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   Table of Contents - Current issue
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October-December 2020
Volume 18 | Issue 4
Page Nos. 269-353

Online since Monday, October 19, 2020

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EDITORIAL  

COVID-19 pandemic: A perspective from the frontline Highly accessed article p. 269
Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_120_20  
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ORIGINAL ARTICLES Top

Thoraco-abdominal injuries among patients presenting with trauma Highly accessed article p. 270
Rakesh Mohanty, Rebecca George, Kundavaram Paul Prabhakar Abhilash
DOI:10.4103/cmi.cmi_35_20  
Background: Globally, injuries contribute to around 10% of total deaths, and in India, to 13%–18%. Among all injury-related deaths, thoraco-abdominal trauma is the second most common cause of death. The aim of the study was to determine the outcomes of patients with thoraco-abdominal injuries presenting to a tertiary-level emergency department (ED) in South India. The study also aimed to verify the impact of extended-focused assessment with sonography in trauma (e-FAST) positivity on outcomes. Materials and Methods: A prospective observational study was conducted over 3 months. A cohort of patients presenting to the ED with abdomino-thoracic trauma were studied. Results: During the study period, we received 1216 trauma patients to our ED. 241 (19.8%) of them had thoraco-abdominal trauma. 158 (65.6%) patients had thoracic injuries and 183 (75.9%) patients had abdominal injuries. Among patients with thoracic injuries, 55 (34.8%) had hemothorax, 33 (20.9%) had pneumothorax, 30 (19%) had lung contusions, 64 (40.5%) had rib fractures, and 2 (1.2%) had pericardial effusions. Among patients with abdominal injuries, 33 (18%) had solid organ injuries, 68 (37.2%) had free fluid being present, and 3 (1.6%) had bowel injuries. 209 (86.7%) patients underwent e-FAST examination, of which 68 (32.5%) were e-FAST positive and 141 (67.5%) were e-FAST negative. Among e-FAST-positive patients, 54 (79.8%) needed admission, 3 (4.4%) were discharged from ED, and 4 (7.3%) died. Among e-FAST-negative patients, 80 (56.7%) needed admission, 54 (38.3%) were discharged from ED, and 1 (0.7%) patient died. 7 (10.2%) patients in the e-FAST-positive group and 15 (10.6%) in the e-FAST-negative group were discharged against medical advice. Systolic blood pressure <90, heart rate <60 and >100, Glasgow coma score ≤8, blood transfusion in the ED, and positive e-FAST were associated with increased risk of mortality. Conclusion: The study showed that abdominal trauma is more in two-wheeler riders and among adult males. e-FAST is a simple tool that can be used in the ED to timely recognize thoraco-abdominal trauma. Patients with e-FAST being positive are at an increased risk of adverse outcomes.
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Models for forecasting the number of COVID cases in Indian states p. 275
T Unnikrishnan
DOI:10.4103/cmi.cmi_105_20  
Introduction: Coronavirus, a worldwide pandemic today, is continuing its spread day by day. The only way that can be adopted at this stage is to control the number of cases to a minimum. Time series-forecasting models can enable the planners and administrators to foresee the picture and take timely action to control. Methodology: To forecast the daily number of COVID cases, prediction models were developed using Autoregressive-Integrated Moving Average (ARIMA) modelling techniques in the various states of India where the cases are highly reported. The main objectives included the assessment of trend and growth rates of number of COVID-19 cases confirmed and identification of the best ARIMA model for their prediction. Results: Excellent parsimonious forecasting equation for each state in India could be generated using the method. These models will be helpful for planning purposes in controlling the cases. The best model for the prediction of number of COVID cases in all over India was observed as ARIMA (0,2,1). ARIMA (0,1,0) was identified as best model for Mizoram and Puducherry. Conclusion: To predict all India cases, ARIMA (0,2,7) was identified as the best model.
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Alcohol-related acute presentations to the emergency department p. 281
P Manimaran, P Neeraj George Paul, Moses Kirubairaj Amos Jegaraj
DOI:10.4103/cmi.cmi_47_20  
Introduction: Alcohol consumption in excess leads to various consequences, either short term or long term. Acute alcohol impairment is a very important analysis topic for traffic safety, and a wide range of studies have indicated that alcohol is one of the root causes of driving impairment across the world. Methodology: The study was conducted at the emergency department (ED) of Christian Medical College, Vellore, from December 2014 to March 2015. After obtaining informed written consent, all patients above the age of 18 were included and data were analyzed. Results: During the study period, 153 patients presented with alcohol-related emergencies. Among them, 45.75% belonged to the age group of 21–30 years. The most common time of presentation to ED was in the evening from 15:30 to 22:30 (59%). Seventy-six percent of the patients presented with road traffic accidents (RTAs), of which 89.6% were two-wheeler-related RTAs. Among the two-wheeler RTAs, 98.2% did not wear a helmet. Nine percent of the total emergencies were related to acute poisoning incidents. Conclusions: Alcohol-related acute presentations to the ED are common but preventable emergencies, with RTAs and acute poisonings comprising the majority.
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Perceived cause and characteristics of headache among undergraduate medical students of Government Medical College, Srinagar: A cross-sectional study p. 285
Tanzeela Bashir Qazi, Sheikh Mohd Saleem, Muhammad Salim Khan
DOI:10.4103/cmi.cmi_71_20  
Background: Headache is prevalent worldwide and it affects people in almost all age groups, irrespective of their gender, educational level, socioeconomic status, and occupation. The aim of this study was to determine the characteristics, perceived cause, and medical consultation sought by undergraduate medical students of Government Medical College, Srinagar. Materials and Methods: A descriptive cross-sectional study was conducted among undergraduate medical students of Government Medical College, Srinagar. One hundred students participated in the study. A 12-item structured questionnaire which included cause, aggravating factors, relieving factors, and frequency of headache was distributed among these students to be filled by them after a proper written consent. Results: Out of 100 participants, 60 were female. The most commonly reported cause of the headache was stress (25%), followed by disturbed sleep cycle (18%) and mobile phone use for social media in (13%) students. Aggravating factors such as less hours of sleep duration were reported by 40% of students and 27% reported having headache after not eating for several hours. Majority (51%) of the participants reported described pain as a sensation of constant pressure, which was mainly concentrated in the frontal region. Family history was found among 18% of students and only 22% had consulted doctor for headache symptoms. Conclusion: Stress was identified as the most common reported cause of headache and sleep as the most reported relieving factor among medical students of Government Medical College, Srinagar.
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An overview of common organisms associated with community-acquired urinary tract infections and their antibiotic sensitivity: Experience from Government Medical College and associated SMHS Hospital p. 290
