burdwan Medical College. Materials and Methods: This pilot study was conducted in a time span of 4 months after obtaining institutional ethical clearance. Two hundred medical students enrolled in the first year participated in this study. The study was conducted in the Department of Physiology. Traditional interactive classes were conducted and these were also shared with other institutions under NKN. Students of Burdwan Medical College were present physically in these classes. Multiple choice questions (MCQ) examinations were conducted to assess knowledge of the students of Burdwan Medical College prior to and after attaining the classes. After the nationwide lockdown, our students had to leave the institution and continue studies online. We were also unable to assess telemedicine-assisted sessions from March 24, 2020 onward. Hence, we started flipped classroom-assisted self-directed learning as the mode of teaching during this period. For these sessions also, MCQ examinations were conducted to assess knowledge of students before and after the teaching learning sessions. Two surveys were conducted to get feedback from students. Results: The students were more satisfied with telemedicine-assisted traditional classes. Academic activities carried by majority of students was 5 h or more. There was no statistically significant difference in performance between telemedicine-assisted traditional lecture classes and FC-assisted SDL in pretest sessions (45.83 ± 20.45 vs. 44.74 ± 17.1; P = 0.67). Students performed significantly better in posttest sessions (61.04 ± 12.75 vs. 45.83 ± 20.45; P < 0.0001**) as compared to pretest sessions in telemedicine-assisted traditional interactive lecture classes. There was no statistically significant difference in performance between telemedicine-assisted traditional lecture classes and FC-assisted SDL in posttest sessions (61.04 ± 12.75 vs. 61.51 ± 13.57; P = 0.74). Students performed significantly better in posttest sessions (61.51 ± 13.57 vs. 44.74 ± 17.1; P < 0.0001**) as compared to pretest sessions in FC-assisted SDL sessions. Conclusions: FC-assisted SDL is equally an effective tool as telemedicine-assisted traditional interactive lecture classes in teaching physiology to undergraduate medical students and may be taken into consideration in future teaching–learning program. Flipped classroom-assisted SDL may be used as an alternative in teaching–learning methodology as it is equally an effective tool as telemedicine-assisted traditional interactive lecture classes in physiology.
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A study of the burden of maternal depression on young mothers and their caretakers p. 615
Vasdev Singh, Preethi Menon, Suprakash Chaudhury, Daniel Saldanha
Aim: This study aims to evaluate the burden of maternal depression in young mothers and their caretakers compared to their non-depressed counterparts. Materials and Methods: This cross-sectional, analytical, case–control study was carried out in a metropolitan tertiary care teaching hospital. Young mothers were screened for probable psychological disorders using 12-item General Health Questionnaire (GHQ-12). The positive cases were administered The Edinburgh Postnatal Depression Scale to identify mothers suffering from depressive illness. All mothers with score above 13, with confirmed diagnosis of depressive disorder by a psychiatrist, were recruited as study subjects. Their caregivers were assessed for burden using burden assessment schedule. The mothers, scoring below the cutoff on GHQ, and their caregivers, were recruited as the comparison group. Fifty consecutive mothers were recruited in both groups. Results: Among depressed mothers 72% had a female child and 28% had a male child. Among nondepressed mothers 60% had a male child and 40% had female child. The caregivers of depressed and nondepressed mothers spent an average of 11.32 h and 9.2 h, respectively, daily. The number of hours spent in caring during any given day was highly correlated with the burden assessment schedule (BAS) score. Greater the number of hours spent-greater was the BAS score. Conclusion: There is a higher likelihood of postpartum depression among mothers if gender of the baby born is a female. There is a considerable burden on caregivers of depressed mothers which is directly correlated with the time the caregiver is providing care for depressed mother.
