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   Table of Contents - Current issue
April-June 2021
Volume 10 | Issue 2
Page Nos. 67-132

Online since Saturday, July 17, 2021

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Health disparities and the COVID-19 pandemic Highly accessed article p. 67
Shyam Chirravoori
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Clinical and laboratory profile of tuberculosis in HIV-positive patients and occurrence of tuberculosis-associated immune reconstitution inflammatory syndrome p. 70
MV S. Subbalaxmi, Sravanthi Guduru, Anu Kapoor, Naval Chandra
Background: Tuberculosis (TB) is the most common opportunistic disease in human immunodeficiency virus (HIV)-positive persons. Methods: We prospectively studied the clinical, radiological, cytological, histopathological and microbiological presentation of TB in HIV-positive patients and occurrence of immune reconstitution inflammatory syndrome (IRIS) in HIV TB co-infected patients. Results: Out of 70 patients studied, 47 were male. Fever was the most common symptom (n = 61, 87.1%). The most common laboratory finding was anaemia (n = 67, 95.7%). In 32 (45.7%) patients presenting with TB, HIV infection was diagnosed. A CD4+ count <200/mm3 was seen in 57 (81.4%) patients. Extra-pulmonary TB (44.3%) was more common than pulmonary TB. All patients were started on anti-TB treatment; 6 had developed IRIS. Conclusions: Our observations suggest that screening all HIV-seropositive patients for TB and careful monitoring for the occurrence of IRIS while on anti-TB treatment are helpful in managing HIV HIV-TB co-infected patients.
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Study of association of age at presentation with outcome in patients with head-and-neck cancer p. 79
Radha Kesarwani, Astha Singh, Virendra Singh, Gyan Prakash
Background: Elderly patients with head-and-neck cancer (HNC) are increasing in number. Outcome of HNC with relation to age is controversial. Methods: In this hospital-based retrospective study, medical records of 76 patients of HNC who were treated with surgery followed by radiotherapy or radiotherapy with or without chemotherapy were analysed. The patients were divided into two age groups: Group I patients ≥55 years and Group II patients <55 years. Patient characteristics, treatment and toxicities were evaluated. They were followed-up clinically and radiologically up to a median time of 16 months. Results: Complete response was 94.4% and 80.05% in Group I and II, respectively. Disease-free survival (DFS) was 53.67% and 47.8% in Group I and II, respectively (P = 0.332), whereas overall survival (OS) was 67.34% and 49.42% in two groups, respectively (P = 0.234); hence, DFS and OS are not statistically significant. Conclusion: Complete response was more frequently among patients older than 55 years in comparison to patients younger than 55 years, even though the dose delivered to them is lower. There was no statistically significant difference in both groups with respect to DFS and OS. Haematological toxicities were found more in older patients in comparison to patients younger than 55 years.
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Validation of surgical APGAR score in abdominal surgeries at a tertiary care teaching hospital in South India p. 85
K Yadhu Bhushanam, Aloka Samantaray, Kaarthika Thottikat, Hemalatha Pasupuleti, R Sri Devi, Mangu Hanumantha Rao, Sumadhu Chukkaluru
Background: A ten-point surgical APGAR score (SAS) has been previously developed and validated that provides surgeons with a simple, objective and direct rating of operative performance and risk. This score has been evaluated in different types of surgeries till date. We validated SAS in both elective and emergency abdominal surgeries separately which was not done previously. Methods: In this prospective, observational and longitudinal study, 105 surgical cases undergoing open abdominal surgeries were studied. The SAS was calculated for all patients, patients were followed up for the occurrence of any major complications or mortality during hospital stay after surgery. All the patients were divided into three groups based on their SAS score (high risk: SAS 0–4, moderate risk: SAS 5–7 and low risk: SAS 8–10) using a threshold that has been previously established. Results: The occurrence of major complications was significantly higher in high-risk SAS group (12%) than in the moderate risk group (5%). In the low-risk SAS group, the occurrence of major complications was low (1%). The mortality rate in high-risk SAS was more than that in low-risk SAS group with statistical significance both in elective and emergency cases. Conclusions: In our study, we found that patients who belong to high-risk SAS group were significantly associated with post-operative major complications and mortality in both elective and emergency surgeries. A patient with low intraoperative SAS should be considered at risk and monitored meticulously. Trial Registration: Clinical Trials Registry-India (CTRI) identifier No. CTRI/2019/02/017567.
