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   Table of Contents - Current issue
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January-March 2023
Volume 11 | Issue 1
Page Nos. 1-64

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EDITORIAL  

AJIM – The Journey So Far…. p. 1
Shrikanth N Hegde
DOI:10.4103/ajim.ajim_135_22  
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REVIEW ARTICLES Top

Multisystem inflammatory syndrome in adults - In COVID-19 Highly accessed article p. 2
Vasantha Kamath, B Nivea, R Sheeba
DOI:10.4103/ajim.ajim_100_21  
The spectrum of COVID-19 continues to evolve, uncovering several manifestations with every passing day. One of the complications is multisystem inflammatory syndrome (MIS) that occurs both in children and adults. MIS in children (MIS-C) has become a recognized syndrome, whereas a parallel syndrome in adults (MIS in adults [MIS-A]) has not been yet well defined. Due to the overlap between COVID 19 and MIS-A, we tend to miss cases of MIS-A. In this review, we have focused on MIS-A, its diagnostic criteria, pathogenesis, treatment, its relationship with vaccination, and differentiation from COVID 19.
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Sudden cardiac death and chronic kidney disease p. 7
Vijoy Kumar Jha
DOI:10.4103/ajim.ajim_114_21  
Sudden cardiac death (SCD) is responsible for approximately one fourth of all cause mortality in dialysis patients. In chronic kidney disease (CKD) patients, unlike general population, traditional coronary artery disease associated risk factors are not the major determinants of SCD. The adverse cardiomyopathic and vasculopathic milieu in CKD predispose these patients to arrythmias, conduction abnormalities, and sudden cardiac death. In advanced kidney disease, these conditions may be further exacerbated by electrolyte shifts, divalent ion abnormalities, sympathetic overactivity, decreased baroreflex sensitivity, iron toxicity, and chronic inflammation. The outcomes after cardiac arrest in CKD patients particularly those on dialysis are poor. The decision to implant a cardioverter- defibrillator deppends on the patient's age and stage of CKD. In this review, we will discuss the definition, pathophysiology, risk factors and preventive strategies of SCD in the setting of CKD.
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ORIGINAL ARTICLES Top

Study on drug-induced parkinsonism and its clinical patterns in Eastern Indian population p. 14
Praveen Kumar Yadav
DOI:10.4103/ajim.ajim_24_22  
Background: Drug-induced parkinsonism (DIP) is important as it is reversible if identified and treated early. We present herewith various clinical patterns and drugs commonly causing DIP. Materials and Methods: This is a retrospective study with done at the outpatient neurology services of Aarogyam Neuroclinic, from Durgapur, West Bengal, during January 1, 2021–July 31, 2021. In this study, consecutive patients satisfying the inclusion criteria for DIP were included in the study. The inclusion criteria were: 1. All patients with two of the four cardinal features of parkinsonism – bradykinesia, tremor, rigidity, and postural imbalance. 2. There should be a temporal relationship of intake of medications before the onset of symptoms. 3. Exclusion of other causes of parkinsonism. The age, sex, and other demographic characteristics of study population were studied. The pattern of parkinsonism – symmetric, asymmetric, tremor-dominant, or rigidity-dominant was noted. Results: Out of 52 patients studied, 34 (65.38%) were male and 18 (34.61%) were female. The most common age group involved was 60–70 years (30.76%), followed by 70–80 years (26.92%) and 50–60 years (19.23%). The mean age was 60.61 years with a standard deviation of 13.44 years. On analysis of the clinical patterns of parkinsonism, the most common type was tremor-dominant symmetric parkinsonism (53.84%), followed by asymmetric parkinsonism (25%) and akinetic-rigid parkinsonism (21.12%). Orofacial dyskinesias were seen in 17.3% along with parkinsonism. Common drugs associated with DIP were gastrointestinal motility agent levosulpiride (25%), calcium channel blockers such as flunarizine (19.23%), aripiprazole (11.53%), amisulpiride (7.69%), sodium valproate (7.69%), olanzapine (3.8%), and itopride, flupenthixol, and risperidone (1.72%). Forty patients were followed up for 6 months, of which, majority (50%) showed complete recovery, whereas 25% each showed partial or persistent symptoms. Conclusion: DIP is a common disorder with varied presentations. Early diagnosis is crucial for complete recovery.