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Assessment of Agreement between the National (Indian Academy of Pediatrics) and International (Centers for Disease Control and World Health Organization) growth references among tibetan adolescent girls of Kangra District, Himachal Pradesh p. 624
Shweta Singh, Neelam Singh, Gautam Kumar Kshatriya
Context: Various growth assessment references are available to assess nutritional status. The use of body mass index (BMI) in adolescents is well established for clinical and public health applications. It is required to compare national references with the international, to avoid over/underestimation of BMI categories. Aims: The aim of the present study was to quantify differences in the assessment of height/age and BMI/age ratios using national (Indian Academy of Pediatrics [IAP]) and international (Centers for Disease Control and Prevention [CDC], and World Health Organization [WHO]) references. Subjects and Methods: Anthropometric measurements of 276 Tibetan adolescent girls (13–18 years old) were taken. BMI-for-age and height-for-age were measured and compared using three references – IAP 2015, WHO 2007, and CDC 2000. Statistical Analysis Used: Kappa coefficient was done between different references using SPSS version 20 and MS-excel. Results: The prevalence of overweight/obesity was reported highest (23.55%) by IAP references, while stunting was highest (17.26%) with CDC references. A substantial agreement (k = 0.623) was observed in stunting and almost perfect agreement (k = 0.868) was observed for BMI categories between WHO and CDC. The disagreement level was highest in IAP and CDC for stunting and IAP and WHO for BMI categories. Conclusions: Prevalence of malnutrition differs with the application of different references. National references producing higher estimates of obesity than international definition indicates that decisions regarding whether or not to use national BMI references, should always be undertaken with caution.
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Critical thinking among anesthesiology residents – “Epidural test dose”-Based experiment p. 630
Vijaya P Patil, Sumitra G Bakshi, Pallavi Patil
Introduction: During the postgraduate course, one is expected to think critically, analyze the clinical situation, and react appropriately. The practice of test dose administration among anesthesiologists is variable. As an initial experiment, we decided to study the common practice of test dose administration through epidural catheters in anesthesia postgraduate students. Methods: After approval from the institutional ethics review board, during a national academic meet for postgraduates, the delegates were asked to fill a 12-item-based survey questionnaire, in English, pertaining to the practice of test dose administration and its interpretation. Results: Eighty-five percent of delegates replied that they were practicing administration of test dose after epidural catheter insertion. Seven percent got the purpose of test dose right. Around 10% of delegates could give correct answer for composition of test dose and 9% of delegates could rightly differentiate between interpretation of test dose for thoracic and lumbar-placed epidural catheters. Discussion and Conclusion: Young anesthesiologists do have a lacuna in knowledge about the basics of administration of test dose, the key components, and the effect it can produce. The students also lack the ability to analyze the effect that the test dose would produce when administered at different segmental levels. Future research critically evaluating our current education process is probably the need of the hour.
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Vestibular migraine: Our experiences at a tertiary care teaching hospital of Eastern India p. 636
Santosh Kumar Swain, Ishwar Chandra Behera, Loknath Sahoo
Introduction: The etiopathology and management of vestibular migraine (VM) are a puzzling dilemma among the clinician. The migraine and vertigo are important symptoms of VM. Objective: Clinical and audio-vestibular evaluation of VM patients. Materials and Methods: It is a prospective study which was conducted between June 2016 and May 2019. Patients attending vertigo clinic were thoroughly reviewed. The patients of VM were selected on the basis of criteria fulfilling the International classification of headache disorders, 3rd edition (beta version). Neuro-otological examinations with videonystagmography (VNG) and vestibular evoked myogenic potentials (VEMPs) tests were done in all cases those diagnosed for VM. Results: There were 51 VM patients out of 168 dizzy patients during the study period. Aural fullness (45.09%) was the most common aural symptom, followed by tinnitus and hearing loss. Phonophobia (82.35%) was the most common migrainous symptom. The relation between headache and menstrual period among female patients was significant. VNG was showing abnormality in 11.76% of cases during caloric test with the highest abnormality in positional test. In VEMPs, 32 patients (62.74%) had abnormal cervical VEMPs response, whereas abnormal ocular VEMPs response seen 38 patients (74.50%). Conclusion: VM is a leading cause of vertigo in the clinical practice and high percentage of patients presented with abnormalities in VNG and VEMPs during vestibular symptoms. Proper history taking and neuro-otological examination and vestibular investigations help for the early diagnosis and treatment.
