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   2020| April-June  | Volume 18 | Issue 2  
    Online since April 17, 2020

 
 
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CME QUIZ
Understanding the radiological imaging of the eye explant
Sunny Chi Lik Au, Callie Ka Li Ko
April-June 2020, 18(2):149-150
DOI:10.4103/cmi.cmi_1_20  
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REVIEW ARTICLES
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
DOI:10.4103/cmi.cmi_48_20  
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.
  3,297 285 1
EDITORIAL
Coronavirus disease 2019: The 6th public health emergency of international concern
Kundavaram Paul Prabhakar Abhilash
April-June 2020, 18(2):75-76
DOI:10.4103/cmi.cmi_18_20  
  803 219 -
REVIEW ARTICLES
Heatstroke
Abhijit Goyal-Honavar, Annsmol P Markose, Kundavaram Paul Prabhakar Abhilash
April-June 2020, 18(2):87-93
DOI:10.4103/cmi.cmi_4_20  
Heat-related illnesses are a common cause of morbidity and mortality in tropical climates; they range from innocuous heat cramps to life-threatening heat strokes, and yet, the data regarding their evaluation and management are far from definitive. It is a condition with an evolving definition, the most recent by the Japanese Association for Acute Medicine eschewing the use of specific temperature cutoffs. Cooling measures such as evaporative cooling are of utmost importance in bringing about a rapid decrease in core body temperature, with evidence showing the effectiveness of invasive measures and other techniques to reduce organ dysfunction unsatisfactory. High-quality prospective studies comparing various modalities of treatment is the need of the hour, and the implementation of preventive measures must be more widely undertaken.
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COVID-19 – A replay of the 1918 pandemic?
Govind Sreekumar, Aparna Lohanathan, Darpanarayan Hazra
April-June 2020, 18(2):83-86
DOI:10.4103/cmi.cmi_36_20  
COVID-19 outbreak is likely to have started from a zoonotic transmission event associated with a large seafood market that also traded in live wild animals. Initial epidemiological studies suggested a predilection for older adult males with comorbidities due to their immunocompromised status and very rarely, coinfection with bacteria and fungi. An exponential increase in the number of nonlinked cases in the late December 2019 pointed toward the risk of human-to-human transmission. Similar to its predecessor, severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) also acts on the angiotensin-converting enzyme-2 (ACE2) present on the type 1 and type 2 alveolar epithelial cells. ACE2 expression has been found to be higher in males than females and in Asian populations compared to White and African-American populations. This led to an agreement that the Asian males were more susceptible to SARS-CoV-2 infection. The ability of SARS-CoV-2 to bind to ACE2 receptor was found to be 10–20 times more than that of the SARS-CoV, thus making the new pathogen much more aggressive. At the time of writing this article, the global burden of confirmed cases of COVID-19 has risen to half a million with death toll touching 25,000 people. For the first time, we may be looking at a pandemic which could be controlled on a short-term basis and prevented on a long term with adequate research and clinical trials for newer therapeutic agents.
  662 178 -
Melioidosis: An emerging infection in India
Maria Koshy
April-June 2020, 18(2):94-97
DOI:10.4103/cmi.cmi_72_19  
Melioidosis, caused by Burkholderia pseudomallei, has been described as the great mimic, as disease manifestations are protean. It is present in the soil and surface water in endemic regions. Although initially thought to be endemic to Southeast Asia and Northern Australia, there has been an emergence of this infection in areas where it was previously absent. In recent years, environmental and clinical studies have shown a significant presence of melioidosis in India. The epidemic of diabetes, the most significant risk factor, could result in a surge of cases of melioidosis in India. Melioidosis can closely mimic tuberculosis. Increased awareness, a high index of suspicion and prompt diagnosis and initiation of therapy are essential to reduce the morbidity and mortality related to melioidosis.
  538 134 -
Postmenopausal osteoporosis – An Indian perspective
Remya Rajan, Jinson Paul, Nitin Kapoor, Kripa Elizabeth Cherian, Thomas V Paul
April-June 2020, 18(2):98-104
DOI:10.4103/cmi.cmi_5_20  
Osteoporosis is the most common metabolic bone disease in humans. It is more common in women and contributes to significant morbidity and mortality. Postmenopausal osteoporosis is due to the withdrawal of the protective effect of estrogen at menopause and increased follicle-stimulating hormone, all contributing to increased bone resorption. Evaluation of osteoporosis involves assessment of risk factors, biochemical evaluation, assessment of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA), identification of vertebral fractures with vertebral fracture assessment tool, and prediction of fracture risk with various tools. Treatment includes prevention of osteoporosis using lifestyle modification and fall prevention, in addition to pharmacotherapy. Several drugs are licensed to reduce fracture risk namely anti-resorptive agents (such as bisphosphonates and denosumab) and anabolic agents (such as teriparatide). Improved understanding of the cellular basis for osteoporosis has resulted in new drugs targeted to key pathways in the pathogenesis. The response to treatment is monitored using bone turnover markers as well as DXA scan.