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A cross sectional study on the impact of coronavirus disease-19 pandemic on the training of interns in a Medical College Hospital, Andhra Pradesh, India p. 19
Roopa Suresh, A C Sanjay Reddy, Suresh Krishnamurthy, R Anil, Y J Visweswara Reddy, P Janakiraman, PJ Harsha, H R Krishna Rao, V S Subba Rao Ryali
DOI:10.4103/ajim.ajim_54_22  
Background: A Medicine and Bachelor of Surgery (MBBS) graduate will gain the required skills and competencies under supervision during the internship training. Many factors influence the competency levels. Coronavirus disease-19 (COVID-19) pandemic could be one of those factors. Objectives: The objectives were to assess the competency levels among medical interns, postinternship, during the COVID pandemic and also to assess the association between the competency levels with their final year results. Subjects and Methods: A cross-sectional study was conducted among 113 interns using a self-assessment questionnaire. Self-perception about the competencies was graded into three categories as low, moderate, and high. The Chi-square test was used for analysing statistical association between self-perception and MBBS final year part II results. Results: The level of self-perception about the competencies among the interns was found to be high in-analysis, display and interpretation of information; hypothesis formulation and decision-making (45.1%) and interpersonal communication, management, organizing health care system and professionalism (42.5%), whereas it was low for obtaining information from the patients and their families (29.2%) and procedural skills (18.6%). About 75.2% and 76.1% of the interns had low self-perception for endo-tracheal intubation and lumbar puncture, respectively. High level of self-perception was noted for urethral catheterization (84.2%) and intramuscular drug administration (76.1%). It was found that none of the competencies were statistically associated with the grade based on marks obtained in final year part II. Conclusion: COVID pandemic has affected the interns training to a significant extent. There was no statistically significant association between final year grades and the competencies.
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Age variation of motor nerve conduction study in healthy adults: A physiological reference p. 24
Sunil Kumar Jena, Manoranjan Acharya
DOI:10.4103/ajim.ajim_63_22  
Background: Nerve conduction study (NCS) is the simple noninvasive technique to assess the functional status of peripheral nerves. Physiological variables such as age, sex, anthropometric indices influence the functional status of peripheral nerves. Hence, this study was designed to assess the effect of age on motor NCS. Materials and Methods: A cross-sectional study was done among healthy adults of different age group to observe the effect of age on nerve conduction. Ninety-eight healthy study participants were selected for this study after getting due approval from ethics committee of the institution. Motor NCS was performed with the standard procedure by trained technician under supervision of neurologists. Median, ulnar, posterior tibial, and common peroneal nerve (CPN) were studied for compound motor action potential. All study participants were classified into three groups according to their age, i.e., Group A (20–35 years), Group B (36–50 years), and Group C (>50 years). Statistical test one way ANOVA was used to analyze the data. Results: Distal latency of older age group participants was prolonged than younger age group. Amplitude in older age group participants was less than younger age group only in median and CPN. Conduction velocity in older age group is less in comparison to younger age group. Conclusion: This study opined age has substantial role in NCS of healthy subjects. Hence, age reference data of motor NCS are helpful for the evaluation of functional status of motor nerves.
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Assessment of insomnia and sleep quality among patients with Type 2 diabetes p. 28
Srjana Karumanchi, Venkata Rambabu Mallela, Krishna Chaitanya Alam, Amith Kumar Pendurthi, B S. V. Manjula, Ananya Pakalapati
DOI:10.4103/ajim.ajim_20_22  
Background: Type 2 diabetes and insomnia are common health issues which have a detrimental relationship with each other. Clinical management of diabetes in patients with poor sleep quality is a challenge. Therefore, understanding the correlation between the diabetic status, the presence of diabetes-related complications, and poor sleep quality among diabetic patients can help physicians in the better management of such cases. Objective: The objective of this study was to study the sleep quality among patients with type 2 diabetes. Materials and Methods: A cross-sectional study was carried out among 200 patients with type 2 diabetes. “The Pittsburgh Sleep Quality Index (PSQI)” questionnaire was used to document the quality of sleep. HbA1c and fasting blood sugar were estimated. Complications of diabetes were assessed using investigations such as electrocardiography, urine albumin, and other relevant investigations as and when indicated. Type of treatment was recorded from the preexisting prescription. Binary logistic regression analysis was used to calculate the adjusted odds ratio. Results: The mean age was 55.08 ± 13.02 years. Forty-five percent reported fairly good subjective sleep quality. 26.5% had 31–60 min sleep latency. Fifty-one percent had sleep duration of more than 7 h. Habitual sleep efficiency was >85% in 82.5% of study participants. 58.5% had sleep disturbances for less than a week. Ninety-five percent did not use any sleep medication and 62% had no daytime dysfunction during the past month. The prevalence of poor sleep quality was 52%. Among all the factors studied for association with poor sleep quality, only the presence of complications of diabetes were found to be significantly associated with poor sleep quality after adjusting for other factors (adjusted odds ratio = 4.33; 95% confidence interval = 2.13–8.78; P = 0.000). Conclusion: The prevalence of poor sleep quality among diabetics in the present study was high. This association was noted only with the presence of complications of diabetes. Hence, efforts to prevent complications of diabetes by regular follow-up and appropriate treatment along with regular screening for complications can prevent complications associated with diabetes and hence prevent poor sleep quality.
