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   Table of Contents - Current issue
July-September 2022
Volume 10 | Issue 3
Page Nos. 141-218

Online since Tuesday, July 12, 2022

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Scientific misconduct – Time for more action p. 141
Manjunath Premanath
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Lung cancer in never smokers: The smoke beyond tobacco p. 143
K Govind Babu, Aparna Sreevatsa
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Atypical manifestations of dengue p. 146
Vasantha Kamath, Buvana Radhakrishnan, Kushal Markanday
Dengue is a major concern in India. It has a diverse spectrum of atypical manifestations across the various systems of the human body with significant mortality and morbidity rates. The following review emphasizes on the various systemic manifestations, including the need for their early recognition and treatment.
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Management of acute stroke p. 153
Ashok Vardhan Reddy Taallapalli, Pooja Mailankody, Girish Baburao Kulkarni
Management of acute stroke has considerably changed over the past 20 years. It has evolved from extreme nihilism to an exciting science where patients can improve to near normal with reperfusion therapies. We have reviewed the recent advances in the management of acute stroke, especially acute ischemic type (AIS). A search was done in pub med with keywords- “Acute Stroke,” “Treatment,” and “Recent advances.” Relevant articles were downloaded, cross-references were reviewed and this article was written. Stroke care requires the organization of the available facilities at the hospital to provide basic to advanced services, with coordination between different centers through the Hub and Spoke model. Recognition of time of onset of stroke, knowledge about options available for AIS patients at 4.5, 6, and 24 h and planning appropriate imaging studies helps in management. Intravenous thrombolysis and endovascular therapies play a key role in the reperfusion in patients with AIS. Patients with transient ischemic attack/minor stroke should be treated with dual anti-platelets, for at least three weeks followed by a single agent. Investigating a stroke patient for modifiable risk factors and classifying them to various subtypes will help in the prevention of recurrence. Management of intracerebral hemorrhage requires evaluation for etiology and supportive care. Cerebral venous thrombosis is a rare but unique type of stroke, which requires knowledge about signs on imaging, risk factor evaluation, and treatment with anticoagulants. Health education plays an important role in prevention and compliance with medications.
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Asymptomatic bacteriuria – Spectrum of organisms and antibiotic resistance pattern in women with type 2 diabetes mellitus p. 164
BS Meghana, K Ravi
Background: Diabetes mellitus (DM) is a major health challenge worldwide. It is a risk factor for the development of asymptomatic bacteriuria (ASB) and urinary tract infection. Although the current guidelines do not recommend treatment of ASB among women with type 2 diabetes, it emphasizes the need for therapeutic trials based on culture sensitivity patterns. This study was aimed to determine the spectrum of organisms causing ASB and antibiotic sensitivity patterns. Therefore, we believe that this study would serve as road map to conduct therapeutic trials in subjects with ASB based on antibiotic sensitivity patterns. Methods: Cross-sectional study was conducted including both outpatients and inpatients on 250 Women with T2DM with no symptoms of UTI, were investigated with FBS, PPBS , HbA1C, Urine routine-microscopy and Urine culture- sensitivity. The presence of ASB among women with T2DM was studied, and antibiotic sensitivity pattern was analyzed. Statistical Package for the Social Sciences (SPSS) version 20 was used for statistical analysis. Results: The frequency of ASB in our study was found to be 39 out of 250 diabetic women, that is, 15.6%. The mean HbA1c was higher among diabetic women with ASB (9.63%) than without ASB (8.42%). Escherichia coli (58.97%) was the most common organism. Antibiotic sensitivity showed that most organisms were sensitive to amikacin (64.1%), followed by nitrofurantoin (59.0%). Most organisms were resistant to fluoroquinolone (79.5%). Conclusions: E. coli was the most common organism causing ASB in our study. Antibiotic sensitivity showed that most organisms were resistant to fluoroquinolones and were sensitive to amikacin. Further large-scale studies are required to study the effect of antibiotic sensitivity-directed therapeutic trials to conclude the efficacy of therapy in patients of ASB.