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ORIGINAL ARTICLES
Scrub typhus: Clinical presentation and severity
Darpanarayan Hazra, Joanna Preritha Fernandes, Ankita Chowdary Nekkanti, Kundavaram Paul Prabhakar Abhilash
April-June 2020, 18(2):111-114
DOI:10.4103/cmi.cmi_10_20  
Background: Scrub typhus is an acute zoonotic febrile illness caused by the obligate intracellular bacteria Orientia tsutsugamushi. In the Indian subcontinent, there has been mounting evidence in the past few years, indicating that it is one of the most prevalent, yet underrecognized entity, probably as a result of its varied presentation, lack of awareness, and hence, a low index of suspicion among clinicians. Materials and Methods: This is a subgroup analysis involving patients diagnosed to have scrub typhus from a large prospective study on patients presenting with acute undifferentiated febrile illness (AUFI) done between October 2012 and September 2013. Results: A total of 452 patients met the eligibility criteria and were included in the final analysis. The mean age of the cohort was 42.7 (standard deviation [SD] 15.1) years and female predominance (266, [58.8%]) was noted. The mean duration of fever was 8.2 (SD 3.2) days. The most common clinical features were chills, generalized myalgia, and breathlessness. A characteristic eschar was noted in 262 (57.9%) patients. Overall, the most common comorbidities were diabetes mellitus, followed by hypertension. Majority of patients were started on doxycycline or azithromycin empirically on clinical suspicion. Among the total study population, 21 (4.6%) patients succumbed to the disease condition and the rest were discharged stable either from the outpatient department or ward. Conclusion: Scrub typhus is one of the most common causes of AUFI in our locality and comprises a third of these cases. The pathognomonic eschar which is present in almost two-third of patients offers a vital clue for the diagnosis of scrub typhus.
  281 55 -
REVIEW ARTICLES
Specific considerations for epilepsy in India
Divyani Garg
April-June 2020, 18(2):105-110
DOI:10.4103/cmi.cmi_6_20  
It is estimated that there are around 50 million people living with epilepsy (PWE) globally. Around one-sixth of this population resides in India. Around 10–12 million people with epilepsy reside in India. A significant proportion of PWE do not receive appropriate treatment, leading to a large treatment gap (TG). Poor awareness of antiepileptic drugs (AEDs), cultural practices, social stigma surrounding epilepsy, lack of accessibility to healthcare, and a severe shortage of medical professionals trained in the management of epilepsy are major contributors to the TG. Infectious diseases, particularly neurocysticercosis, form a major bulk of underlying cause for epilepsy. Certain geographical regions exhibit typical patterns of epilepsy. In this article, we attempt to provide a broad overview of the incidence, prevalence, etiology, types, mortality, and treatment of epilepsy derived from the data from Indian studies. India provides particular challenges in the management of patients with epilepsy, not only in terms of the wide spectrum of epileptic conditions but also in the demand for medical practice based on economic constraints.
