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   Table of Contents - Current issue
October-December 2020
Volume 9 | Issue 4
Page Nos. 191-253

Online since Tuesday, January 5, 2021

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Managing type 2 diabetes during COVID-19: Unanswered questions and key issues Highly accessed article p. 191
Sudha Vidyasagar
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Effects of intravenous clonidine or dexmedetomidine on haemodynamic responses to laryngoscopy and endotracheal intubation and sedation: A randomised double-blind clinical efficacy study p. 194
Aloka Samantaray, Mangu Hanumantha Rao, R Naga Divya, Shameem Sunkesula
Background: Laryngoscopy and tracheal intubation (LTI) is associated with undesirable haemodynamic (HD) responses. Both clonidine and dexmedetomidine have been tried to attenuate this HD response. The present study was to assess whether single pre-induction dose of intravenous clonidine (2 μg/Kg) or dexmedetomidine (1 μg/Kg) is more efficient to attenuate the HD response to LTI. Methods: Sixty patients belonging to American Society of Anesthesiologists Grade I and II were randomly divided into two groups: group C (clonidine 2 μg/Kg) and Group D (dexmedetomidine 1 μg/Kg). Study drug was given as an infusion over 10 Min before induction of anaesthesia followed by standardised anaesthetic technique. Heart rate (HR) and blood pressure (BP) were studied at baseline, before study drug infusion (BSD), after study drug infusion, before LTI and at 1, 2, 3, 5 and 10 m in after intubation. Sedation score was analysed BSD, after study drug infusion and at the end of surgery Results: This study revealed suppression of HR and BP at all time points in both the groups without any significant difference in suppression of HR between the groups. The magnitude of fall in BP in the clonidine group is more compared to the dexmedetomidine group before LTI and at 3, 5, and 10 min after tracheal intubation. The patients in the dexmedetomidine group were more sedated than in the clonidine group at the end of the study drug infusion. Conclusions: Both clonidine and dexmedetomidine were effective in attenuating HD response to LTI. Dexmedetomidine appears to be superior to clonidine in maintaining stable HD.
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A study of bacterial pathogens obtained from various samples in a tertiary care hospital and their antimicrobial susceptibility patterns Highly accessed article p. 200
N Ramakrishna, R Jayaprada, KK Sharma, S Yamini, VS Srikala
Background: Antimicrobial resistance (AMR) is of great concern in recent years as it is posing a global threat. The present study was undertaken to identify the prevalence of common bacterial isolates and their antimicrobial susceptibility patterns and to tackle the AMR by strict implementation of antibiotic stewardship programme (AMSP). Methods: We prospectively studied the microbiome and its antibiotic susceptibility patterns from various clinical samples at our tertiary care hospital, from January to June 2018. All samples were processed as per standard protocols. Antibiotic susceptibility testing was performed using Kirby–Bauer disc diffusion method as per the Clinical and Laboratory Standards Institute 2016 guidelines. Results: Escherichia coli was the predominant organism followed by Klebsiella spp, Acinetobacter spp and Pseudomonas spp. More than 50% resistance was observed to third generation cephalosporins and quinolones in all Gram negative isolates. Methicillin-resistant Staphylococcus aureus and methicillin-resistant coagulase negative Staphylococcus constituted 41% and 54% respectively. Vancomycin intermediate-sensitive S. aureus/vancomycin resistance S. aureus were not evident. Vancomycin-resistant enterococci (n = 10) were also isolated, but all were sensitive to linezolid. Conclusions: The present study highlights the alarming development of multidrug-resistance to almost all the drugs with a very few exceptions. Continuous and periodic evaluation of bacteriological profile and its susceptibility patterns are helpful in formulating appropriate antibiotic policy to tackle the AMR.
