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   Table of Contents - Current issue
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January-March 2020
Volume 18 | Issue 1
Page Nos. 1-73

Online since Monday, February 3, 2020

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ORIGINAL ARTICLES  

A retrospective study on clinical profile of patients with firecracker-related injury presenting to the emergency department of a tertiary care center in South India p. 1
Akash Sethy, Shubhashis Saha, Darpanarayan Hazra, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_56_19  
Background: Firecracker injuries are very common in India. They are mostly used during the various festivals celebrated in India. This study analyses the profile and outcome of firecracker injuries in the emergency department (ED). Materials and Methods: This was a retrospective observational study of all firecracker-related injury patients presenting to our ED. Details of the incident, injuries, management, and outcome were noted. Data were extracted from the ED triage software and hospital electronic database. Results: We received a total number of 13,604 trauma patients to our ED, among which 92 (0.7%) had firecracker burst-related injury. The mean age of the patient was 27 (standard deviation 11.6) years. Male (97.8%) predominance was noted. Majority of them were triaged to Priority II, i.e., 64 (70%) patients and 6 (6%) in Priority I. The mean number of incidents per month during the festive season of Diwali was 3.25 compared to 3.95 during the rest of the year. The majority of the injuries had sustained lacerations (78.5%), followed by abrasions (12.9%). Among all patients, only 4.3% (4) suffered second- and third-degree burns each. It was noted that the upper limbs (79.6%) were most commonly involved as expected, followed by the face (16.1%). The new injury severity score was more than 5 in (6.4%) of patients. Most patients were taken up for emergency procedures such as wound wash, debridement, suturing, or nailing of the fractures in the ED. Majority (81.5%) required hospital admission and had to undergo major surgical intervention. The rest were either discharged stable or discharged against medical advice after primary care. Conclusions: This study has expressed the pattern of firecracker injuries. An alarmingly high number of young adolescents with significant upper limb injuries were noted. Public awareness and education along with increase legislative enforcement are needed for the betterment and well-being of the mass during the festival season to prevent the catastrophe since these injuries are prevalent in the productive age groups.
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A prospective study on the comparison of contamination rate and risk factors of blood culture done in the emergency department and medical high-dependency unit/medicine intensive care units p. 7
Pranav Kumar, Darpanarayan Hazra, Ankita Chowdary Nekkanti, Mamta Madhiyazhagan, Thomas Sundarshanam, Veera Raghavan Balaji, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_59_19  
Background: Blood culture (BC) is an important tool and also considered the “gold standard” for the diagnosis of bacteremia. Emergency departments (EDs) and medical high-dependency units/medicine intensive care units (MHDUs/MICUs) are particularly susceptible to contaminated BCs due to high staff turnover. However, the need to collect cultures in critically ill patients is essential before the first dose of antibiotics. Aim: This study aimed to calculate the rate and risk factors of contamination of BC in ED and MHDU/MICU. Materials and Methods: This is a 2-month prospective observational study with a total of 998 patients – 570 in ED and 428 in MHDU/MICUs. The primary investigator collected the data, and culture reports were followed up to 7 days. Categorical variables were presented as percentages, and quantitative variables were summarized using mean and standard deviation. Results: The mean age of the population in the ED culture arm was 51 years and in the MHDU/MICU was 46 years. There was a male predominance of 61%. From ED, the most common admission diagnosis was acute undifferentiated febrile illness accounting to 23% of total patients. Lung pathologies were the most common MHDU/MICU admission diagnosis encountered in the study comprising 193 (19.3%) cases. The most common site for culture in ED was the brachial vein (81%) followed by the dorsum of the hand (14%). The most common contaminant was coagulase-negative Staphylococcus (CoNS) with 26 cases, of which 16 were from MHDU/MICU. A total of 48 cases (4.8%) were contaminated in the study, of which 25 (4.4%) cases were from ED and 23 (5.4%) from MHDU/MICU. Conclusions: BC contamination is a common clinical problem and often leads to adverse impacts on both health care and costs. It is challenging to prevent contamination because of inadequate inpatient capacity, high severity of illness, the rapid turnover of staff, and the high workload and overcrowding.
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Retrospective study on cost accounting of trauma patients presenting to the Emergency Department in a tertiary care hospital in South India p. 14
Didla Gautam, Darpanarayan Hazra, Ankita Chowdary Nekkanti, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_62_19  