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Consequence of phubbing on psychological distress among the youth of Hyderabad p. 642
Sri Dharani Tekkam, Sudha Bala, Harshal Pandve
Background: Phubbing is defined as modern communication in which a person snubs another in a social setting by concentrating on their phone instead of having conversation. Derived from phone and snubbing words. This phenomenon has got a negative consequence that effects the psychological well being. Aim and Objectives: 1.To determine the prevalence of phubbing and characteristics of Phubbing behavior among youth2.To assess the consequence of Phubbing on psychological distress among youth. Material and Methods: A cross sectional study to be conducted among youth as they were more likely to use smartphones for many purposes. About 430 Students of Medicine(MBBS), Engineering, Arts and Unani college which were closer to the vicinity of our medical college located at Hyderabad were included using simple random sampling. Variables included socio demographic, phubbing characteristics, phubbing prevalence questionnaire using phubbing scale (Karadag) and Kesslers psychological distress scale to assess the consequence of phubbing. Results: Prevalence of phubbing was found among 223(52%) of the youth. Among them home phubbers were 118(52.9%) and college phubbers were 105(47.1%) with majority using whatsapp and facebook. Majority35% were phubbing for a duration of half an hour to one hour for more than of 3-5 times a day. Psychological distress was found to be mild (43%), moderate (34%) and severe (23%) of youth. There was statistically significant association between phubbing scoring and psychological distress by ANOVA. Conclusions: Early identification of this consequence helps to improve their behavior and psychological well being..
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Clinicopathological correlation in the diagnosis of skin diseases: A retrospective study p. 648
Ruby Venugopal, Prerna Shankar, Vikas Pathania
Introduction: Skin biopsy is an indispensable tool in dermatological diagnosis.Various factors that influence the outcome of a biopsy include information recorded on the histopathology request form by the treating dermatologist to the reporting pathologist. Conversely, a good biopsy report is vital for the clinician to arrive at a diagnosis. Materials And Methods: The present study was conducted at a tertiary care hospital in the form of a retrospective investigation of histopathology requisition forms and reports of skin and mucosal biopsies done over a period of one year.If the pathological diagnosis was definite and matched one of the clinical diagnoses, it was grouped under the category definite and consistent. If the pathologist gave a descriptive diagnosis that matched one of the clinical diagnoses, it was grouped under the category descriptive and consistent. If the pathologist gave a definite diagnosis that did not match any of the clinical diagnoses, it was grouped under definite and inconsistent and if the pathological diagnosis was descriptive and did not match any clinical diagnoses, it was grouped under descriptive and inconsistent. Data analysis was done using R Statistical Software v3.6.0 (R Statistical Corp, Vienna, Austria). Level of significance was set at p<0.05. Results: A total of 403 skin biopsy requisition forms and their reports were analysed. 46.5% were given a definite pathological diagnosis consistent with the clinical diagnosis, 21% were given a descriptive pathological diagnosis consistent with the clinical diagnosis, 6% had a definite pathological diagnosis inconsistent with clinical diagnosis and 26.5% had a descriptive pathological diagnosis inconsistent with the clinical diagnosis. Conclusion: The present study has shown that clinicopathological consistency in diagnosing skin diseases is 67.5%. Providing comprehensive clinical description and repeat biopsy increases the diagnostic accuracy rate.
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Is conservative treatment still gold standard for the management of both-bone forearm fracture in children? p. 653
Rohan R Patil, Ankit B Waghela, Mriganka N Medhi, Chandrashekhar M Badole
Background: Forearm diaphyseal fractures constitute around 6% of all other children's fractures. Despite conservative management is proven and gold standard but still operative management is on rise. Aims and Objective: The aim of this study was to evaluate the outcome in conservative and surgical management of both-bone forearm fractures in children. Materials and Methods: This prospective study was conducted in children aged 3–12 years. Clinical and radiological features, time for union, angular correction over a period of management, and functional outcome were assessed. Data were entered and analyzed with Epi Info software. Results: There were 48 males (72.7%) and 18 (27.3%) females, with a mean age of 85 months (±29.7). In the present study, 34 (51.2%) at middle third was the most common site of diaphyseal fracture followed by distal third 28 (42.2) and proximal one-third. Conclusion: Fractures treated conservatively had greater healing potential and faster healing, whereas functional outcome was comparable in both conservatively and surgically treated patients.
