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   Table of Contents - Current issue
April-June 2022
Volume 10 | Issue 2
Page Nos. 57-139

Online since Tuesday, April 5, 2022

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Hypertension: Changing trends and targets … and guidelines galore! p. 57
Nagaraj Desai, Prabhakar Koregol
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Sepsis-associated acute kidney injury and the need for renal replacement therapy: A physician's perspective p. 60
Vijoy Kumar Jha, Debasish Mahapatra
Sepsis associated acute kidney injury is a very common complication and carries unacceptable mortality in the setting of critical illness. Physicians should be very prompt to recognise it an an eartly stage, as providing supporting care early will limit further insults to the kidney. By the time patients seek medical attention, acute kidney injury has already happened. Microvascular dysfunction, inflammation, and metabolic reprogramming are three mechanisms that have been proposed to explain the pathophysiology of acute kidney injury associated with sepsis. The role of early renal replacement therapy /blood purification technique is still controversial. We need more studies to better understand the complex pathophysiology of this complication and translate these findings into potential treatment strategies. In this review, new definitions of sepsis and acute kidney injury, risk factors, pathophysiology and management strategies of sepsis- associated acute kidney injury are being discussed.
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Omicron: An emerging variant of concern p. 69
Vasantha Kamath, Deepthi Reddy
Emerging infectious diseases are now a concern worldwide and can evolve into a global health-care crisis or pandemic. Identification of the Omicron variant (B.1.1.529) of severe acute respiratory syndrome-2 (SARS-CoV-2) which is considered a variant of concern has added fuel to the eternal flame of the global COVID-19 pandemic. There is an apparent sharp rise in cases of the new variant which is setting off alarm bells. The emergence of this new strain of the virus has taken a disproportionate toll in few countries including India. The need of the hour is to track the concerning rise of the new variant of the SARS-COV-2 causing COVID-19 and to prevent the reinfection.
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A study on physicians' adherence to joint national committee guidelines for hypertension p. 73
Nagavaishnavi Venkata Bhaskara, Ravi Kiran Andra, Medha Bhat, KK Mithun Reddy, Ravi Shankar, Amogh Diwakar, Pratibha D Nadig
Background: Increased blood pressure (BP) is the second leading risk factor for death and disability globally according to the Global Burden of Disease Study. Therefore, various guidelines have been issued. The American College of Cardiology/American Heart Association issued guidelines and Joint National Committee (JNC) 7 and JNC 8 guidelines, which were laid down by the JNC are a few guidelines for hypertension (HTN) management. Many countries have not implemented effective public policies to prevent and control HTN. Objective: The objective of this study was to assess the number of physicians' adherent to JNC 7, JNC 8, and AHA guidelines when prescribing medications to patients. In addition, the efficacy of the medications, trends in prescribing medications, and adverse drug reactions that a few patients presented with were assessed. Materials and Methods: A cross-sectional, questionnaire-based observational study was conducted on hospitalized hypertensive patients in a tertiary care hospital in South India. Data were collected on a detailed interview basis after receiving an informed consent based on a specific set of preformulated questions. The sample size was met, and the obtained data were analyzed appropriately using the SPSS software version 21. Results: Seventy two patients had diabetes and/or CKD along with hypertension out of 198 patients who participated in the study.Maximum number of prescriptions were adherant to JNC 8 and the least were observed with AHA guidelines.The blood pressure was more controlled in those patients where physicians were adherant to guidelines.The most commonly prescribed drugs were Calcium channel blockers followed by Angiotensin receptor blockers,beta blockers and ACEinhibitors. Adverse drug reactions were seen in only 5 patients Conclusion: The overall adherence to antihypertensive medications guidelines by physicians in India is only modest and much lesser when comorbidities are associated. There is a need to build awareness. Further the antihypertensive classes of medications currently recommended appear to be efficacious and safe.