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A retrospective study on seroprevalence and clinical spectrum of syphilis from a tertiary care center in South India p. 169
Ananya B Reddy, Malcolm Pinto, Spandana Prakash Hegde, Amina Asfiya M. Iqbal, Vishal Bejai, M Manjunath Shenoy
Objectives: Syphilis is a sexually transmitted disease (STD) and a great imitator with a varied range of clinical manifestations. Incidence of syphilis has been on the rise in the last decade. In this study, we have analyzed the seroprevalence and clinical staging of syphilis cases reported in our healthcare facility. Materials and Methods: We conducted a retrospective analysis of syphilis by reviewing data from hospital sources from January 2017 to December 2019. Out of 8827 screened patients, the clinical data from patients who were serologically positive for both rapid plasma reagin and Treponema pallidum hemagglutination tests were retrieved and statistically analyzed. Results: Of the 8827 samples screened, 35 were diagnosed as cases of syphilis. Among 35 cases, primary syphilis was diagnosed in 8, secondary syphilis in 10, and latent syphilis in 17 cases. There were 4 (11.4%) females and 31 (88.6%) males. Twenty-one (60%) were married. Of 31 males, 23 (74.2%) were men who have sex with men (MSM). Among the 35 patients, 33 (94.3%) had unprotected and 2 (5.7%) had protected sexual activity. Out of them, 3 patients were human immunodeficiency virus positive, which included 2 with secondary and 1 with latent syphilis. Conclusion: Identification and health education of MSM, especially with respect to using barrier methods of contraception, are necessary in the prevention of transmission of STDs. With epidemiological trends showing syphilis re-emerging as a major sexually transmitted infection, there is a need to conduct multicenter prospective studies with larger sample size for better understanding and effective assessment of control measures.
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Patient-related risk factors for predicting severity of COVID-19 infection admitted to a tertiary care hospital in Telangana p. 174
Dhanunjaya Dasari, Venkata Rambabu Mallela, K Varsha Reddy, Krishna Chaitanya Alam
Background: Study of factors/predictors leading to the disease severity is important. They help us for the early identification of the patients who are susceptible to develop severe form of disease. Cases with a set of unfavorable factors can be given priority attention for the management thereby it may be possible to reduce the mortality rates. Objective: The objective of this study was to study the patient-related risk factors for predicting severity of coronavirus disease 2019 (COVID-19) infection admitted to a tertiary care hospital. Methods: A hospital-based retrospective study was carried out among 305 cases of COVID-19. Hospital records of these cases were studied. Sociodemographic variables and presence of comorbidities were noted. Disease severity was classified as per the standard guidelines. It was classified as mild, moderate, and severe. Univariate and multivariate analysis was carried out. Results: Majority, i.e., 42.3% had severe disease. On univariate analysis, advanced age, coming from rural area, preexisting hypertension, being obese were significant risk factors for severe disease (P < 0.05). Those with severe disease had total risk factors score of 3.36 ± 1.68 compared to 2.48 ± 1.67 for mild or moderate disease, and this difference was statistically significant (P < 0.05). In the final model, coming from rural area and advanced age were the significant predictors of severe disease in the present study (P < 0.05). Conclusion: Advanced age and being from rural area were the significant predictors of severe disease in the present study.
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Evaluation of serum uric acid among new-onset primary hypertension patients – A cross-sectional study p. 178
Rani Ghali, Arif Maldar, Pournima Patil, Romana Khursheed
Background: Hypertension is associated with a myriad of confounding factors, out of which elevated serum uric acid (SUA) profile is of interest as a biomarker. Despite a handful of studies alluding to the seminal relationship between the two, its prevalence and correlation in the Indian context have not been adequately investigated. Hence, the present study was aimed to evaluate the relationship between SUA levels and primary hypertension (HTN). Materials and Methods: This 1-year hospital-based cross-sectional study comprised 100 patients who were recently diagnosed with primary HTN and had not received antihypertensive medications, SUA levels and severity of HTN among patients were assessed along with their age, sex, body mass index, total cholesterol, and lipid profile. Results were statistically analyzed by Chi-square test, logistics regression, t-test/Welch t-test/Mann–Whitney U-test, and Pearson–Spearman rank correlation. Results: A strong correlation between SUA level with systolic blood pressure (SBP) in patients with primary HTN (r = 0.5046; P < 0.0001) was observed. The mean SBP (163.89 ± 9.99 mmHg) was significantly high (P < 0.001) in hyperuricemic patients, and raised SUA was noted in 38% of the cohort. Stage II hypertensive subjects of the 58–66 years age group were found to be a particularly vulnerable group (odds ratio of 32). History of diabetes mellitus, tobacco, and alcohol consumption showed a significant association with elevated SUA levels in males (P < 0.05). Conclusion: One in every three primary hypertensive patients is likely to present with hyperuricemia, and there exists a pertinent association between elevated SUA levels with SBP.
