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Risk assessment of intrauterine growth restriction
Reeta Vijayaselvi, Anne George Cherian
October-December 2017, 15(4):262-266
Intrauterine growth restriction is a condition where the estimated fetal weight is less than the 10th percentile on ultrasound and the fetus has not attained its biologically determined growth potential because of a pathologic process. This review deals with the definitions of fetal growth restriction, the etiology associated with it, the types of fetal growth restriction and discusses how to differentiate between them. The various screening mechanisms available, the approach to a patient who is at risk for fetal growth restriction and whether they will benefit from any of the prophylactic measures available are also discussed.
  3 9,487 294
Unexplained infertility: An approach to diagnosis and management
Mohan S Kamath, Mogili Krishna Deepti
October-December 2016, 14(4):94-100
The cause of infertility is said to be unexplained when there is normal ovulatory function, semen analysis is normal, and tubal patency is established by hysterosalpingography or laparoscopy. Some of the factors that may contribute to the etiology of unexplained infertility are inability to identify the subtle reproductive abnormalities, endocrine/genetic/immunological disorders, minimal/mild endometriosis, and compromised ovarian and natural fecundability that may be less than normal. Prognostic factors in unexplained infertility include maternal age, duration of infertility, and previous obstetric history. The management options depend on various factors such as age of woman, duration of infertility, couples' preferences, and the health-care setting. The options available for treatment include expectant management, clomiphene citrate, super ovulation with intrauterine insemination, and in vitro fertilization/intracytoplasmic sperm injection.
  3 5,718 216
Diuretic strategies in medical disorders
Vijoy Kumar Jha, KV Padmaprakash, Rajesh Pandey
April-June 2018, 16(2):60-67
Diuretics are often the cornerstone of treatment for volume overload in the emergency setting. The pharmacokinetic and pharmacodynamic properties of diuretics differ in various clinical scenarios. The choice of a diuretic, its maximum dosage, and spacing of doses are important clinical issues which every medical practitioner needs to be aware of. In this review, we discuss the pharmacokinetic and pharmacodynamic properties of diuretics, their therapeutic implications, and best strategies for use in various clinical conditions.
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Splenic injuries in blunt trauma of the abdomen presenting to the emergency department of a large tertiary care hospital in South India
Kundavaram Paul Prabhakar Abhilash, Moses Amos Kirubairaj, Kiruthika Meenavarthini
October-December 2017, 15(4):278-281
Background: Trauma is an increasing cause of morbidity and mortality in India. Blunt injury to the abdomen frequently results in life-threatening splenic injuries. Materials and Methods: This was a retrospective observational study of all patients more than 18 years old presenting to our emergency department with blunt abdominal trauma resulting in a splenic injury between 2006 and 2011. Details of the incident, injuries, and outcome were noted. Results: During the study of 2006–2011, 51 patients with splenic injury following blunt trauma to the abdomen were enrolled. There was a significant male predominance (94.1%). Road traffic accident (RTA) was the predominant mode of injury (66.7%) followed by fall from height (25.5%). On examination, the majority of the patients (82.4%) had abdominal tenderness while abdominal distension and guarding were seen in 60.8% and 31.4% of patients, respectively. A third (35.3%) of the patients was hypotensive at presentation. All the patients were started on crystalloids while blood products were transfused in 70.6% of the patients. Splenic injury was diagnosed during the primary survey in 92% of the patients. Emergency department (ED) physicians diagnosed free fluid and solid organ injuries on focused abdominal sonography in trauma (FAST) in 80.4% and 47.1% of patients, respectively. Computed tomography scan of the abdomen was performed in 57% of the patients. More than half (58.8%) were managed conservatively. The mortality rate was 10%. Conclusions: RTAs are the most common cause of splenic injury. ED physicians are quite reliable in diagnosing free fluid in the abdomen with FAST. Aggressive fluid resuscitation with blood products is the key to survival in both conservatively and surgically managed patients.
  2 2,141 72
Scrub typhus in children
Winsley Rose
April-June 2017, 15(2):90-94
Scrub typhus is a mite-borne acute febrile illness caused by Orientia tsutsugamushi, and is transmitted by the bite of the trombiculid mite. It presents with high-grade fever which may be associated with nonspecific signs and symptoms such as rash, muscle and abdominal pain, headache, and lymph node enlargement. Scrub typhus is, therefore, one of the differential diagnoses to be considered in a child with acute undifferentiated febrile illness, especially if the disease is endemic to the region. The presence of a painless eschar at the site of the bite is an important pointer to the diagnosis. The illness responds well to antibiotics, usually within 48 h.