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Neuroendocrine tumors of gastrointestinal tract with special reference to immunohistochemistry markers at a tertiary care hospital p. 78
Hilal Abdullah, Zahid Wani, Zarkah Nabi, Parveen Shah, Shuaeb Bhat
Background: Neuroendocrine tumors (NETs) are epithelial neoplasms that originate from the endocrine cells, contain cytoplasmic granules, and secrete a variety of biogenic amines, which are responsible for a variety of signs and symptoms produced by these tumors. Endocrine cells are interspersed within the mucosa of the gastrointestinal tract (GIT) and are also present in a variety of other viscera such as pancreas, adrenal gland, lung, and thyroid. The present study included forty cases of NETs of the GIT (excluding pancreas) reported in the Department of Pathology at Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Kashmir. The objectives of this study were to study the histopathological spectrum of NETs of the GIT and to evaluate the immunohistochemical (IHC) expression of chromogranin, synaptophysin (SYP), neuron-specific enolase, and Ki-67 (MIB) in these tumors. Materials and Methods: The study was conducted at the SKIMS, Srinagar, Kashmir, in the Department of Pathology. It was a prospective study for a period of 1½ years starting from July 2015 to December 2016 and retrospective study for 3½ years from January 2012 to June 2015. The study included all cases of NETs of GIT with or without nodal metastasis. Results: Most of the tumors were well-differentiated NETs (45% G1 and 25% G2). Stomach was the most common site (27.5%) followed by duodenum (25%). Regional lymph node involvement was present in 25% of the cases. Liver was the most common site for distant metastasis. There was a slight female predominance (57.3%). On IHC, SYP, chromogranin-A, and neuron-specific enolase were positive in 100%, 77.5%, and 85% of cases, respectively. Ki-67/MIB-1 index was used to grade the neuroendocrine neoplasms and 45% were graded as G1 NETs, 25% as G2 NETs, and 30% as NEC. Conclusion: Lately, there has been a surge in the number of cases being diagnosed as NETs most probably due to advancement in various diagnostic modalities and increasing knowledge about these tumors which have helped in diagnosing more of these tumors early and correctly.
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Varied profile in acute coronary syndrome: One size does not fit all p. 86
Chetsi Shah, Punam Bhende, Labani M Ghosh, Jyoti G Mannari
Objective: The objective was to study the clinical profiles of patients undergoing coronary angiography (CAG). Setting and Design: It was a cross-sectional retrospective study of 207 patients who have undergone CAG at B and M Cardiac Centre, Shree Krishna Hospital, from study period of September 2018 to April 2019. Materials and Methods: The patients included were those undergoing CAG of more than 20 years of age. Those who underwent coronary artery bypass graft in the past or re-do CAG and those under 20 years of age were excluded. Data were entered and analyzed with Epi Info version 7. Statistical Analysis: Association between categorical variables was tested with Chi-square test. P <0.05 was considered statistically significant. Observations and Results: Males were higher in the age group of 50–59 years while females predominated in the higher age groups. Hypertension was the most common comorbidity (43.48%) followed by diabetes. Males presented predominantly with anterior and inferior wall myocardial infarction (MI) whereas non-ST-elevation MI, unstable angina, chronic cardiac failure, and atypical presentation were higher in females. Twenty-two percent had normal electrocardiogram whereas a CAG was normal in 22.7% of the patients. Left anterior descending (LAD) involvement was predominant in both males (78.81%) and females (78.57%). Single-vessel disease (SVD) was significantly higher in females (45%). Chest pain (87.4%) and dyspnea (23.2%) were the most common complaints. Smoking was the most significantly associated addiction (P < 0.05). Conclusion: The most common presentation is unstable angina followed by anterior wall MI (AWMI). SVDs are common in females, but when presented with AWMI, triple-vessel disease was found to be most commonly associated with AWMI in females than males. As age progresses, the number of vessels involved increases. Echo is best correlated with anterior and inferior wall MI. LAD is the most common culprit vessel in both males and females. Multiple vessel involvement was common in diabetics. SVD was most common in hypertensives.
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Clinical profile of new-onset seizures in the elderly p. 93
Mahadev Hanmantappa Malge, BS Nagaraja, Avinash Hanbe Rajanna
Aim: The aim of the study is to determine the etiology of seizures in the elderly and types of seizure in elderly populations. Materials and Methods: This was a cross-sectional study carried out on patients of age more than 60 years with seizures and who satisfied inclusion and exclusion criteria, admitted in Bangalore Medical College and Research Institute (BMCRI) attached hospitals, Bengaluru, between November 2016 and October 2018. After obtaining ethical clearance and approval from the institutional ethics committee of BMCRI, written informed consent was taken from the patients. Detailed history was taken from all patients, and all patients underwent thorough clinical examination and investigations. The diagnostic probability was based on the clinical data obtained from the patient charts and the results of electroencephalography (EEG) and computed tomography (CT) scans. The etiology of seizures was determined on the basis of medical history, neurologic examination, EEG, and CT scans. Results: A total of 58 patients of new-onset seizure included in the study out of which 30 were male and 28 were female. Majority of the patients were aged between 60 and 70 years. Male-to-female ration was almost equal. GTCS was the major type of seizure. Cerebrovascular infarct was the most common etiology. Diabetes and hypertension (HTN) were the most common comorbid conditions. Conclusion: Seizure was the dominant manifestation of various underlying disorders in the elderly, of which cerebrovascular disease was the most common cause, followed by metabolic cause. Comorbidities such as diabetes and HTN also had an important role in seizure activity. GTCS was the most common type of seizure in the elderly.