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Serum uric acid and clinical outcome of patients with acute exacerbation of chronic obstructive pulmonary disease p. 658
Siddharth Patanwar, Amartya Chakraborti, Lokender Kumar, Vikram Vohra, Devika Tayal
Introduction: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and India contributes a significant and growing percentage of COPD mortality. Chronic hypoxia is a known condition causing tissue inflammation which may lead to an increased uric acid synthesis due to an increased RNA-DNA breakdown. Studies have shown the relationship between uric acid and adverse clinical outcomes in COPD. Data are lacking regarding this from the Indian subcontinent for which this study was undertaken. Materials and Methods: A prospective observational study was carried out at a tertiary respiratory care hospital for approximately 1 year to enroll patients admitted with acute exacerbation of COPD. Patients were divided into two groups with high and normal serum uric acid and were followed up for 30 days from admission. Following clinical outcomes were looked at duration of hospital stay, intensive care unit (ICU) admission, need for noninvasive ventilation (NIV)/invasive mechanical ventilation (IMV), mortality. Results: A total of 135 patients were enrolled (88 with normal and 47 with high serum uric acid levels). Patients with high serum uric acid had longer hospital stay (17.65 ± 4.41 vs. 11.65 ± 4.9 days), higher rates of ICU admission (60% vs. 21%), use of NIV/IMV (95% vs. 57%) and mortality (17% vs. 9%). Negative correlation was seen between serum uric acid and FEV1% predicted values in patients (r = −0.4, P = 0.017). Multiple logistic regression showed that high serum uric acid level was an independent risk factor for worse outcomes in all clinical parameters mentioned above. Conclusion: Serum uric acid is a widely available test which is economical can be used in stratifying the COPD patients who are more prone to adverse outcomes and may need intensive management. This will lead to proper resource utilization and patient management in a developing country like India.
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Role of uric acid in chronic obstructive pulmonary disease exacerbations: Current concepts and perspectives p. 665
Rajlaxmi Sarangi
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Assessment and reliability of suspect flags in automated hematology analyzers for diagnosing white blood cell and platelet disorders p. 667
Namrata Patro, Archana C Buch, Mukta D Naik, Shruti Vimal, Shirish S Chandanwale
Background: The automated hematology analyzers have replaced the traditional manual methods for assessing hematological parameters. Most of the automated hematology analyzers are programmed to identify abnormalities in the form of “suspect flags.” Aims: The aim of the study was to correlate white blood cell (WBC) and platelet (PLT) flag messages provided by automated analyzers with their respective peripheral blood smear (PBS) findings. Materials and Methods: A descriptive cross-sectional study was undertaken on 100 patients who showed WBC and PLT suspect flags and/or abnormal peripheral smears. The flag messages were analyzed with their respective PBS findings. Pearson's Chi-square test was used for the statistical analysis. Results: Analyzer and PBS showed WBC defects (n = 46, 32), PLT defects (n = 39, 54), and combined defects (n = 36, 43) respectively. WBC defects included leukocytosis (n = 27, 22), leukopenia (n = 20, 18), immature granulocytes (n = 10, 3), left shift (n = 3, 2), myeloblast blast (n = 2, 1), and eosinophilia (n = 4, 4) on analyzer and PBS. Correlation between the WBC suspect flags and their peripheral smears was found to be statistically significant (P = 0.006). PLT defects included thrombocytopenia (n = 22, 30), thrombocytosis (n = 13, 17), giant PLTs (n = 10, 15), PLT clumps (n = 8, 12), and PLT debris (n = 2, 5) on analyzer and PBS. Correlation between the PLT characteristics in analyzers and in peripheral smears was statistically significant (P = 0.042). Conclusion: Suspect flags should be used as a screening tool to pick up pathological samples. These should then be followed up with a PBS examination for definitive diagnosis.