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Circulating serum micro-ribonucleic acids 155 and 205 before and after surgery in patients with breast cancer p. 91
K Rama, Aparna R Bitla, Narendra Hulikal, Mutheeswaraiah Yootla, Lakshmi Amancharla Yadagiri, T Asha, M Manickavasagam, PV L. N. Srinivasa Rao
Background: Micro-ribonucleic acids (miRNAs) are small non-coding RNAs that regulate gene expression. Expression of miRNAs has been shown to be dysregulated in patients with breast cancer. These markers have been shown to be potential markers of diagnostic significance. We intended to study the usefulness of miRNA-155 and miRNA-205 in monitoring response to surgery by monitoring their pre- and post-operative expression. Methods: Twenty patients newly diagnosed with malignant breast disease along with 20 age-matched females not having any breast lesion were included in the study. Reverse transcription–polymerase chain reaction was used to assess the expression of circulating miRNAs. Results: MiRNA-155 was found to be significantly upregulated and miRNA-205 was significantly downregulated in patients with breast cancer compared to controls. There was no change in expression of miRNA-155 and miRNA-205 following surgery. Conclusions: The findings of the present study do not support the role of miRNA-155 and miRNA-205 as markers suitable for follow-up. However, the findings of the present study need to be confirmed in a larger sample size and samples collected over a defined post-operative period.
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Clinical utility of 18fluorodeoxyglucose positron emission tomography-computed tomography in rheumatology p. 97
Sirisha Kommireddy, Ranadheer Mantri, Sabella Aparna Reddy, D Ravisankar, Tekchand Kalawat
Background: Several studies with 18fluorodeoxyglucose positron emission tomography with computed tomography (18FDG PET-CT) have indicated that 18fluorodeoxyglucose uptake in affected tissues reflects the disease activity. In addition, the usage of PET-CT for early detection, extent and monitoring of the treatment response has been reported. Methods: In this retrospective study, all 18FDG PET-CTs requested by rheumatologists were reviewed retrospectively. The clinical findings and scan findings were noted. Considering the final diagnosis made by the clinician as “gold standard”, he sensitivity, specificity and positive were calculated. Results: Out of 48, 18FDG PET-CT requests, two were excluded (39 females, mean age – 39.22 ± 15.349). The indications included establishing diagnosis (n = 31 [67.4%]) and disease activity/extent (n = 15 [32.6%]). It contributed to the diagnosis in 9 (31%), when 18F FDG PETCT is used for establishing the diagnosis. It identified abnormalities in 14/15 when used for disease activity and active disease was identified in 10. Seventeen patients had a final diagnosis of fibromyalgia. Overall, 18FDG PET-CT had 100 sensitivity and NPV. The diagnostic accuracy was 56.52%. Conclusions: The 18FDG PET-CT has high diagnostic sensitivity and poor specificity in rheumatology practice with respect to establishing the diagnosis as well as to detect the extent and activity of disease.
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Membranous nephropathy and malignancy p. 103
Vinod Khelgi, Paul Stack, Sree Krishna Venuthurupalli
Background: There is variable association of membranous nephropathy (MN) with malignancy predominantly of solid organ tumours. There is debate as to how to screen and or investigate for evidence of malignancy in this group. Methods: Retrospective analysis of kidney biopsies performed between 2006 and 2016. Patients with MN were identified and clinical course including age, degree of proteinuria, histology details, treatment and rates of remission documented. Evidence of malignancy and its temporal association with MN noted. Results: Over ten-year period 216 biopsies were performed of which 20 patients (10.8%) had MN [mean age 48.5 years (range 20-82 years); there were to males]. Of these, eight patients (40%) had evidence of malignancy. Four patients were diagnosed with malignancy prior to the biopsy (mean duration 39.7 months) whereas, 4 patients were diagnosed after the biopsy (mean duration 6.7 months). Patients with MN and malignancy were older compared to those without malignancy (63.0 Vs 38.2 years) (P = 0.0054). There was no statistical difference in degree of proteinuria, focal segmental glomerulosclerosis lesions, and number of inflammatory cells in the study population. Conclusions: Higher prevalence (40%) of malignancy was associated with biopsy proven MN from Darling Downs which was statistically significant. Although age appropriate investigations are indicated in these patients, it may be prudent to actively look for evidence of underlying malignancy especially in elderly population given the concerns associated with immunosuppressive therapies.
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Microsponge: An advanced drug delivery system p. 108
Kumari Nidhi, Shubham Verma, Sokindra Kumar
Microsponge drug delivery system (MDS) was developed to deliver the pharmaceutical ingredients efficiently at the site of administration at a limited dose. MDS is based on pore size of sponges. The action of microsponges lasts up to 12 hours. MDS is also dependent on the physicochemical properties of the drug. These are used in bone tissue engineering, for reducing skin irritation and have a self-sterilisation property. This review provides an overview regarding the characteristics, methods of preparation, properties, evaluation, applications and limitations of MDS.