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Disseminated Histoplasmosis in HIV patients- Case series from a single tertiary care centre in India p. 98
Sumit Arora, Kuldeep K Ashta, Syed Asif Hashmi, N Arun, Sharmila Dudani
Introduction: HIV-positive patients are at risk of developing various opportunistic infections, including disseminated histoplasmosis, the incidence of which is 29% in India. Diagnosis is usually delayed as the clinical manifestations are diverse and mimic other common diseases endemic to this region such as tuberculosis and visceral leishmaniasis. This leads to preventable morbidity and mortality. Materials and Methods: We carried out a retrospective data analysis of 1280 HIV positive patients' who were on treatment at our centre between 2016 and 2020., of which 8 cases of confirmed histoplasmosis were identified. The clinicopathological spectrum and outcomes of these patients were analyzed and presented as a case series. Results: The median age of patients was 39.5 years. In six out of eight patients, disseminated histoplasmosis was the initial presentation of HIV. Fever, weight loss, macular-papular skin lesions, bicytopenia, and respiratory system involvement were the most common clinical manifestations. Pulmonary lesions included patchy areas of consolidation, miliary nodules, and pleural effusion. Gastrointestinal symptoms were uncommon. In six out of eight patients, CD4 count was <50/mm3. The median CD4 count and median HIV RNA at presentation were 21.5 per mm3 (interquartile range [IQR]: 12–54) and 2.98 × 105 copies/ml (IQR: 1.24 × 104–5.33 × 106), respectively. Diagnosis in all cases was made by direct visualization of the fungus on biopsy. Most patients responded to L-amphotericin or itraconazole. Three out of eight patients expired due to septic shock following disseminated disease. Conclusion: A high index of clinical suspicion along with early institution of therapy is essential to reduce mortality.
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Role of anti-phospholipase A2 Receptor antibodies in patients with membranous nephropathy: A prospective study on Indian cohort p. 103
Afreen Karimkhan, Usha Kini, Pradeep M Shenoy, Renuka Satish, Divya Puttegowda
Context: A search for a cause for membranous nephropathy (MN) is crucial to determine its treatment and management. Primary MN was a diagnosis of exclusion until the discovery of the target antigen, phospholipase A2 receptor (PLA2R). Lack of published data from the Indian population prompted this prospective study to determine the sensitivity and specificity of circulating anti-PLA2R antibodies in MN patients by using cell-based indirect immunofluorescence test (IIFT) and correlating with clinical–histopathology features and response to treatment. Settings and Design: This was a cross-sectional prospective study. Materials and Methods: MN cases (n = 34) diagnosed by renal biopsy and IIFT were evaluated along with 10 controls for serum anti-PLA2R antibodies using IIFT on biochip containing HEK 293 cell lines transfected with cDNA coded for PLA2R in this cross-sectional prospective study and simultaneously investigated to find the cause for MN. Positive cases treated with the Ponticelli regimen were followed up for 6 months with repeat testing for PLA2R. Statistics were performed using Statistical Package for Social Sciences version 18 (IBM). P < 0.05 considered significant. Statistical parameters were analyzed using the Chi-square test. Results: Anti-PLA2R antibodies-positive MN (primary MN) cases (n = 20) had higher 24-h proteinuria (10.09 ± 2.46 g) with 25% cases showing mesangial hypercellularity and basement membrane thickening in all (100%), while 50% of secondary MN cases showed mesangial hypercellularity with 7.17 ± 3.8 g of proteinuria. The sensitivity, specificity, and accuracy rate of anti-PLA2R antibodies for a diagnosis of primary MN were 70%, 100%, and 82%, respectively. Conclusion: Anti-PLA2R antibody in serum is a good reliable noninvasive diagnostic biomarker for primary MN and for monitoring its disease activity.