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Reconstruction of neglected Tendo-Achilles tears using the technique of Gastrocnemius-Soleus turndown graft: A case series p. 672
Rajiv Kaul, Manish Prasad, Mohammed Schezan Iqbal
Chronic, neglected Achilles tendon ruptures cause a significant impairment of ankle function due to weakness of active plantar flexion which is required in performing day-to-day activities such as walking and climbing stairs. The causes range from trivial trauma like a slip and fall to high impact injuries. Predisposing factors include a history of previous steroid injections, advanced age, and vigorous sporting activities. Tears involving the zone 2, where vascularity is compromised, pose a challenge to surgeons, as the repair is often jeopardized by wound complications and re-ruptures. Of the several techniques described, we have used the Bosworth's technique of gastrocnemius-soleus turndown to reconstruct defects in this zone in 16 patients and have achieved a satisfactory functional outcome at 1 year with a relatively low incidence of complications. However, this technique requires the presence of an intact distal stump of the tendon of adequate length, the absence of which precludes the use of this method.
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Maternal 2:18 chromosomal translocation manifesting as cause for developmental delay in a proband p. 677
Purushottam Rao Manvikar, Preeti Awari
Developmental disabilities are a group of related chronic disorders of early onset and said to affect 5% to 10% children. Mental Retardation or intellectual disability has been redefined and replaced with Global developmental delay by WHO as the parameters of diagnosis of such a condition become valid and reliable by the age of five years of the proband. In Indian context the incidence is 2.5%.Chromosomal aberrations either structural or numerical account for 25-30% in general population. Chromosomal analysis and karyotyping is considered as primary investigation in management protocols of such children. Authors present a case of six months old child referred to cytogenetic laboratory with a clinical suspicion of delayed mile stone. Proband was born to a non-consanguineous couple delivered by lower segment caesarian section (LSCS) with no untoward incidents during intraoperative and post-operative phase of surgery. There was history of earlier fetal loss at third month of gestation due to cardiac defects diagnosed prenatally. Karyotyping of proband revealed 2:18 translocation. Karyotype of parents was done to find out the source of translocated chromosome. It was revealed that 2:18 translocated chromosome was seen in karyotype of mother of proband. Karyotype of proband was reported as 46,XX; der(18) t(2:18)(q31q35 ;q21q22)mat As per ISCN guidelines. Case has been reported for the rarity of such an occurrence.
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Laugier–Hunziker syndrome: A rare cause of diffuse orofacial pigmentation p. 681
Ashwini Deshpande, Silky R Punyani
Laugier–Hunziker syndrome (LHS) is lesser known and important differential of the multifocal mucocutaneous pigmentation. Essentially idiopathic in nature, this syndrome is characterized by multiple melanotic macules on the oral mucosa, lips, perioral region, and melanonychia. A young Indian male reported to us with a complaint of multiple brown-black spots on the lips and inner surface of the cheeks accompanied by the pigmentation of fingernail. The patient was evaluated for the possible causes of multifocal oral pigmentation. After taking an exhaustive clinical history and thorough investigations, no exact cause for this condition could be definitively ascertained. Eventually, he was diagnosed as a case of LHS, a rare cause of idiopathic oral pigmentation. The various differential diagnoses for the condition are also discussed.
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Unilateral hypoglossal nerve palsy with malignancy of unknown origin p. 685
Chaitanya R Patil, Shrikant Atreya
Paralysis of hypoglossal nerve is rare and often underreported. The paralysis leads to the deviation of tongue, dysarthria, dysphagia, and airway dysfunction, affecting the quality of life. We report a case of a middle-aged woman with malignancy of unknown origin with bone and brain metastasis who presented with unilateral deviation of the tongue. Detailed workup inferred with metastasis to the clivus bone which is related to the hypoglossal canal at the base of the skull and the primary origin could not be established. Intravenous steroids, radiotherapy, and systemic chemotherapy were helpful in improvement of the nerve palsy in our patient. Hypoglossal nerve palsy is often an underrated and underreported lesion; however, it can be a starting point for a major underlying problem.