  262 63 -
ORIGINAL ARTICLES
A retrospective study on the use of blood products in the emergency department
Ajay Christopher, Darpanarayan Hazra, Sandhana Inian, Jaquiline C Jose, Angelene Eliseba Philip, Sherin Susan Thomas, Gina Mariyann Chandy, Joy Mammen
April-June 2020, 18(2):125-129
DOI:10.4103/cmi.cmi_8_20  
Background: Blood product transfusion occurs in a significant percentage of patients admitted in the emergency department. Adverse reactions occurring in the setting of transfusion are associated with increased morbidity and mortality and inadvertent use of blood can do more harm to the patient than good. Analyzing blood transfusion data will help in formulating policies for transfusion in the emergency medicine department (ED). Aim: To characterize transfusion requirements in the ED. Materials and Methods: This was a retrospective cohort study analyzing patients who required blood or blood product transfusion in the ED in January 2017. Results: The total number of patients requiring blood transfusions in January 2017 in the ED was 214, of which 56% were men with an average age of 44 years. The overall total number of blood products requested was 272, among them 78.7% of the blood products were ultimately transfused. Hematological diseases (30.4%) were the most common indication for blood product transfusion, followed by trauma (20.1%) and upper gastrointestinal bleed (18.7%). Among the blood products requested, 52.2% were packed red cells, 34.5% were platelet-rich concentrate, 8.1% were fresh frozen plasma, 3.7% were cryoprecipitate, and 1.5% were whole blood. The mean hemoglobin level for transfusion was 6.7 g/dL. Only 1.4% of patients developed adverse reaction during transfusion. Among the total study population, 58.4% of the patients were admitted, 34% of the patients were discharged stable, 6.5% of the patients took discharge against medical advice, and 1.1% of them died in the ED. Conclusion: There is large quantity of blood being transfused in the emergency department, for various indications. There is a discrepancy between the quantity cross-matched and that which is transfused. As we have characterized the same, we can further look at the policy-making for blood transfusions in the ED.
  269 39 -
Prospective observational study to assess the circulatory status of the patients presenting to resuscitation room in emergency department
B Divya, Ivy George Edacheril, Mariam Jacob, Kundavaram Paul Prabhakar Abhilash
April-June 2020, 18(2):115-119
DOI:10.4103/cmi.cmi_7_20  
Background: Circulation forms an integral part of a patient presenting to the emergency department (ED). Appropriate management of critically ill patients being brought to the ED is of paramount importance, and inappropriate resuscitation during prehospital transfer could be fatal. Methodology: This prospective study included all priority 1 and trauma patients arriving to the resuscitation room of our ED between August 2018 and October 2018. Details of prehospital management of the circulatory status in the different types of prehospital transport and methods used were noted. A comparison was done between ambulances and private vehicles and receiving prehospital care with the help of univariate analysis. Results: During the study, we recruited 209 patients which comprised trauma (64.1%) and 67 nontrauma (35.9%) priority 1 patients. There was a male predominance (76.7%). Patients were transported by 108 ambulances (9.6%), private ambulances (26.9%), and private vehicles (car, auto, and other vehicles) (60.3%). Of the 142 trauma patients, 66.1% received hemorrhage control as a part of prehospital management. Of the 39.4% trauma patients transported through an ambulance, hypotension was observed in 3.6%, upon their arrival to the ED. Dead and left against medical advice was seen in 0.5% and 1.9%, respectively, whereas 48.8% were discharged stable from the ED. Conclusion: Ambulances bought in patients with adequate hemorrhage control than other vehicles. With an unstable prehospital management in place, a significant sample of patients arrived at ED with a compromised circulatory status. Our study clearly highlights the glaring deficiency in circulatory status at arrival to ED.
  245 54 -
Does Mindfulness-based meditation improve the psychosocial well-being among patients with chronic pain conditions? A pilot study from Chennai
Nithya S Pradeep, S Suthanthira Kannan, Vijayaprasad Gopichandran
April-June 2020, 18(2):120-124
DOI:10.4103/cmi.cmi_14_20  
Background: Mindfulness-based meditation has been shown to reduce stress and even reduce pain in chronic pain conditions. Objective: To study the effect of mindfulness-based meditation on pain and psychosocial wellbeing among patients living with chronic musculoskeletal pain conditions. Methods: We conducted a quasi-experimental pre-post comparison study among 15 patients suffering from various musculoskeletal chronic pain conditions to assess the impact of mindfulness-based meditation on chronic pain. The participants were given an audio recording which gives specific instructions about the method of practicing the mindfulness-based meditation for a period of 2 weeks. The Brief Pain Inventory was used to measure pain and associated psycho-social wellbeing at baseline and after two weeks of the practice of meditation. The scores on the inventory were compared before and after the meditation using the paired sample t test. Results: There was a statistically significant reduction in the overall Brief Pain Inventory score of 11.6 units (95% CI= 8.2 to 15.0; P < 0.05). The reduction in score was not significant in the pain subscale but was significant in the psycho-social wellbeing subscale. Conclusions: Mindfulness-based meditation can be a useful adjuvant to pain management protocols in patients living with chronic musculoskeletal pain conditions.