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Study of clinical phenotypes and its outcomes in patients of COVID-19 in a tertiary care hospital p. 185
Vishwanath Krishnamurthy, K Mohammed Suhail, Madhu P Raj, Eilene Basu, S Shaikh Mohammed Aslam, Selva Kumar
Introduction: The world has witnessed a surge of COVID-19 cases since the first case was reported in 2018 December, and despite the large number of cases seen across the world, there are still many gaps in the understanding of the course of the disease in different people. Several scoring systems and early warning signs have been developed to prognosticate the disease process. Clustering the patients into specific clinical phenotypes is one such strategy. In this study, we have clustered the COVID-19 patients using different variables into phenotypes and studied the outcome based on this classification. Aim and Objectives: To derive clinical phenotypes based on demographic, clinical, and laboratory data of COVID-19 patients and look at the efficiency of the phenotypes as a model for predicting course of disease. Materials and Methods: A retrospective cohort study on COVID-19 patients admitted to a tertiary care hospital in South India between July 2020 and October 2020 was conducted. Nine hundred and eighty-seven subjects fulfilling the inclusion criteria were enrolled. Results: Three clinical phenotypes were derived using 43 independent variables which included epidemiological, symptomatology, comorbidities, and laboratory values. Of the 987 patients studied, patients could be clustered into three phenotypes named A, B, and C. There were 379 patients in phenotype A, 313 in phenotype B, and 295 were in phenotype C. Males predominated in phenotypes C and B, which was 218 patients (73.9%) and 204 (65.2%), respectively. Mild disease was predominant in phenotype A (89.2%) patients, followed by10.3% of moderate disease and 0.5% of severe COVID disease. In phenotype B, 93.3% of patients had mild disease and the rest 21 (61.7%) had moderate disease. In phenotype C, 177 (60%) patients had severe COVID disease. Mortality was seen in phenotype C (23.1%). Conclusions: It can be inferred that among the phenotypes, the hyperinflammatory group was phenotype C. The independent predictive association of each variable such as age, male gender, and comorbidity is an important factor in determining the outcome but, because of the varied distribution of the multiple variables in each patient, it is not possible to consider each of these values independently and deduce the outcome, hence phenotypes which cluster the patients based on all these variables are associated with predictable outcomes The phenotypes thus can be implicated as a tool to aid in clinical management of COVID-19.
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Gastrointestinal manifestations among hospitalized coronavirus disease 2019 patients in Vadodara, Gujarat, India Highly accessed article p. 190
Jugal Hiren Bhatt, Rikin Raj, Kedar Gautambhai Mehta, Meenakshi Shah, Bhoomi Bavadiya
Background: SARS-CoV-2 is an RNA virus that causes coronavirus disease 2019 (COVID-19) which was initially detected in the province of Wuhan, China, and World Health Organization ultimately determined the outbreak to be labeled as a “pandemic” in March 2020. It lead to various clinical manifestations among COVID-19 patients and so, this study was conducted with the objective to study gastrointestinal (GI) symptoms among hospitalized COVID-19 patients. Materials and Methods: This retrospective study was conducted at a tertiary-level hospital in Vadodara. Hospital records of hospitalized COVID-19 patients from September to November 2020 were reviewed and included in the study. Clinical profiles including GI symptoms, respiratory symptoms, comorbidities, and length of hospital stay were extracted from the records. Results: A total record of 439 COVID-19 positive patients admitted during the study duration were reviewed. Out of 439 patients, 264 were males and 175 were females. Almost one-fifth (21.2%) of total patients had GI manifestations. The most common GI symptom was anorexia, followed by diarrhea, vomiting, and abdominal pain. Other less frequent GI symptoms include nausea and blood in stools. Around 30% of patients showing GI symptoms had comorbidities of diabetes mellitus or hypertension or both. The length of hospital stay was higher among patients with one or more comorbidities as compared to patients without any comorbidities. Conclusions: The proportion of having GI manifestations in hospitalized COVID-19 patients was 21.2%. The common GI symptoms were diarrhea, vomiting, anorexia, nausea, abdominal pain, and blood in stools. Patients with comorbidities had an elongated length of hospital stay.