Background: Accelerated urbanization and industrialization have led to an alarming increase in the rates of trauma that eventually increases the financial burden of society. Understanding the direct medical costs associated with trauma provides a window for assessing the potential cost reductions with improved quality care in the Emergency department (ED). Aim: The aim is to analyze the possibilities of minimizing the expenditure of trauma patients presenting to priority I and priority II of the emergency department (ED), without compromising care and treatment. Materials and Methods: This is a retrospective study done in the ED of CMC Vellore in the month of January 2017. Multiple regression was used to categorize patients into major or minor trauma on the basis of Glasgow Coma Scale, hemodynamic stability, unstable abdominal/pelvic fractures, chest trauma (subcutaneous emphysema/open pneumothorax/penetrating chest injury), hypovolemic shock, and polytrauma. The costs of each type of trauma were then calculated after adjusting for differences in age, gender, mode of injury, influence of alcohol, and system(s) involvement. Results: A total of 119 trauma patients who were admitted in priority I and II were studied in a period of 1 month, among which majority were male 97 (81.5%) patients. It was noted that the incidence of trauma was the highest in the adult age group, i.e., 91 (76.5%) patients. Road traffic accident was the most common mode of injury and seen in 83 (69.7%) patients. In injury profile, lower limb injuries were most commonly involved and contributed to 37 (31.1%) patients, followed by upper limb injuries in 21 (17.6%) patients and isolated head injuries in 15 (12.6%) patients. The average cost was more in patients suffering from major trauma (Rs. 10,983/-) in comparison to minor trauma (Rs. 6464/-), with the maximum expenditure in radiological investigation. In about 18 (15%) patients, blood tests and imaging were done without proper indication which led to additional expenditure. Among all these trauma patients, 40.3% of patients needed admission either in ICU or ward and underwent major surgical procedures, 44.5% of patients were discharged in a stable condition, 13.5% of patients were either discharged against medical advice or discharged at request after primary care and 1.7% of the patients died during their stay (primary Resuscitation) in the ED. Conclusions: This study shows the cost-benefit analysis in major trauma while maintaining high quality care and treatment.
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Prehospital care in the management of snakebites p. 19
T Reginald George Alex, GR Divya, John Emmanuel Jesudasan
DOI:10.4103/cmi.cmi_68_19  
Introduction: Snakebite is a significant public health problem in India. A variety of prehospital practices are commonly followed after a person has been bitten by a snake before he/she reach a health center. Methodology: This was a prospective, descriptive study done in the emergency department which included adult patients above the age of 18 years who presented with a history of either a snakebite or an unknown bite. All other known bites were excluded from the study. The period of the study was between August 2015 and March 31, 2016. Results: The study cohort included 62 patients, with a majority being male (61.3%; 38/62). 32.3% (20/62) of patients were farmers and homemakers constituted 30.6% (19/62). Tying a tourniquet above the bite mark (66.1%; 41/62) was the most common prehospital care administered to the victims. Traditional methods such as performing ritual prayers (1.6%; 1/62), sucking out blood (3.2%; 2/62), or applying traditional medicines (1.6%; 1/62) were the other practices followed before they reached a health center. Conclusion: A significant number of snakebite victims received prehospital care before they reached a health-care facility. Application of tourniquet is the most common prehospital practice followed in the community. However, the other traditional methods are rarely practiced nowadays.
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Emergency department revisits within 72 hours to a tertiary care referral hospital in South India p. 23
Namrata Mathew, Apoorva Guttikonda, Shubhanker Mitra, Joshua J Vijay, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_65_19  
Introduction: Emergency department (ED) revisits are an important indication of health-care quality provided by a hospital. In the West, ED revisits rate range from 2.9% to 4.9%. However, data from India are lacking, and hence. this study was done. Methodology: This retrospective observational study was done in a 45-bedded ED of a teaching hospital in South India. All the patients who revisited the ED within 72 hours over a 1-year period were considered. The revisit was categorized as unavoidable if the patient was diagnosed correctly and managed appropriately during the first visit or if the patient presented with an unrelated illness within 72 hours. Results: The ED revisit rate was 0.8% (549/65,900). The monthly revisit rates ranged from 0.50% to 1.91%. About 57.9% were initially categorized as priority 3, 33.9% as priority 2, and 8.3% as priority 1 patients. During the revisit, 41.6% were priority 3 patients, 44.3% were priority 2 patients, and 13.7% were priority 1 patients. Gastrointestinal symptoms such as abdominal pain, vomiting, diarrhea, and constipation were the most common initial presenting complaints seen in 36% of the patients followed by fever (15.3%). A majority (75%) of these patients were initially discharged by the ED registrars. More than half (55.2%) of the revisits were avoidable. During the second visit, 58% were discharged in a stable condition, 31.7% were admitted to the hospital, and 4.8% died in the ED. Conclusion: ED revisits are associated with significant distress to the patients and more than half of them can be avoided.
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REVIEW ARTICLES Top