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C-reactive protein and lactate dehydrogenase in intensive care unit and nonintensive care unit COVID-19 patients – A retrospective study p. 33
Muragendraswami Astagimath, Raviraja Aryapu, Vishwanath Patil, Suman Doddamani
DOI:10.4103/ajim.ajim_18_22  
Background: Appropriate diagnostic markers play an important role in categorizing COVID-19 patients with respect to the severity of the disease. Aims and Objectives: The aim and objective of this study were to compare C-reactive protein (CRP) and lactate dehydrogenase (LDH) in intensive care unit (ICU) and non-ICU patients of COVID-19 disease. Materials and Methods: Data was collected from the COVID-19 laboratory (n = approximately 3700). The patients were divided into two groups: ICU and non-ICU. The levels of CRP and LDH were estimated by the microslide method based on an enzymatic heterogeneous sandwich immunoassay. Results: In the ICU group, patients above 50 years were four times in number compared to patients below 50 years. COVID-19 infection was twice more common in males than females. The mean CRP levels in the ICU group were higher compared to non-ICU group, and this difference was statistically significant. LDH was elevated significantly in ICU patients compared to non-ICU patients. Conclusion: The study concludes that patients aged above 50 years are more prone to develop severe COVID-19. Men are more susceptible to develop severe COVID-19. The most evident finding of this study is that among patients below 50 years, higher CRP levels can be used as an alarming marker in predicting severe COVID-19 disease. We suggest that LDH can be used as a marker to predict the severity of COVID-19 disease in all age groups. We also suggest that in patients above 50 years, it is better to use the combination of CRP and LDH in the assessment of severe COVID-19, rather than using CRP alone.
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Association of hematological parameters (mean platelet volume and red cell distribution width) with nonalcoholic fatty liver disease p. 37
Sonika Verma, Manish Verma, Sunny Khari
DOI:10.4103/ajim.ajim_11_22  
Objectives: We aimed to compare mean platelet volume (MPV) and red cell distribution width (RDW) values of the nonalcoholic fatty liver disease (NAFLD) patients with the normal population and also assess the correlation of MPV and RDW with grades of NAFLD. Methods: An observational case–control study was conducted over a period of 21 months (November 2018–July 2020). Sixty-five patients with NAFLD and 65 healthy controls were enrolled in this study. Demography, symptoms of the patients, and clinical investigations comprising hematological profile, liver enzyme tests, lipid profile, and viral markers were done. Ultrasound liver was done to assess the grading of NAFLD. The outcome measures were correlation between RDW, MPV, and NAFLD grade. Results: The median of RDW in cases was 14.5% which was significantly higher as compared to controls 12.4% (P < 0.05). The median MPV (μm3) in cases was significantly higher than controls (11.4 vs. 9, P < 0.05). The mean RDW (%) in Grade 3 was significantly higher as compared to Grade 2 and Grade 1 (17.04 vs. 14.63 vs. 12.95, P < 0.05). The mean MPV (μm3) in Grade 3 was significantly higher as compared to Grade 2 and Grade 1 (13.32 vs. 11.43 vs. 8.96, P < 0.05). A significant positive correlation was seen between grade of fatty liver with MPV (r = 0.908, P < 0.0001) and RDW (r = 0.892, P < 0.0001). Conclusion: Overall, our study results show increased MPV and RDW in cases as compared to controls with significant correlation with liver grade, suggesting that these markers can be used to assess the onset and severity of NAFLD.
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Study of post COVID-19 sequelae at a tertiary rural health care center p. 45
Satish Reddy, Vasantha Kamath, Josna Ganesh Teli, Nisha Davy Olakkengil, Buvana Radhakrishnan, Kushal Markanday
DOI:10.4103/ajim.ajim_10_22  
Background: Following partial recovery from acute COVID-19 disease, patients have been reported to suffer from long-term sequelae (beyond 12 weeks from the onset of symptoms), Symptoms vary from mild to life-threatening conditions. This phenomenon is now called post-COVID-19 or long COVID-19. Materials and Methods: Of the total 81 patients with a history of COVID-19, 72 patients were considered for the study. Their clinical data, risk factors, laboratory investigations, radiological findings, management, and outcomes were recorded and statistically interpreted and analyzed. Results: Majority of the patients belonged to the elderly age group. Respiratory symptoms persisted in 53 patients followed by musculoskeletal symptoms seen in approximately 40 patients (55.5%). Renal, neurological manifestations, gastrointestinal, cardiac manifestations, and thromboembolic phenomenon were also seen. Conclusions: In our study, it was concluded that majority of patients presenting with post-COVID-19 sequelae came with persistent respiratory symptoms followed by musculoskeletal and neuropsychiatric manifestations. The repercussions of COVID-19 illness are reverberating and should be managed extensively, as with the rising numbers the burden on health care will also rise. Hence, a need for more research in this field for better diagnosis and management of post COVID-19 syndrome.