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Profile of geriatric patients presenting to the emergency department
Kundavaram Paul Prabhakar Abhilash, Moses Amos Kirubairaj, Saurabh Ramesh Sahare
July-September 2017, 15(3):227-230
Background: In both developed and developing countries, the proportion of people over60years of age is growing faster than any other age group as a result of longer life expectancy due to improved health care. As a result, emergency department(ED) visits are on the rise. Materials and Methods: This retrospective observational study was conducted in the ED of a large tertiary level hospital between September 2014 and December 2014. All patients>65years presenting to the ED were included in the analysis. Results: During the study period, 1090 geriatric patients comprised 13.9% of the ED admissions. The mean age of the patients was 74.2±20.32years. There was a male predominance(65.4%). The most common presenting complaints were breathing difficulty(28%), fever(21.6%), vomiting(14%), chest pain(11.5%), abdominal pain(11.5%), trauma(11%), giddiness(10.4%), and altered sensorium(10%). The distribution of the most common organ systems involved are as follows: Cardiovascular system(18.7%), respiratory system(15.8%), trauma(13.9%), genitourinary system(13.8%), neurological system(12.3%), skin and soft tissue infections(6%), and others(25.1%). Among the respiratory conditions, acute exacerbation of asthma/chronic obstructive pulmonary disease was the most common(61.2%), followed by pneumonia(28.9). More than half(51.5%) were discharged from ED, 47.5%(518patients) were admitted to the hospital, and 0.91%(10patients) expired in the ED. Afurther 64patients expired during the hospital stay. The overall inhospital mortality among the geriatric emergencies was 6.8%(79/1090). The mean length of hospital stay was 8.06days. Conclusion: The admission profile among this geriatric population showed that cardiorespiratory conditions are the most common emergencies, followed by trauma. ED of India should be aware of this demographic profile and be prepared to handle these emergencies efficiently.
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Comparative assessment of private and public health care providers' Knowledge on malaria treatment in bassa local government area of plateau state
Nanloh Samuel Jimam, Shalkur David, Bulus J Kaben
January-March 2017, 15(1):45-50
Background: Health-care workers have a major role to play in ensuring that malaria treatment is carried out in accordance to treatment guidelines, to ensure the quality of patient care. Having the requisite knowledge of the ailment and its management is a necessity in achieving optimal treatment outcomes. Objectives: The purpose of this study was to assess and compare health-care workers' knowledge on malaria and its treatment across public and private primary health-care facilities of Bassa Local Government Area, Nigeria. Materials and Methods: Two hundred pretested semi-structured questionnaires were administered to health-care workers across selected public and private facilities; and the generated data were analyzed using Statistical Package for Social Sciences software version 20. Results: A total of 184 health-care workers (92% of the study population of 200) participated in the study. The majority of the health-care workers (65.8%) were from the public sector, while 34.2% were from private health facilities. Most of the respondents were Junior Community Health Extension Workers (23.4%) and Community Health Extension Workers (22.8%). The other health workers included in the study were nurses and laboratory and pharmacy technicians involved in the management of malaria. The respondents had a good knowledge of the cause, symptoms, and diagnosis of malaria across the facilities, based on their item scores; however, their knowledge on anti-malarial drugs was poor. Workers with >10 years in practice had significantly better knowledge (45.3%) than those with lesser experience (28.4%) (P = 0.018). Those in private practice had marginally better knowledge (44.4%) than those in public sectors (38.8%). Conclusion: The respondents had good knowledge of the etiology, symptoms, and diagnosis of uncomplicated malaria across the facilities, but knowledge of the recommended antimalarials and symptoms of complicated malaria was poor. The outcomes will be useful in educating health-care professionals in the facilities, with an emphasis on the recommended drugs for malaria.