Iqra Majid, Nahid Nehvi, Saqib Rishi, Sheikh Mohd Saleem
DOI:10.4103/cmi.cmi_74_20  
Background: Appropriate knowledge about the organism and antibiotic susceptibility are the key factors to be known by the health-care professionals for effective treatment of symptomatic urinary tract infection (SUTI). This forms the basis of our study to document the common microbial agents responsible for SUTI and antibiotic susceptibility pattern of pathogens causing SUTI. Materials and Methods: Urine specimens from the patients attending the outpatient department (OPD) and hospitalized patients were collected as per standard microbiological laboratory procedures. Urine specimens were inoculated on blood and MacConkey medium. Plates were incubated overnight at 37°C and the next day were visualized for any visible growth. The characteristic colony character and colony count was taken into consideration. The organisms were later confirmed using conventional biochemical techniques after doing Gram staining. Results: On culture of 2473 specimens, 1940 (78.44%) were sterile and 533 (21.55%) urine specimens yielded significant bacterial growth. Among the 533 positive culture uropathogens isolated, 191 (35.8%) specimens were of males, whereas 342 (64.2%) specimens were of females. The mean ± standard deviation of the age of the patients was 46.1 ± 13.49. Most of the positive specimens, i.e., 316 (59.3%), were from the patients who were >40 years old. The prevalence of Escherichia coli was highest (52.2%), Enterococcus (17.3%), Pseudomonas (7.3%), and Klebsiella (6.0%). Enterococcus (83.7%), methicillin-resistant Staphylococcus aureus(MRSA) (90%), E. coli(93.2%), and Klebsiella (37.5%) isolates were found to be susceptible to nitrofurantoin, whereas Enterococcus (95.7%) and MRSA (95%) isolates were susceptible to antibiotics such as linezolid. All isolates from Morganella species were susceptible to amikacin and gentamicin. Conclusion: E. coli was the most common uropathogen isolated from the urinary specimens, followed by Enterococcus and Pseudomonas among patients who reported with symptoms of UTI in OPD.
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Serological and molecular methods in diagnosis of lower respiratory tract infections caused due to Chlamydia pneumoniae p. 296
YB Ashwin, Susmitha Karunasree Perumalla, Valsan Philip Verghese, Anna Simon, Indira Agarwal, John Antony Jude Prakash
DOI:10.4103/cmi.cmi_33_20  
Introduction: Lower respiratory tract infections (LRTIs) continue to be a major health problem in children. Increasingly “atypical” agents such as Chlamydophila pneumoniae are being recognized as a significant cause of LRTI. The current study evaluated serological and molecular methods in detection of LRTI due to C. pneumoniae in young children. Materials and Methods: Serum and nasopharyngeal aspirate (NPA) were collected from 53 treatment-naïve children (6 months–6 years) with LRTI. Immunoglobulin M (IgM) and IgG antibodies to C. pneumoniae were detected in serum by enzyme-linked immunosorbent assay (ELISA) and microimmunofluorescence (MIF) test. Nonnested polymerase chain reaction (PCR) to detect a 183-bp fragment of the 60-kDa outer membrane protein 2 of C. pneumoniae was performed on DNA extracted from the NPA samples. Results: Of the 53 children tested, 14 (26.4%) children were diagnosed to have acute C. pneumoniae infection according to CDC guidelines. When compared with IgM MIF (reference test), PCR and IgM ELISA showed a sensitivity of 36% and 71%, respectively, and a specificity of 100%. IgG antibodies were positive in an additional 8 cases, by both MIF and ELISA, suggesting “possible” reinfection. Conclusion: This study despite its drawbacks provides evidence that C. pneumoniae is a significant cause of LRTI in young children.
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Altered mental status in the emergency department, a retrospective analysis p. 300
Sai Kiran Cherukuri, Vineet Subodh Dhanawade
DOI:10.4103/cmi.cmi_64_20  
Background: Altered mental status (AMS) is a common presentation of patients to the emergency department (ED), posing a significant challenge for the physician to accurately diagnose and begin appropriate management. The etiology of AMS spans a wide variety of clinical syndromes and is not consistent in all countries and regions. Materials and Methods: This was a retrospective analysis of 407 patients presenting to the ED with AMS in the months of January 2013 to April 2013. The details of the presentation, investigations, final diagnosis, and management were extracted from charts in the hospital electronic database. Results: AMS constituted 2.8% of patients registered at the ED during the study period. Of the 407 patients, 254 (62.3%) were male, and 153 (37.5%) were female. Mean age was 52.34 ± 17.84 years. Majority (n = 287; 70.4%) of the patients were in the age group between 18-64 years. Etiological factors were neurological (n = 151; 37.1%), metabolic/endocrine (n = 75; 18.4%), infections (n = 55; 13.5%) system/organ dysfunction (n = 49; 12%), toxicological (n = 39; 9.6%), miscellaneous (n = 19; 4.7%), oncological (n = 12; 2.9%), and psychiatric (n = 7; 1.7%). About 17.9% had mild AMS, 47.4% had moderate AMS, and 34.6% had severe AMS. Majority (65.1%) presented to ED within 24 h of onset of AMS. Total mortality rate was 11.5% (n = 47). Conclusions: This study has conveyed the frequency of various etiologies of AMS and its stratification in regards to age and severity. Neurological conditions remain the most common cause of AMS. Data reveal a large fraction of patients presenting beyond 24 h of onset of AMS. Public education concerning the establishment of support systems for the vulnerable population can lead to faster presentation to the ED and subsequent management.
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Psychological resilience of COVID-19 frontline warriors: Need of the hour p. 305
D Vinoth Gnana Chellaiyan, AY Nirupama
DOI:10.4103/cmi.cmi_121_20  
Background: Amid the rapid rise of COVID-19 cases, risk of infection from patients, isolation, and other factors are taking its toll on the mental health status of the healthcare professionals. The frontline health workers in the COVID-19 pandemic are undergoing psychological turbulence handling the corona situation. Objectives: The present study assessed the self-reported mental health status of healthcare professionals and studied their perspectives of COVID-19 control. Materials and Methods: A descriptive study was conducted among healthcare professionals in India using a web-based online questionnaire. A total of 152 participants took part in the survey in April 2020. Self-reported mental health status was assessed using the DASS-21 scale. Mann–Whitney and Chi-square tests were applied. Results: The overall prevalence of depression, anxiety, and stress was 13.82%, 8.55%, and 23.68%, respectively. A higher prevalence of depression, anxiety, and stress was found in the frontline workers subgroup. The median (interquartile range) scores of frontline workers for depression, anxiety, and stress were 6 (10.5), 6 (8), and 10 (10), respectively. Fifty percent of the participants responded that quarantine and isolation was the best method for control of COVID-19 in Indian setting. Conclusion: The psychological disturbance was found among frontline health workers involved in the diagnosis and management of COVID-19. Psychological debriefing and regular mental status evaluation in addition to psychological counseling may be indispensable.
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REVIEW ARTICLES Top