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Incremental value of post-high dose therapy I-131 scan over pre.therapy diagnostic I-131 scan in patients with differentiated thyroid cancer: Experience from a tertiary care centre in South India p. 206
Chandra Teja Reddy Singareddy, Ranadheer Gupta Manthri, VS Krishnamohan, KB Sricharan, Tekchand Kalawat, Narendra Hulikal
Objective: Objective of this study is to establish the incremental value of post-high dose therapy I-131 whole body scintigraphy (WBS) over diagnostic pre-therapy I-131 WBS in the detection of radioiodine avid foci, staging and change in the management in patients with differentiated thyroid carcinoma post-total thyroidectomy. Methods: We retrospectively studied 93 post-total thyroidectomy patients with well differentiated thyroid cancer (mean age 47 [range 18–78] years; 72 females) who underwent diagnostic dose pre-therapy? I-131 WBS and post-high dose therapy? I-131 WBS from January 2017 to June 2018 were included. Discordance rate of pre-therapy? I-131 WBS findings with post-therapy? I-131 WBS was calculated. Results: Post-therapy I-131 WBS revealed additional radioiodine avid foci not detected on pre-therapy? I-131 WBS in 16 (17.2%) patients. Upstaging was more common in patients =55 years (8 of 23, 34.8%) when compared to patients <55 years (1 of 70, 0.014%). In 13/93 patients (13.9%) who were considered as low risk on pre-therapy? I-131 WBS, 10 patients (10.7%) were found to be intermediate risk and 3 patients as high risk on post-therapy I-131 WBS. Conclusion: Post-therapy? I-131 WBS revealed new foci in 17.2% patients and clinical upstaging occurred in 9.6% of patients compared to pre-therapy I-131 WBS. There is a significant improvement in the detection of radioiodine avid foci overall and also metastatic lymph nodes by doing post-therapy? I-131 WBS. We suggest that post-therapy? I-131 WBS should be routinely done as it had an incremental role over pre-therapy? I-131 WBS in establishing the true extent of tumour burden, in upstaging the disease and thereby planning adequate hormone suppression to attain target thyroid stimulating hormone levels.
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A study of Trichomonas vaginalis and risk factors in women of reproductive age attending health facilities in Okene metropolis, Kogi State, Nigeria p. 213
Joshua Idakwo, Clement Ameh Yaro, Queen Pheobe Akoh, Rukayat Ovayioza Raji
Background: This study was conducted to determine the prevalence and risk associated with Trichomonas vaginalis amongst women in Okene metropolis, Kogi State. Methods: High vaginal swabs were collected from females of reproductive age groups using swab sticks from February to May 2019 and were examined microscopically using wet mount preparation and were confirmed with Dorset culture method. Structured questionnaires were administered to assess the risk factors. Results: A total of 180 (40.7%) women were infected with T. vaginalis. The General Hospital had the highest prevalence of 80 women (42.1%), whereas the least was from Oyiza Hospital (66 women, 39.3%). The age group of 21–30 years (65, 55.1%) had the highest prevalence, whereas the age group of 14–20 years (20, 25.0%) had the least prevalence. Divorced women, women with multiple partners and those that do not use condom are at higher risk of infections. Conclusion: T. vaginalis is endemic amongst women in Okene metropolis, Kogi State, with an overall prevalence of 40.7%. Proper awareness on this disease should be heightened to help reduce the burden of infection.
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Evaluation of chronic idiopathic urticaria patients with autologous serum skin test p. 218