  243 41 -
CASE REPORTS
Drug-induced oculogyric crisis – A rare presentation to the emergency department
Darpanarayan Hazra, AT Prabhakar, Kundavaram Paul Prabhakar Abhilash
April-June 2020, 18(2):136-137
DOI:10.4103/cmi.cmi_49_19  
Oculogyric crisis (OGC) is an acute dystonic reaction of the ocular muscles characterized by the bilateral dystonic elevation of visual gaze lasting from seconds to hours. OGCs are nonepileptic eye movements and therefore should be distinguished from more commonly occurring tonic eye deviation, seen in seizure disorders, paroxysmal tonic upward gaze, and encephalopathy, commonly encountered in the emergency department. This rare neurological condition may be easily misinterpreted or overseen as functional or as an exacerbation of psychotic illness.
  217 43 -
ORIGINAL ARTICLES
A prospective study on patients with transient ischemic attack and minor ischemic stroke presenting to a tertiary care emergency department
Jubin Merin Jacob, Aparna Lohanathan, Sanjith Aaron
April-June 2020, 18(2):130-135
DOI:10.4103/cmi.cmi_2_20  
Background: The incidence of stroke after transient ischemic attack (TIA) has been observed to be high in the first 90 days. There are very few studies conducted in India to assess the risk of stroke in patients presenting with TIA. Hence, the primary aim of our study is to assess the risk of stroke in patients presenting to the emergency department (ED) with TIA or minor ischemic stroke (MIS) and the various risk factors associated with it. Materials and Methods: This was a prospective observational study done on consecutive patients who presented to our ED with neurovascular deficits suggestive of TIA or MIS within 16 h. Results: During the study period, a total of 71 patients were recruited. The mean age of the study group was 58.07 (standard deviation: 13.15) years. There was a male predominance of 70.4%. The incidence of TIA during the study period was 56 (78.9%) and that of MIS was 6 (8.5%) in our ED. Based on the magnetic resonance imaging stroke protocol finding, it was observed that among the TIA patients, about half of them had an infarct and 8.45% had a minor stroke with acute infarct. Overall, we observed that 19.7% of the recruited patients with TIA or MIS developed stroke within 3 months and majority of the clinical deterioration were in the 1st week post index event. Conclusion: TIA and MIS should be considered as a major ischemic event and should be treated aggressively with effective collaboration of various departments. Early diagnosis and proper treatment will help prevent further grave neurological deterioration.
  205 44 -
LETTER TO THE EDITOR
Curbing the practice of female genital mutilation to strengthen the economy of the affected nations
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
April-June 2020, 18(2):145-146
DOI:10.4103/cmi.cmi_12_20  
  205 37 -
CASE REPORTS
Carcinoma stomach in pregnancy: Report of a rare association
Nitin Paul Ambrose, Pranay Gaikwad
April-June 2020, 18(2):138-141
DOI:10.4103/cmi.cmi_64_19  
The occurrence of gastric cancer in pregnancy is rare and can potentially have devastating effects on both the mother and the fetus. There is often a delay in the diagnosis as the symptoms during pregnancy may confuse the presentation and may be overlooked. Not unexpectedly, gastric cancer in pregnancy is diagnosed at its late or advanced stage. In addition, in the presence of a live fetus, there is an ethical component to the decision-making for the best possible course of treatment. Treating physicians need to consider several factors such as the optimal surgical outcome, maternal safety, fetal safety, and prevention of miscarriage or preterm labor. This dilemma continues even postoperatively to decide on the further course of the treatment as indicated through several multi-disciplinary tumor board meetings to decide on the timings of the delivery, induction of labor, and adjuvant chemotherapy. We report the case of a 23-year-old female patient who presented with vomiting and loss of weight at 22 weeks of gestation was diagnosed to have poorly differentiated gastric cancer and underwent subtotal gastrectomy at 25 weeks of gestation. The article reviews the association of gastric cancer with pregnancy, discussing the pathogenesis and management of such a case.
  164 44 -
Fatal paraquat poisoning: A case report and review of literature
Vijoy Kumar Jha, Anand Shankar Kannapur, Ravikumar Hiremath
April-June 2020, 18(2):142-144
DOI:10.4103/cmi.cmi_67_19  
Paraquat poisoning is almost fatal if associated with the features of systemic toxicity. In this case report, we present a case of fatal paraquat poisoning and a detailed review of its intoxication, systemic manifestations, and recent development in its management. We conclude that in a case of severe paraquat poisoning, even aggressive and invasive therapies in an intensive care unit are unlikely to improve prognosis.
  169 39 -
CME QUIZ
Ocular myasthenia gravis and thymoma
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
April-June 2020, 18(2):147-148
DOI:10.4103/cmi.cmi_60_19  
  151 34 -