Role of tranexamic acid in trauma: Recent updates p. 309
Anmol Jindal, Sandeep Nathanael David
DOI:10.4103/cmi.cmi_26_20  
Tranexamic acid (TXA) is a wonder drug in the acute management of hemorrhage in trauma. Recent publication of the CRASH-3 trial results further exemplifies this drug's use in isolated head injury. This article is a review of scientific evidence for TXA in trauma. There is an established role of TXA in trauma with intracranial hemorrhage within 3 h of presentation with 1.5% decrease in mortality of trauma victims with isolated head injury, as per the results of the CRASH-3 trial. However, the optimal dosing and role of the second dose of TXA requires further verification.
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Choline-stabilized orthosilicic acid and bone health p. 312
Ram Prabhoo
DOI:10.4103/cmi.cmi_78_20  
Certain trace elements play a very important role in bone health. Silicon is one such essential trace element required for bone regeneration, bone mineral density, and overall bone biology. Deficiency of silicon is associated with bone resorption rate, decreased osteoblastogenesis, increased osteoclastogenesis, reduced collagen, and glycosaminoglycan formation, suggesting a definite role of silicon in osteoporosis. Choline-stabilized orthosilicic acid (ch-OSA®) is a stable and bioavailable form of silicon. Due to its stable nature, it cannot be converted into nonabsorbable silica (polymerized) gel form. ch-OSA® is known to stimulate the enzymatic pathway of endogenous collagen synthesis. Silicon supplementation stimulates osteoblasts, osteoblastic differentiation, osteopontin, osteocalcin, alkaline phosphatase, and bone matrix mineralization. It inhibits bone resorption by reducing the surface area of osteoclasts. ch-OSA® has shown synergistic effects with calcium and Vitamin D, indicating its potential role in the management of osteoporosis. The aim of this review is to outline the importance of ch-OSA® on bone health.
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Atopic dermatitis in children: An update for pediatricians p. 317
Dharshini Sathishkumar, Ankan Gupta, Kriteeka Saini
DOI:10.4103/cmi.cmi_81_20  
Atopic dermatitis (AD), also known as atopic eczema, is a chronic, relapsing, inflammatory skin disorder commonly affecting children, and its hallmark is constant pruritus. The etiopathogenesis is complex, involving genetics and environmental triggers. There is skin barrier dysfunction along with an aberrant helper T-cell type 2 immune response. Diagnosis is primarily clinical, and a simplified version of the United Kingdom Working Party's diagnostic criteria can be helpful. The disease can be debilitating and significantly impairs the quality of life of the patients and family. The treatment has to be tailored to an individual patient, and the various components include education, identification and avoidance of triggers, skin barrier repair and maintenance, control of inflammation, management of secondary infection, and prevention of flares. The mainstay of treatment includes emollients to maintain the skin barrier, as well as topical anti-inflamamtory agents to control inflammation. However, in moderate-to-severe disease, systemic agents might be required. We hope to provide an overview of the pathogenesis, clinical features, and pharmacological and nonpharmacological treatment of AD, which will help a family physician or a pediatrician to manage children with AD preting to them.
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CASE REPORTS Top