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A retrospective study on the profile and outcome of polytrauma in the emergency department
Navin Clement, Divya Lovelin Regina, Kundavaram Paul Prabhakar Abhilash
April-June 2018, 16(2):56-59
Background: Polytrauma is a major cause of morbidity and mortality in developed and developing countries. This study aims to assess the prevalence and outcome of polytrauma patients, in a tertiary care hospital. Materials and Methods: This retrospective observational study was conducted in a large emergency department (ED) between January 2016 and December 2016. All patients >15 years presenting to the ED with polytrauma were included in the analysis. Results: Among 98 polytrauma patients, majority (86%) were male. The mean (standard deviation) age was 41.6 (±14.85) years. Less than one-third of the patients presented to the ED within 3 h of the time of injury. A quarter of the patients have severe traumatic brain injury. Plasma alcohol levels were sent in 22 patients and were found to be elevated in 12 (15%) patients. Majority (78%) of the patients required orthopedic evaluation and intervention. Forty-four patients required 1 unit packed cell blood, whereas 11 patients received two units packed cell blood and 4 patients needed three units packed cell for resuscitation in the ED. Focused assessment with sonography for trauma was done in 66 (85%) patients and was positive in 32 (41%) patients. The ED outcome is shown in [Figure 1]. The ED mortality rate was 15%. Conclusion: Less than one-third of the patients presented to the ED within 3 h of the time of injury which stresses the need to improve prehospital care and transport in our country. Aggressive resuscitation with crystalloids and blood products is of paramount importance in treating polytrauma victims.
  1 2,232 96
National Accreditation Board for Hospitals and Healthcare Providers (NABH) Standards: A review
Samuel N. J. David, Sonia Valas
July-September 2017, 15(3):231-236
Quality has become an important buzzword for the current generation of healthcare providers. Most hospitals and healthcare providers are differentiated and evaluated according to their organization performance and quality.National Accreditation Board for Hospitals and Healthcare Providers(NABH) is an integral board of Quality Council of India, established to operate accreditation program for healthcare organizations/institutions. Accreditation is a public recognition awarded to healthcare organizations which fulfill the standards laid by NABH through an independent external assessment conducted by qualified team of assessors.
  1 13,817 253
Endovascular therapy in vascular surgery - how relevant is it to India?
Edwin Stephen
July-September 2020, 18(3):153-155
The world has seen a sea of change in options available to patient's with peripheral vascular disease be it venous or arterial pathology – when it comes to endovascular therapy over the past decade. Intervention in most cases can be carried out as outpatient, day-care, or short stay in hospital. However, all this comes at a price. This article looks at the relevance of “The Endovascular revolution” in the context of Indian health care.
  1 916 111
Is a university competent to confer a “Recognized” medical degree or diploma in India
D Samuel Abraham
October-December 2017, 15(4):295-298
There have been several legal enactments in the Indian legal system that were put into force with the intention of standardizing and regulating medical education and the conferring of medical qualifications. There is a common misunderstanding that a medical degree or diploma is recognized or is legally valid if it is provided by a university. However, from a legal standpoint, while Indian Universities may provide medical education courses, they are not fully competent and cannot independently confer a degree/diploma on their own, unless they have obtained sanction from the Medical Council of India and Central government. No medical professional can suffix the name of the Diploma/Degree/Certificate after their name in the business card or seal if they are not approved by both MCI and Central Government. The issue of a Medical Degree or Medical Diploma by a University without the approval of the Central Government and the Medical Council of India (MCI) will be incomplete and invalid legally.
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Clinical profile and outcome of the patients presenting to the resuscitation room of the emergency department in a Tertiary Care Hospital of South India
Y Billy Rufus, Kundavaram Paul Prabhakar Abhilash, RJ Swadeepa, Sarah Ann Koshy, Gina Maryann Chandy
April-June 2019, 17(2):25-29
Background: The sickest patients who visit the emergency department (ED) are triaged as priority one based on guidelines. To improve the quality of Emergency medicine (EM) care, a better understanding of patients is needed; hence, this study was done on priority one patients of the ED. Materials and Methods: This retrospective study included all priority one patients during a 4-month period (February, May, September, and December), over 1 year (2017). Demographic details, vital signs at the time of presentation, and details of disposition were noted. Results: Among 2333 priority one patients, majority (89.3%) had non trauma-related diseases, while only 10.7% had trauma as the cause of disease. Males were predominant (64%) and females accounted for 36%. Adults were more than half (59.16%), followed by the geriatric age group. Bradycardia was noted in 6.4% (149) patients, while 52.1% (1212) had tachycardia and 29.7% of the population presented with hypotension. Breathlessness was the most common complaint (44.6%); trauma specialty departments were referred to include neurosurgery (43.1%) and orthopedics (27.5%). Broader specialties such as general medicine and general surgery had majority of their spectrum-related cases referred to them, 44.9% (n = 716) and 39.3% (n = 50), respectively. More than a quarter of patients (27.2%) were discharged from the ED, one-third (68.1%) of the patients were discharged from the hospital overall, and 7.4% succumbed to death. Conclusion: The patient demographics and other characteristics identified by this study help us to guide and shape Indian EM training programs, infrastructure, and faculty development, to more accurately reflect the burden of acute disease in India.