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Ambulatory blood pressure monitoring and its utility in management of hypertension in a clinic setting in South India p. 111
Subhashchandra B Hegde, Shivaramakrishna Aroor, Yedabettu Janardhana Anupama, Shrikanth N Hegde
Introduction: High blood pressure (BP) is an important risk factor for cardiovascular diseases. The association of short-term BP variability (BPV) with target organ damage (TOD) is not clearly established. We conducted this observational study to evaluate the degree of concordance between Office BP measurements (OBPM) and ambulatory BP monitoring (ABPM) and to study the association of ABPM parameters on TOD. Materials and Methods: Patients attending clinics of the authors between January 2018 and August 2019 were enrolled. Their BP status was determined by OBPM and ABPM and the degree of concordance analyzed. ABPM parameters between those with TOD and without TOD were compared using appropriate statistical measures. Results: Data from 968 subjects (males 61.5%, mean age 59.39 ± 14.86 years) were analyzed. Masked hypertension (HTN) and white coat HTN were seen in 138 (14.3%) and 50 (5.2%) participants, respectively. There was moderate concordance between ABPM and OBPM readings (Cohen's κ =0.571, 95% confidence interval [CI]: 0.445, 0.595, P < 0.001). There were 530 (54.8%) nondippers and 189 (19.5%) reverse dippers. High morning surge (MS) was seen in 193 patients (19.9%) and TOD was seen in 378 patients (39%). Among all the ABPM parameters which were significantly associated with TOD on univariate analysis, only BPV (P = 0.04, odds ratio [OR]: 1.04, 95% CI: 1.00, 1.08) and systolic BP in active phase (P = 0.01, OR: 1.02, 95% CI: 1.00, 1.04) were found to be predictors of TOD after multiple logistic regression analysis. Dipping status and MS were not associated with TOD. Conclusions: ABPM is a useful tool for diagnosis and accurate categorization of HTN. The analysis of ABPM parameters helps to identify the patients with BPV which has important implications for the prevention of TOD. ABPM is recommended in all individuals with cardiometabolic risk profile or with established TOD even with normal office BP readings.
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Fine-needle aspiration cytopathology correlation study of thyroid nodule with the postoperative histopathological reporting in a rural medical setup p. 118
Rufus K Sam Vargis, Tony Joe Peechatt, CR Raghuveer, MS Sharada, Arun Mathew Chacko, Arya Vijayan
Background: Fine-needle aspiration cytology (FNAC) is the examination of cells that are obtained through a fine needle under vacuum. Due to the superior diagnostic reliability and cost-effectiveness of FNAC, American thyroid association had setup some guidelines stating that FNAC must be used as a diagnostic test initially before the ultrasonography and thyroid scintigraphy. This present study was undertaken to categorize and correlate all the thyroid FNAC samples according to the Bethesda system and for assessing the efficacy of the Bethesda reporting system in the preoperative evaluation of thyroid lesions. The major aim of study is to identify the nodules which require surgery and those benign nodules that can be observed clinically, thereby reducing the overall rate of thyroidectomy among patients with benign disorders. Materials and Methods: The present prospective study was conducted among 428 patients with thyroid lesions at a tertiary care rural medical set up. All the specimens were fixed in 10% formalin, and detailed gross examination was done. 3–10 tissue bits were selected from representative areas and all the bits were processed and stained with H and E stain. Cytological diagnoses were correlated with histopathology and the efficacy of The Bethesda System for Reporting Thyroid Cytopathology for reporting FNAC was estimated. Discussion: Out of 428 patients with thyroid lesions, 96 cases of histopathological specimens were collected. The histopathology lesions were divided into benign nonneoplastic, benign neoplastic, and malignant to study the gender, age group affected with these lesions and to calculate the association of malignancy with gender and age. The result showed that diagnostic tests are not significantly different with respect to sensitivity. Hence, FNAC is a reliable test for histopathology in diagnosis of thyroid lesions. In the present study, although the malignancy rate was higher among males, no association of gender and malignancy was not significant (P > 0.05). Conclusion: The Bethesda standardized system for reporting cytopathology improved the communication between pathologists and clinician promoting an interlaboratory agreement.
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Takayasu arteritis in young female a case report p. 124
AV Umakanth, Sangram Biradar
Takayasu arteritis (TA) is a systemic inflammatory large vessel vasculitis. Here, we report a rare case of 18-year-old female with complaints of upper and lower limb pain with blackish discoloration along the veins. During hospital stay, she developed breathlessness and limb pain limiting her daily activities. As her right lower limb peripheral pulses were feeble lower limb and abdominal Doppler was performed which showed thrombosis of right common femoral and superficial artery thrombosis and concentric thickening of theaorta, celiac trunk, and superior mesenteric artery, respectively. Computed tomography aortogram supported Doppler findings and two-dimensional echo showed pulmonary artery hypertension and dilated right chambers of the heart. She was started on systemic steroids and anticoagulation to which she fairly responded and she was discharged with maintenance steroids. Hence, we suggest early and prompt diagnosis of TA in young females can improve the condition and reduce the sufferings.