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A rare cause of bilateral facial nerve paralysis due to acute otitis media in a 52-year-old man p. 688
Santosh Kumar Swain, Alok Das, Sampada Munjal
Facial nerve paralysis is a known complication of middle ear diseases such as chronic otitis media. However, it is rarely seen in acute otitis media (AOM). Bilateral facial nerve paralysis is an extremely rare incidence in AOM in an adult patient. As it is a rare clinical entity, the management of this condition is not very well outlined as per the standard guidelines. Aggressive and appropriate treatment in the earliest period helps patients to recover from facial nerve paralysis. Here, we present a case of bilateral facial nerve paralysis in a 52-year-old male with bilateral AOM. Facial nerve paralysis in both sides recovered to normal with appropriate treatment along with myringotomy.
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Growing skull fracture with leptomeningeal cyst associated with superior sagittal sinus thrombosis p. 692
Jay Kantilal Satapara, Hiral Parekh, Nandini Bahri
Growing skull fracture is a rare complication of head injury usually occurs during the first 3 years of life. It may be associated with cerebral herniation, subdural hygroma, and subgaleal cerebrospinal fluid collection (leptomeningeal cyst). Posttraumatic cerebral venous sinus thrombosis is also an unusual complication of head injury associated with skull fracture extending to a dural sinus or the jugular bulb. It may be associated with ischemic damage to adjacent brain parenchyma. We report the case of growing fracture with leptomeningeal cyst associated with superior sagittal sinus thrombosis. A 2-year-old female child presented to the hospital following head trauma. The patient was drowsy and had hypotonia of all four limbs. Computed tomography was performed which showed a linear fracture of bilateral parietal bone with superior sagittal sinus thrombosis, subgaleal scalp collection in the bilateral parietal region, and ischemic changes in adjacent bilateral parietal lobes. Follow-up magnetic resonance imaging was done after 12 days of conservative treatment which showed similar findings. Surgical correction was done without any intraoperative or postoperative complications. As the delay in treatment may be associated with neurological complications, early diagnosis and prompt treatment are essential to prevent it and imaging modalities help in the early diagnosis.
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A case of generalized myasthenia gravis with bilateral optic neuritis – A rare association p. 697
Atanu Chandra, Anirban Ghosh, Uddalak Chakraborty, Indranil Sen
Myasthenia gravis (MG) is a relatively uncommon autoimmune disorder of neuromuscular junction characterized by fatigable muscle weakness, bulbar symptoms, and weakness of extraocular muscles with a significant diurnal variation. Among all other autoimmune disorders associated with optic neuritis, the association of MG with optic neuritis is very rare, with only a few cases have been reported till date. We present a rare case of 37 years old female who was admitted in November 2018 with generalized MG (seronegative) along with isolated bilateral optic neuritis, and the patient responded significantly to steroids, immunomodulators, and anticholinergics.
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Recurrent episodes of acute psychosis like illness: A very delayed presentation of Sheehan syndrome p. 700
Atanu Chandra, Suman Roy, Uddalak Chakraborty, Saikot Ganai
Sheehan syndrome, also known as postpartum pituitary gland necrosis, is a very serious complication of postpartum hemorrhage. Although it is a rare disorder in western countries, it is not much uncommon in developing countries like India. We describe 46-year-old female from a rural area of eastern part of India who presented with recurrent episodes of acute psychosis like illness over the last few years. When she came to our medical emergency unit, she was found to have hypoglycemia, hyponatremia, and hypotension. Further evaluation revealed history of postpartum hemorrhage during her last childbirth 17 years back which was followed by amenorrhea, lactation failure, and associated psychiatric illness. Magnetic resonance imaging pituitary showed empty sella and there were decreased levels of all the anterior pituitary hormones. All these parameters led to the final diagnosis of Sheehan syndrome which was diagnosed after a significant delay.
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Empathy in the time of artificial intelligence: Fiction not fact may hold the key p. 703
Vadisha Srinivas Bhat
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Novel coronavirus infection: What's the risk occupation? Analysis on nonimported cases p. 705
Beuy Joob, Viroj Wiwanitkit
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COVID-19 and face mask insufficiency crisis: A note p. 706
Sora Yasri, Viroj Wiwanitkit
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Challenges of COVID-19 case detection in a resource-limited primary care setting: A commentary p. 707
Godpower Chinedu Michael, Ibrahim Aliyu
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