Background: Chronic idiopathic urticaria (CIU) is a common disabling disorder. Sparse published data are available on the utility of autologous serum skin test (ASST) in patients with CIU from south India. Methods: We prospectively studied 81 patients with CIU and report their demographic characteristics, clinical spectrum and proportion of patients with positive ASST. Results: Their mean age was 35.2 ± 12.4 years; there were 50 (62%) females. ASST was positive in 39 (48%) patients.Daily attacks of urticaria were seen in 50 (62%), atopy was present in 18 (22%) and angioedema was present in 14 (17%) patients. Their median [interquartile range (IQR)] duration of disease was 28 (6-34) months and median (IQR) duration of single wheal was 20 (10-90) minutes.On univariate analysis, longer duration of single wheal, higher frequency of attacks and presence of angioedema were found to be associate with a positive ASST. Conclusions: ASST was positive in 39 (48%) patients with CIU. ASST-positive individuals are younger, had a statistically significant longer duration of single wheal (P = 0.001), higher frequency of attacks (P = 0.039) and occurrence of angioedema (P = 0.018). ASST positive patients had severe form of the disease.
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Clinical profile of hypertensive patients presenting to the emergency department p. 224

Background: The clinical profile of patients with hypertension presenting to emergency is understudied and unknown in developing countries like India. Method: We prospectively studied the clinical profile, target organ damage, laboratory parameters and imaging parameters in 532 patients with hypertension (461 [86.7%] previously known hypertensives and 71 [13.3%] newly diagnosed hypertensives) presenting to the emergency department at our tertiary care teaching hospital. Results: Their mean age was 57 ± 13.2 years; 65.6% were males. Neurological deficits (n = 164; 30.8%) were the commonest presenting symptom followed by chest pain (n = 143; 26.9%) and dyspnoea (n = 109; 20.5%). Hyponatremia (n = 188; 35.3%) and hyperkalemia (n = 59; 11.1%). Cerebrovascular accidents were the commonest target organ damage. Higher blood pressure at presentation and at 8 hours were associated with fatal outcomes. Conclusion: Target organ damage was higher in known hypertensives with poor drug compliance and higher age groups particularly males. Cerebrovascular accidents were the commonest mode of presentation.
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Alternobaric vertigo – An uncommon medical hazard p. 229

Alternobaric vertigo (AV) is a type of barotrauma of the middle ear which occurs if the asymmetric middle ear pressure in both sides. If pressure differential exceeds a threshold, asymmetric stimulation of the labyrinth will occur, leading to vertigo, called as AV. The classical presentations is transient vertigo which appear sudden onset during the time of diving or flying, typically when ascends or when a Valsalva manoeuvre is performed. Other symptoms associated with AV are nausea, vomiting, disorientation and generalised malaise. If the descent or ascent is reversed immediately, vertigo suddenly disappears or may cause sudden spatial disorientation which may lead to catastrophic outcome. AV is often overlooked but this mishap should not be ignored as it may lead to fatal accident. The patient should be properly counselled for aetiology and nature of AV and its potential risks including aspiration and death. This review article focuses on the prevalence, etiopathology, clinical presentations and current management of the AV amongst underwater divers and aviators. This article will surely increase awareness amongst the clinicians and people those are practicing underwater diving or in aviation and help them to resolve this problem to a great extent.
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Diagnosis of antiphospholipid syndrome following snakebite p. 235

Isolated prolongation of activated partial thromboplastin time (aPTT) is an exceedingly rare finding in the event of a snakebite from a haemotoxic snake. Herein, we present the case of a 25-year-old asymptomatic female following snakebite. Laboratory testing revealed prolonged aPTT which persisted inspite of administration of 30 vials of antisnake venom. Further diagnostic testing eventually led to the diagnosis of antiphosholipid syndrome.
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Anaesthetic management of a parturient patient with peripartum cardiomyopathy p. 238

Peripartum cardiomyopathy (PPCM) is a rare life-threatening clinical entity of unknown aetiology. The hallmark of the disease is the onset of decreased left ventricular ejection fraction either in late pregnancy or puerperium. The clinical presentation and the basic and intensive interventional strategies of the disease are more or less similar to that of dilated cardiomyopathy due to any other cause. Apart from intensive care management, these patients also require anaesthetic intervention for the management of painless labour for either vaginal or operative delivery. Favourable maternal and foetal outcomes require haemodynamic goals to be always kept in mind while choosing the technique and drugs to provide anaesthesia to the patients with PPCM. We report the case of a patient with PPCM requiring emergency lower segment caesarean section who was managed with titrated epidural anaesthesia.
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An unusual and interesting case of phaeochromocytoma p. 242

Phaeochromocytomas are catecholamine-secreting tumours that arise from chromaffin cells of the adrenal medulla. The common age of onset is between the third and fifth decades of life. Commonly adrenal phaeochromocytoma secretes epinephrine (its metabolite metanephrine). Extra-adrenal phaeochromocytoma secretes norepinephrine and normetanephrine. Herein, we present the case of a 13-year-old male patient who presented with palpitations, giddiness and increased appetite for 3 days. He was found to have de novo hypertension. Imaging showed bilateral adrenal masses. Biochemical analysis revealed normal levels of plasma and 24-h urinary metanephrines. On further evaluation, serum metanephrine-fractionated assay showed marked elevation in normetanephrine levels. The patient was initially managed medically with alpha- and beta-blockers. After controlling blood pressure, adrenalectomy was done. The histopathological examination was suggestive of phaeochromocytoma. Adrenal phaeochromocytoma-secreting normetanephrines are a rare entity. On reviewing literature, only a few cases of this type were published.
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Digital learning in medical education p. 245

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Renin-angiotensin axis as a trigger for immune dysregulation in COVID-19 p. 247

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Authors' response p. 249

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Journal scan p. 251
V Suresh, AR Bitla
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Erratum: Evaluation of hepatitis B vaccination status and immune response among clinicians in a tertiary care hospital in South India p. 253

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