Sexually transmitted diseases vaccines: Progress and challenges p. 28
Abha Sharma
DOI:10.4103/cmi.cmi_52_19  
Many sexually transmitted diseases (STDs) such as hepatitis B virus, and human papillomavirus can be effectively prevented with vaccines. However, vaccines for other STDs (e.g., human immunodeficiency viruses (HIV), herpes simplex virus (HSV), gonorrhea, syphilis, chlamydia, etc.) are under development. Although the focus of most researchers worldwide is more on HIV vaccine development, this review focuses largely on challenges being faced and current development on vaccines against gonorrhea, syphilis, chlamydial infection, chancroid, and trichomoniasis.
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Early management of trauma: The golden hour p. 36
Kundavaram Paul Prabhakar Abhilash, A Sivanandan
DOI:10.4103/cmi.cmi_61_19  
The first 60 minutes after traumatic injury which is the most crucial period that determines the patient's outcome has been termed the “golden hour.” The concept that definitive resuscitative trauma care must be initiated within this early window has been publicized, taught, and practiced worldwide for more than four decades. The main steps in the early management of trauma are primary assessment; resuscitation: perform primary assessment and resuscitation together; reassessment of airway, breathing, and circulation; and secondary assessment. The primary assessment provides basic data essential for the patient's survival when life or limb is threatened. Resuscitation should be initiated simultaneously with the primary assessment. It is performed when any component of the primary assessment appears unstable. The secondary assessment is to be performed after the completion of primary assessment and resuscitation. It provides comprehensive information about the various organ systems.
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Procedural sedation and analgesia in the emergency department p. 40
Sandeep Nathanael David, Priya Ganesan
DOI:10.4103/cmi.cmi_63_19  
Emergency medicine as a medical specialty has come a long way since its evolution from the now obsolete “Casualty Department.” A prevalent challenge in the emergency department (ED) is safe and effective administration of anesthetic agents to a patient in pain or altered mentation without compromising their airway control and hemodynamics. Fear and unfamiliarity with the use of various anesthetic agents is the major stumbling block in this regard. Procedural sedation and analgesia (PSA) in the ED improve patient satisfaction, reduces physiological stress and allows for rapid return of consciousness after traumatic procedures while providing sedation, analgesia, and amnesia. PSA is a planned service which should be provided under strict monitoring with proper preanesthetic workup and emergency measures easily available. PSA strengthens the armament of the emergency physician, allowing a better understanding of pain control and sedation without resorting to general anesthesia.
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CASE REPORTS Top