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Paraquat poisoning management
Ramya Iyyadurai, Jambugulam Mohan, Arun Jose, Sohini Das, Jacob Johnson, Karthik Gunasekaran
April-June 2019, 17(2):34-37
Paraquat a rapidly acting, nonselective herbicide is a leading cause of fatal poisoning in many parts of Asia. After rapid absorption, paraquat is concentrated inside many cells where it undergoes redox cycling. Clinical features are largely due to intracellular effects. Paraquat is actively concentrated into lung tissue leading to pneumonitis and lung fibrosis. Paraquat also causes gastrointestinal, renal, and liver injuries. Activated charcoal and Fuller's earth can minimize further absorption. Gastric lavage is contraindicated. Hemodialysis and hemoperfusion are unlikely to change the clinical course. The use of immunosuppression with dexamethasone, cyclophosphamide, and methylprednisolone evidence for efficacy is weak. Antioxidants such as acetylcysteine and salicylate used as free radical scavenging might be beneficial. The case fatality is very high in this herbicide due to the lack of effective treatment options.
  1 2,222 236
Venomous snakebites: Management and anti-snake venom
John Emmanuel Jesudasan, Kundavaram Paul Prabhakar Abhilash
July-September 2019, 17(3):66-68
In the Indian subcontinent, the “Big four” snakes of cobra, krait, Russell's viper, and saw-scaled viper are responsible for most of the venomous snakebites. Diagnosing envenomation is a pure clinical skill with no diagnostic kit available yet. Anti-snake venom (ASV) is a precious commodity, and clinicians across the country must be aware of the process of production of ASV so that they may use it judiciously for the treatment of envenomation.
  1 1,682 144
Low-volume plasma exchange and low-dose steroid to treat secondary hemophagocytic lymphohistiocytosis: A potential treatment for severe COVID-19?
Vijay Alexander, Uday Zachariah, Ashish Goel, Subramani Kandasamy, Binila Chacko, John Victor Punitha, Sukesh Nair, Vinoi David, Savit Prabhu, KA Balasubramanian, Ian Mackie, Elwyn Elias, CE Eapen
April-June 2020, 18(2):77-82
Secondary hemophagocytic lymphohistiocytosis (sHLH) may be responsible for some of the deaths in adult patients with severe COVID-19. We present our experience of low-volume plasma exchange (PLEX) with low-dose steroid in the treatment of adult patients with sHLH and acute liver failure caused by dengue virus and other nonviral triggers and discuss how this may be effective in the management of severe COVID-19. sHLH is poorly understood and without effective treatment. Endothelium of the capillaries of the lungs and kidneys and of liver sinusoids does not express von Willebrand factor (VWF) in health and is where most macrophages are located. Plasma VWF levels are high in sHLH and require clearance by macrophages, which when activated enlarge and likely block the lumen. Current histology studies neither appreciate microcirculatory sludge nor display endothelial–macrophage interactions. We hypothesize that low-volume PLEX and low-dose steroid may reverse sHLH and improve survival in severe COVID-19 patients with acute lung injury.
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Subclinical hypothyroidism
K Felix Jebasingh, Dukhabandhu Naik, Nihal Thomas
April-June 2018, 16(2):39-41
Subclinical hypothyroidism (SCH) is defined as an elevated serum thyroid-stimulating hormone level with a normal total and free thyroxine (T4) level. There is a certain degree of debate regarding the risks associated with this condition and whether treatment is beneficial. Individuals with SCH are either asymptomatic or present with milder symptoms than those with overt hypothyroidism. Although SCH does not cause significant clinical abnormalities, there are certain long-term consequences which have been documented. The diagnosis is based purely on biochemical investigations. Treatment of this condition is not indicated in all cases since thyroid function tests tend to normalize in 6%–35% of patients. However, there are specific clinical indications for treatment and oral levothyroxine is the treatment of choice in such situations.