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An observational study to evaluate the relation between infarction type, site, and the degree of conductive system damage p. 50
K Sangeetha, S Myilsamy, Praveen Vijayakumar, Panneerselvam Periaswamy
DOI:10.4103/ajim.ajim_40_22  
Background: Obesity, insulin resistance, and type 2 diabetes mellitus are all on the rise, and they are all significant risk factors for ischemic heart disease (IHD). The prevalence of risk factors for IHD is quickly growing in developing countries as a result of urbanization. Large rises in IHD are observed around the world, and IHD has overtaken cancer as the leading cause of death after 2020. Materials and Methods: This is a 6-month prospective observational research undertaken at a tertiary care hospital where the myocardial infarction (MI) patients admitted to the intensive coronary care unit were included in the study. Results: Atrioventricular (AV) block was absent in 178 of 200 patients with acute MI. AV block was found in 22 of the remaining cases. The following is the frequency of each form of AV block: 12 patients had type 1 AV block. In five of the cases, type 1, 3 transition was found. Type 2 AV block was found in two cases. In one case, there was a 2, 3 transition. Conclusion: Preventing conduction system block may require the effective management of hypertension and maintaining appropriate blood glucose levels.
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CASE REPORTS Top

Porphyria cutanea tarda: An uncommon condition in a patient on chronic hemodialysis p. 53
Yedabettu Janardhana Anupama, Yabagodu Ramavakoda Parameshwara
DOI:10.4103/ajim.ajim_65_21  
Patients with chronic kidney disease can have many dermatological manifestations. One of the very rare conditions is porphyria cutanea tarda (PCT), which manifests with hyperpigmentation of skin and photosensitivity along with painful bullae in sun-exposed areas. It is due to deficiency of uroporphyrinogen III decarboxylase enzyme which takes part in heme synthesis. The deficiency could be genetic or sporadic. Iron therapy and hepatitis C infection are known to precipitate these lesions. We report a case of PCT in a woman undergoing chronic maintenance hemodialysis, review the literature, and discuss the problems with management specific to the dialysis population.
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An interesting case of peripheral arterial disease as presentation in systemic lupus erythematosus p. 56
Sumati Kulkarni, Sangram Biradar
DOI:10.4103/ajim.ajim_63_21  
Systemic lupus erythematosus (SLE) is a chronic multisystemic autoimmune disease. Among the cutaneous manifestations of SLE, peripheral arterial disease and digital gangrene are considered very rare. Digital ulcers are relatively rare in SLE and never present as an initial manifestation of disease. The presence of an extremity ulcer is one of the more obvious clinical signs that can be due to ischemia (peripheral arterial disease). Digital gangrene is seen mostly at a late stage of the disease proposing that a long history of SLE is a considered risk factor. Only 0.2% of patients with SLE presented initially as digital necrosis. This is a case report of a 55-year-old male patient who presented with primarily with acute painful localized dry digital gangrene associated with bilateral lower limbs. Serology was positive for SLE. Doppler study of both the lower limbs vessels showed digital artery of second toe of both feet shows reduced flow on doppler study. Disarticulation of the toes was adviced as treatment.
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Extrahepatic portal vein occlusion presenting with vascular, biliary, and visceral complications evaluated on multidetector computed tomography p. 60
Vaishali B Dhawan, Roohi Gupta, Amruta Varma
DOI:10.4103/ajim.ajim_49_21  
Extrahepatic portal venous obstruction, predominantly a disease of childhood, is a chronic and long-standing disease characterized by thrombosis of the portal vein, leading to multiple collateral formation and other associated complications owing to long-standing nature of the disease. We present the case of a 22-year-old male with symptoms and signs of gastrointestinal bleed and pain in the left upper abdomen with similar episodes in the past.
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Rhabdomyolysis in hepatitis A: Uncommon complication of a common infection p. 63
M Suresh Babu, HG Ashoka, Anusri Adusumilli
DOI:10.4103/ajim.ajim_98_20  
Hepatitis A is usually a mild self-limiting infection of liver. Rhabdomyolysis complicating acute nonfulminant hepatitis A is exceedingly rare. We present here a case report of 19-year-old young male with hepatitis A, who developed rhabdomyolysis with acute renal failure. He underwent dialysis and made a complete recovery with normalization of laboratory tests.
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