A case of tubercular lymphadenopathy and review of literature p. 45
KM Mohammad Iqbal, Muhammed Jasim Abdul Jalal, Thara Pratap, Iona Leekha Mathew
DOI:10.4103/cmi.cmi_30_19  
Tubercle bacilli infects approximately one-third of the world's population as per the World Health Organization. New cases of the active disease developing each year constitute eight million of which three million people die. Tubercular lymphadenopathy is often rare compared to pulmonary tuberculosis. We present a case of a 29-year-old Indian female, who was immunocompetent and HIV negative, with a 3-month history of recurring fever, loss of appetite, abdominal pain, vomiting, and loss of weight. On examination, she had disseminated lymphadenopathy including supraclavicular lymph nodes. Fine-needle aspiration cytology of the right supraclavicular node showed acid-fast bacilli along with caseation necrosis and was consistent with tubercular lymphadenopathy. Disseminated tubercular lymphadenopathy is extremely rare in immunocompetent individuals. The crux in the approach to disseminated lymphadenopathy lies in the diagnosis of tubercular lymphadenopathy, confirmed by histological and microbiological findings since it has a good prognosis with an active antituberculous treatment regime resulting in a favorable outcome.
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Lumbar vertebral ring apophysis fracture with disc herniation in a young male p. 48
Raj Kumar Kollam, Emmanuel Akanksh Bheri, Samson Sujit Kumar Gaddam
DOI:10.4103/cmi.cmi_40_19  
Lumbar vertebral ring apophysis fracture is an uncommon cause of low back pain. It usually occurs in adolescents and young adults following a history of trauma. A high degree of suspicion and computed tomography of the spine is necessary to differentiate these injuries from the regular isolated lumbar disc herniations to enable appropriate further management. These fractures are usually associated with lumbar disc herniation in adolescents. Conservative management is the mainstay in patients without neurological deficits. Those with deficits may require surgical intervention – usually bilateral laminectomy or laminotomy and the removal of avulsed bone fragments and associated prolapsed disc. We report a case of a 24-year-old male with lumbar (L4) vertebral ring apophysis fracture with disc herniation who responded to conservative treatment.
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Systemic lupus erythematosus presenting as macrophage activation syndrome in an adult male p. 52
Muhammed Jasim Abdul Jalal, KM Mohammad Iqbal, Pushpa Mahadevan, S Neethu
DOI:10.4103/cmi.cmi_50_19  
Macrophage activation syndrome (MAS) is a rare, life-threatening, hyperinflammatory state where there is a combination of fever with cytopenias, high ferritin, high aspartate transaminase, and high triglyceride levels. In adults, MAS infrequently occurs as a complication of systemic lupus erythematosus (SLE). SLE presenting as MAS is extremely rare in adults. We report a patient with MAS who presented with fever, rash, and high ferritin level (>2000).
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Metastasis of carcinoma rectum to the breast: A rare entity p. 55
Royson Dsouza, Gigi Varghese, Shawn Thomas, Deepak Abraham
DOI:10.4103/cmi.cmi_45_19  
A 28-year-old female presented to the endocrine surgery clinic with complaints of the right breast lump for 3 months. Clinical examination revealed a 3 cm × 2 cm hard lump in the upper outer quadrant, suspicious of carcinoma breast with clinical staging of T2N0M0. Three years before this, she was diagnosed to have adenocarcinoma of the rectum and had undergone treatment. On serial follow-up, there was no evidence of locoregional recurrence of the disease. Ultrasound imaging of the right breast was suggestive of BI-RADS V lesion, highly suspicious of primary breast malignancy. However, the core biopsy was reported to be mucinous adenocarcinoma with immunohistochemical markers suggestive of a colorectal primary. Metastasis to the breast from a primary colorectal carcinoma is an exceedingly rare clinical entity. The imaging findings may not yield any characteristic differences between primary breast cancer and breast cancer due to metastasis from other cancerous primary. Biopsy of the lesion with relevant immunohistochemical markers remains the mainstay of the diagnosis. The overall prognosis is poor, and the treatment comprises oral capecitabine as a palliative agent with or without wide local excision of the metastatic breast lesion.
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Petersen's space hernia - An expanding diagnosis after bariatric surgery: A case report and review of literature p. 59
Royson Dsouza, Vijay Abraham, S Suraj
DOI:10.4103/cmi.cmi_44_19  
Petersen's hernia refers to an internal herniation of small bowel through the potential space between the transverse mesocolon and the Roux limb of gastrojejunal anastomosis. The incidence of this is increasing with the widespread practice of bariatric surgery in the last decade. In this report, we present the case of a 44-year-old male who had undergone a laparoscopic Roux-en-Y gastric bypass for morbid obesity and presented after 14 months with a history of nonspecific abdominal pain. The examination of his abdomen was unremarkable. The computed tomography scan revealed the suspicious features of internal herniation of the small bowel and a twist in the mesentery. On diagnostic laparoscopy, he was found to have Petersen's space hernia. His clinical presentation, investigations, and treatment have been highlighted in this case report with a review of the literature. Although rare, Petersen's hernia could lead to a disastrous complication of small bowel strangulation if not intervened early. Hence, if suspected, the threshold to perform a diagnostic laparoscopy should be low.
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Right middle and lower lobe collapse by an ascending thoracic aortic aneurysm p. 62
Darpanarayan Hazra, Joanna Preritha Fernandes, Aparna Lohanathan, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_31_19  
We report a case of a 60-year-old male patient who presented to the Emergency Department of Christian Medical College, Vellore, with a history of right-sided pleuritic chest pain. Thoracic aortic aneurysms are usually asymptomatic unless any complication occurs (e.g., dissection, rupture) or an imaging study has been performed demonstrating the aneurysm. Chest radiograph of this patient showed collapse of right main bronchus due to an aneurysm, which to our knowledge has not been previously reported in literature.
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MEDICAL NEWS Top

Updates on contraception services for women at high risk of human immunodeficiency virus: World Health Organization p. 64
Saurabh Ram Bihari Lal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_57_19  
Use of contraception has been recommended to prevent pregnancy, practice family planning and also to prevent the acquisition of sexually transmitted infections. It is important to advocate that regardless of geographical settings, all the women should have access to the wide range of contraceptives, so that based on their preferences or values, an appropriate and well-informed choice can be made. The revised recommendation for women at high risk of HIV advocates for the use of any form of reversible contraception, including progestogen-only injectables. In conclusion, the sexual and reproductive health needs of all women are quite variable and it becomes even more challenging for the women who are either at high risk of HIV or HIV positive. The recent recommendations to expand the range of services offered, including contraceptive methods, is an important step, but will also require strengthening of the existing services.
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LETTER TO EDITOR Top

Evaluation of medical education programs: Need, scope, and tools p. 66
Saurabh Ram Bihari Lal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_42_19  
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CME QUIZ Top

Corticobasal degeneration presenting with primary progressive aphasia p. 68
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
DOI:10.4103/cmi.cmi_41_19  
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Bulging fissure sign p. 72
Darpanarayan Hazra, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_25_19  
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