Beneath a behavioral change p. 326
Inês Ferreira Santos, Pedro Joel Xavier Vasconcelos, Rita Alexandra Bernardino Figueiredo
DOI:10.4103/cmi.cmi_79_20  
When approaching symptoms suggestive of cognitive decline or dementia, it is important to rule out possible conditions that can lead to the emergence of psychological/behavioral changes. Herein, we present the case of a 69-year-old male, whose wife complained of sudden behavior and memory changes. He was diagnosed with syphilis and treated with three doses of penicillin. We report this case to highlight the importance of considering syphilis in the differential diagnosis of a fast onset cognitive decline. It also demonstrates the value of family physician proximity to the different members of a family, often a determining factor in establishing a diagnostic hypothesis, especially when complaints are not spontaneously exposed by the patient.
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Pagetic osteosarcoma detected in bone scintigraphy p. 329
Junita Rachel John, Julie Hephzibah, Regi Oommen, Nylla Shanthly
DOI:10.4103/cmi.cmi_96_20  
Paget Disease (PD) is a disorder of the skeleton characterized by increased osteoclastic activity. Sarcomatous transformation, though rare, is a serious complication of PD and begets a poor prognosis. Bone scintigraphy is a useful tool in the early identification of fractures and osseous sarcomas. We report a case of PD presenting with sarcomatous transformation as the primary symptom which has rarely been described in the Indian population.
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Double-penile frenulum: An unusual developmental anomaly p. 332
Suresh Kumar Goyal, Shifali Gupta, Suman Gupta
DOI:10.4103/cmi.cmi_99_20  
Double frenulum is a rare penile developmental anomaly. This anomaly may remain unnoticed before presenting in sexually active males with complaints of dyspareunia. This may be an ncidental finding in patients for unrelated complaints. We present a case of an adolescent sexually inactive male who came with complaints of unusual appearance of the penis.
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PRACTICE STORY/OPINION Top