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Changing Trends of adenocarcinoma among other nonperipheral lung tumors in smokers and nonsmokers: A Tertiary care center's experience p. 195
Ajit Harsha, Srikanth Katare, Adimalla Raja Kumar, Shuaeb Bhat, Suhas Dhulipala
Background: Globally, modern lifestyles and the increasing incidence of lung cancer have changed the histopathological presentation of lung cancer to the point that it has reached epidemic proportions. It is well known that tobacco smokers are more prone to lung cancer. Nonsmokers are no exception. We conducted this study to determine if primary lung cancer is increasing in nonsmokers and examine the differences in clinicopathological patterns and disease staging between smokers and nonsmokers. Objective: (1) Comparing the occurrence of nonperipheral lung tumors in smokers and nonsmokers, (2) to determine whether bronchogenic carcinoma in smokers and nonsmokers exhibited the same histopathological shift, (3) a comparison of lung cancer in smokers and nonsmokers based on clinical and radiological findings. Materials and Methods: A prospective study in Pulmonary Medicine was conducted over 7 years from August 2012 to January 2020. All adult patients were screened with a detailed history and risk factors. Histopathological analysis was performed on patients with X-ray findings that appeared to be a mass or collapse caused by endobronchial growth, as well as on patients who were clinically, radiologically, and bronchoscopically suspicious for malignancy. Results: The study reports that out of the 386 cases of bronchogenic carcinoma, 295 (76.4%) were between 46 and 70 years of age, 282 (73.05%) were male, 250 (85%) smokers, and 104 (27%) females, 44 (14.9%) smokers. Smokers outnumbered nonsmokers by a ratio of 3.1:1. In 257 patients, fever was the most common symptom, followed by hemoptysis in 245 patients. Mass lesion was the most common radiological finding in 245 (63.4%) patients. Squamous cell carcinoma 123 patients (43.6%), Adenocarcinoma 107 patients (37.9%) and small cell carcinoma 35 patients (12.4%) were more common in males, while adenocarcinoma patients 48 (46.1%), squamous cell carcinoma 36 patients (34.6%) and small cell carcinoma 12 patients (11.5%) were more common in females. Conclusion: Majority of elderly patients have an increased risk of developing malignancy, as shown by this study. Smokers are still more likely to develop primary lung cancer than nonsmokers. Squamous cell carcinomas constituted a greater proportion of all histopathological types than adenocarcinomas. Adenocarcinomas are more likely to develop centrally during their later stages. The majority of adenocarcinoma patients presented at the terminal stage and were not smokers.
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Avascular necrosis of bilateral femoral head in a HIV patient p. 203
Vivekanand R Kamat, Murugesh Pastapur, Sangram Biradar
Avascular necrosis (AVN) is due to ischemic death of the bone involving typically the femoral heads. Its incidence rate is higher in HIV-infected patients and is multifactorial. The factors such as dyslipidemia, alcohol use, steroid use, protease inhibitor in highly active anti-retroviral therapy (HAART) regimen and HIV infection itself increases the incidence of AVN. Here, we report the case of 52-year-old female with a history of pain in bilateral hip joint with no history of trauma. She was a known case of retroviral disease since 9 years and was on HAART. On examination, her vitals were stable, and she had restriction in both passive and active movements around bilateral hip joint, and they were painful. There was no obvious swelling, and other joints were normal. General and systemic examinations, including neurological and musculoskeletal, were normal. Laboratory parameters showed hematological renal and liver functions to be normal, but total cholesterol was 285 mg/dl and triglycerides were 231 mg/dl. Magnetic resonance imaging showed STIR hyperintense band sign corresponding to T1 hypointense rim suggestive of bilateral AVN of head of femur (FICAT and ARLET Classification Stage 1). The aim of this case report is to alert the clinicians involved in HIV care regarding AVN as a subtle yet frequent complication in a HIV-infected patient with known predisposing factors when presenting with acute spontaneous nontraumatic bilateral hip joint pain.
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A case of fever of unknown origin – Was it really unknown? p. 205
Manjunath Premanath
A 66-year-old male patient with diabetes and hypertension presented with a history of 2 months of continuous fever and weight loss. He was investigated earlier and treated for upper respiratory infection, typhus, and other infections with no reduction in his fever. He had high eosinophilia and was investigated for malignancy and rheumatological diseases. Positron emission tomography-computed tomography scan revealed an increased uptake in the thyroid, and the thyroid profile clinched the diagnosis.
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Doctor as a detective: Musings from a long innings of clinical practice p. 210
Raghavendra Bhat
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Salvo of Ventricular Premature Complexes in Ischemic Heart Disease p. 213
Gautam Jesrani, Samiksha Gupta, Arshia Bhardwaj, Harsheel Gupta
Nonsustained ventricular tachycardia can be observed in various cardiac conditions, which can be benign or life-threatening, and is commonly encountered in patients with underlying structural heart disease. Hemodynamic instability in this rhythm abnormality is uncommon, but emergency management is warranted for unstable patients to mitigate dire consequences.
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Fluconazole-Induced fixed drug eruption and herpes simplex virus reactivation: A case report p. 216
K Geetha
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Cerebral venous sinus thrombosis with lower motor neuron facial palsy p. 217
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
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