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Management of intrauterine growth restriction
Liji S David, Anne George Cherian, Manisha Madhai Beck
October-December 2017, 15(4):271-277
Intrauterine growth restriction (IUGR) is a condition where the fetus does not attain its biologically determined growth potential due to a pathological process. The main tools for antenatal surveillance in a growth-restricted fetus include amniotic fluid volume, Doppler studies, and biophysical profile. The frequency of surveillance depends on the severity of the growth restriction and the findings on previous ultrasound studies. The decision to deliver the fetus is dependent on factors such as gestational age, severity of growth restriction, and findings on the Doppler studies. If there is severe abnormality in the Doppler studies, lower segment cesarean section is recommended as the mode of delivery. Vaginal delivery may be attempted after induction of labor if Doppler parameters are normal, in a center with adequate facilities for monitoring facilities and when there are personnel with expertise. This review provides an overview of antenatal monitoring in a pregnancy with IUGR and decision-making during the time of delivery.
  1 9,333 206
Oral antidiabetic agents: Recently available novel oral antidiabetic agents in India: Aclinical review
Nitin Kapoor, Nihal Thomas
July-September 2017, 15(3):169-176
Oral anti-diabetic agents form an important therapeutic strategy in the management of diabetes, after lifestyle modification. There are several new agents available, like dipeptidyl peptidase 4 (DPP4) inhibitors and sodium- glucose cotransporter 2 (SGLT2) inhibitors have been approved for use as monotherapy when diet and exercise are inadequate and when metformin is not tolerated, and can also be utilized as an add on to other glucose-lowering agents, including insulin. The therapeutic, pharmacokinetic and safety profiles of these agents are different from the older agents. Hydroxychloroquine (hcq) and bromocriptine have been recently cleared for use and show beneficial effects in control of blood glucose and HbA1C levels.
  1 19,536 490
Clinical features and diagnosis of autism spectrum disorder in children
Susan Mary Zachariah, Samuel Philip Oommen, Beena Koshy
January-March 2017, 15(1):6-16
Autism spectrum disorder (ASD) is a neurodevelopmental disorder of behavior that presents in childhood. It is a clinically heterogeneous disorder of behavior, characterized by two features - (1) impairment in social communication and interaction and (2) repetitive patterns of behavior. The diagnosis is essentially clinical and is based primarily on history-taking and observation of the child over a period. There are several standardized screening tools and scales available to help make a diagnosis. Children with autism often present with speech delay and this has to be distinguished from other conditions. ASD is often associated with comorbid conditions which have to be identified to tailor the treatment program for each child. It is important that the parents or caretakers of the child are involved in the process of assessment and diagnosis and that their misconceptions and fears are addressed.
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Management of autism spectrum disorder: A case-based overview
Samuel Philip Oommen, Suman Bhattacharyya, Beena Koshy, Reeba Roshan, Lincy Samuel, R Preethi
January-March 2017, 15(1):17-27
The management of autism spectrum disorder requires a multidisciplinary team (MDT) comprising parents, therapists, psychologists, special educators, and medical specialists. Therapy is aimed at helping the child acquire functional skills in daily living, to minimize the core features of autism, and eliminate behaviors that are unhelpful or disruptive. The child must be adequately assessed by every member of the MDT to formulate an intervention plan which is then brought together to tailor a specific treatment plan for each child. The involvement of the parents or caretakers in the entire process is critical. The plan should address multiple areas such as communication, social skills, behavior, daily living, motor skills, and learning early and intensive treatment has been shown to be much more effective than treatment that is delayed. The child's progress should be monitored and documented, and only then can the intervention model's effectiveness be gauged.
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Polycystic ovarian syndrome: Treatment options for infertility
Sumi Thomas, S Sudharshini
October-December 2016, 14(4):87-93
Polycystic ovarian syndrome (PCOS) is a common cause of infertility and is characterized by clinical features of irregular menstrual cycles, hirsutism, and anovulatory infertility. The diagnosis is made based on the presence of two of three features (oligo/anovulation, hyperandrogenism, and polycystic ovaries on transvaginal ultrasound) according to the Rotterdam diagnostic criteria. Lifestyle modifications to reduce weight and the use of ovulation induction medications form the cornerstone of treatment of anovulatory infertility secondary to PCOS. Clomiphene citrate is the most effective as an agent for ovulation induction. The other therapeutic options include laparoscopic ovarian drilling, ovulation induction with gonadotropins, and in vitro fertilization.
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