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Posterior reversible encephalopathy syndrome in spotted fever group of rickettsial infection with brugada syndrome p. 128
Siva Karthik Reddy Palleti, Viswateja Kolla, Vasantha Kamath
Rickettsioses are one of the common causes of undifferentiated febrile illness. Patients present commonly with fever, rash, and eschar. Posterior Reversible Encephalopathy Syndrome (PRES) also known as reversible posterior encephalopathy syndrome is a rare condition, in which parts of the brain are affected by swelling as a result of an underlying cause such as infection. However, PRES caused by spotted fever group of rickettsiosis is rarely reported. We are here with reporting such a case. A 55-year-old male was admitted to MVJ Medical College and Research Hospital, Bengaluru, with complaints of fever for 3 days and one episode of Generalized Tonic Clonic Seizures (GTCS) following which he was in altered sensorium. On examination, there was hepatosplenomegaly. Weil-Felix OX19 and OX2 were 1:320. Lumbar puncture was done which showed 15 cells 98% lymphocytes and 2% neutrophils, proteins-119 mg/dl, and sugar- 153 mg/dl. Magnetic resonance imaging of the brain showed bilateral symmetric hyperintensities on T2-weighted imaging in the parietal and occipital lobes. The calcarine and occipital lobes were spared suggestive of posterior reversible encephalopathy syndrome. Electrocardiogram showed ST elevation in V1 and V2 along with T-wave inversion (Brugada sign). Posterior reversible encephalopathy syndrome is usually commonly seen in hypertensive encephalopathy and in infections such as dengue and few cases of scrub typhus. This is one of the rare cases where spotted fever group of rickettsia has caused posterior reversible encephalopathy syndrome and Brugada syndrome.
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Basedow's paraplegia, a rare presentation of severe untreated hyperthyroidism p. 131
Saqlain Mohamed, Jayachandra , Nagaraj Nanjundaiah
Typical presentations of hyperthyroidism are palpitation, nervousness, tremor, malaise, and weight loss. Hyperthyroidism affects nearly every system in the body, and some patients may manifest neurologic symptoms. Atypical presentations of hyperthyroidism often pose a great challenge in diagnosis and treatment. We report a case of Basedow's paraplegia, A 45-year-old male auto driver by occupation presented with complaints of weight loss of 15 kg in 2 months and weakness of the lower extremities for 1 month. On examination, he had weakness of both lower limbs and on investigation, he was found to be in severe hyperthyroid status, other investigations done to look for the causes of weakness of lower limbs were negative. The patient was treated for hyperthyroidism and gradual improvement of the weakness was observed.
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Incorporation of the Humanities Component in the Medical Curriculum p. 133
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
In the current setup, the delivery of medical education primarily targets the scientific and technical domain with minimal consideration about the humanity aspect. The training offered to the medical students as a part of humanity helps them to acquire the skills to make ethical decisions, keeping the interests of the patients, family members, and the community in mind. An extensive search of all materials related to the topic was carried out in the PubMed search engine and the Medical Council of India website. A total of 15 articles were selected based on the suitability with the current review objectives. The introduction of medical humanities in the curriculum can be either done in the form of integration across the different professional years or it can be kept optional for the students. It is quite obvious that mere exposing students to medical humanities will not deliver the desired outcomes unless they are being assessed as well to measure the learning. In conclusion, the training offered to the medical students during their course not only targets clinical judgment but even humane judgment. Humanities is an integral aspect of patient care and it is high time that it is integrated within the curriculum based on the well-formulated educational objectives and a comprehensive assessment framework.
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Reviewing cullen's sign in acute pancreatitis p. 136
Gautam Jesrani, Samiksha Gupta, Amandeep Kaur, Yuvraj Singh Cheema
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Heart and vessels failure: A new pathologic description to consider in vascular disease p. 138
Andrés Felipe Vela-Montenegro, Laura Yesenia Ardila-Acuña, Adrian Camilo Ropero, Ivan David Lozada-Martinez
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Paternal diabetes screening: Obstetrician's novel and noble obligation to an unborn child p. 139
Sadananda B Naik, K Ramesha
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