Fighting coronavirus in a far and forgotten corner of India: Formidable challenges faced in a remote mission hospital p. 334
George Mathew
DOI:10.4103/cmi.cmi_115_20  
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CME QUIZ Top

Not just skin-deep! p. 338
Priya Jeevamani Chandrasekaran, Saro Mathew
DOI:10.4103/cmi.cmi_45_20  
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Postherpetic neuralgia and varicella-zoster virus p. 340
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
DOI:10.4103/cmi.cmi_94_20  
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LETTERS TO THE EDITOR Top

The need for level I trauma centers in India p. 343
Krema Sabateena Pushpa
DOI:10.4103/cmi.cmi_21_20  
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The need to introduce research initiative in the undergraduate medical curriculum p. 344
K P. A. Chandrasekhar
DOI:10.4103/cmi.cmi_30_20  
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Status and role of antiretroviral therapy in the treatment of HIV: World Health Organization p. 345
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_31_20  
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Ensuring delivery of quality-assured health services to individuals in prison p. 346
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_42_20  
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Justifying the inclusion of structured integrated teaching in competency-based curriculum to bridge the lacunae in traditional curriculum p. 347
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/cmi.cmi_84_20  
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Fracture liaison service: A friend in need p. 349
Ganesh Singh Dharmshaktu
DOI:10.4103/cmi.cmi_97_20  
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COMMENTARY Top

Fracture liaison service p. 351
Remya Rajanl, Kripa Elizabeth Cherian, Nitin Kapoor, Thomas Vizhalil Paul
DOI:10.4103/cmi.cmi_112_20  
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ERRATUM Top

Erratum: Pain management in acute trauma p. 353

DOI:10.4103/0973-4651.298606  
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We are seeking partners who can join us in caring for severely injured people. As a generous individual or a Company through CSR and other philanthropic initiatives, you can help us save lives!
For more details, please visit https://givecmcv.org/trauma-centre/
OR https://www.cmch-vellore.edu/