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Tailoring antituberculosis treatment regimen in a patient with serious adverse drug reactions to multiple drugs p. 112
MV S. Subbalaxmi, Suneel Kumar Bagadi, Sandeep Baddepuram, Radhika Soanker
Stevens–Johnson syndrome (SJS) and hepatitis are serious adverse drug reactions following the administration of anti-tuberculosis treatment (ATT). Here, we report a case of a young woman who developed hepatitis and SJS following ATT. Identifying the culprit drug and tailoring the appropriate regimen is a challenge to the clinicians. We described the clinical features, laboratory findings, hospital course and follow-up in a young female with tuberculosis, SJS and hepatitis in the case report. After the resolution of hepatitis, we confirmed the diagnosis of extrapulmonary tuberculosis and treated her after a cautious rechallenge with antitubercular drugs.
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Stevens–Johnson syndrome/toxic epidermal necrolysis overlap syndrome due to oral phenytoin p. 115
J Harikrishna, Vasili Pradeep, V Devika Reddy, M Krishna Kumar, A Surekha, Pilla S Surya Durga Devi, Alladi Mohan
Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but lethal manifestation of hypersensitivity reaction precipitated by certain drugs and viral infections. Among the drugs, it is more common with antibiotics, antiepileptics and nonsteroidal anti-inflammatory drugs. We report the case of a 14-year-old male who presented to the medicine out-patient department with a history of fever since the previous day. Four days before this, he had developed an episode of generalised tonic–clonic seizures and was initiated on oral phenytoin since then. Following admission to the medical intensive care unit, fever persisted on the 2nd day as well. The patient developed a maculopapular rash over face and trunk, ulceration over lips and skin peeling involving >10% <30% body surface area suggestive of SJS/TEN overlap syndrome. Oral phenytoin was stopped, and he was started on oral levetiracetam. He was treated with intravenous corticosteroids, topical antibiotics and symptomatic management. The patient recovered, skin lesions subsided and he discharged in a stable condition after 2 weeks of in-hospital stay. The present case documents the rare occurrence of SJS/TEN overlap syndrome as an adverse drug reaction caused by phenytoin. Early identification and stopping of offending drug will aid in better management of the patient.
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A case of predominantly chief cell parathyroid adenoma showing early washout of 99mTc MIBI detected by single-photon emission computerized tomography-computed tomography (SPECT-CT) p. 118
KB Sricharan, Rayudu Amrutha Lakshmi, VS Krishna Mohan, Gali Sai Chandana, Ranadheer Manthri Gupta, Mutheeswaraiah Yootla, Tekchand Kalawat
Parathyroid adenoma is a major clinical manifestation of primary hyperparathyroidism, which is usually diagnosed with invasive methods. In most of the cases delayed washout of radio tracer is appreciated on routine parathyroid scintigraphy. Exceptionally in some cases, early washout of tracer is seen which results in false negative parathyroid scintigraphy due to various factors such as expression of p glycoprotein, expression of multidrug resistant protein 1, small glands and presence of chief cells. We present a the case of a patient with parathyroid adenoma showed fast tracer clearance on delayed images but anatomically localized by the additional images using single-photon emission computed tomography-computed tomography (SPECT-CT). The anatomically localized structure further characterized by histopathological examination with presence of abundant chief cells, the cause of poor tracer retention and fast clearance in delayed images. Knowledge about differential presence of chief cells and oxyphilic cells in various parathyroid adenomas must be considered by nuclear physician to avoid false negative parathyroid adenoma.
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Anaesthetic management for electroconvulsive therapy during the second trimester pregnancy p. 122
KG Sreehari, Jeevan Babu, J Radha, T Jamuna, I Vamsi Krishna, V Rambhoopal Reddy
Electroconvulsive therapy (ECT) is a highly effective treatment for patients with psychotic disorders that do not respond to medication. Usually, many psychotropic drugs have a teratogenic effect on the foetus. ECT seems to be a relatively safe and effective choice of treatment in pregnant patients. Adverse events such as foetal heart rate reduction, uterine contractions and premature labour do occur during ECT. We report our experience with ECT in the treatment of first episode of mania with psychosis in a patient in second trimester of pregnancy.
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Successful outcome with outpatient acenocoumarol therapy for echocardiographically visible pulmonary thrombus p. 125
Karanam Gowrinath, K Padmanabha Kamath
Visualisation of thrombus in the main pulmonary artery through two-dimensional transthoracic echocardiography (TTE) without cardiovascular instability is rare. We report a unique case of echocardiographically diagnosed acute pulmonary embolism (PE) in an ambulatory patient with concomitant cor pulmonale secondary to idiopathic interstitial lung disease. The mobile thrombus was first visualised at the junction of bifurcation of the pulmonary trunk with left pulmonary artery through routine two-dimensional TTE. Two days later, the contrast-enhanced computerised tomographic scan of the chest showed the thrombus to be in the distal portion of the right pulmonary artery. Complete resolution of pulmonary thrombus was achieved with a 3-month course of outpatient oral anticoagulation treatment with acenocoumarol without recurrence of PE during the 1-year follow-up.
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Problem-based learning in medicine: Role of medical students and the attributed benefits p. 129
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
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Fasting samples for biochemical analysis-changing concepts p. 131
Naresh Yajamanam
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