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   Table of Contents - Current issue
October-December 2021
Volume 11 | Issue 4
Page Nos. 205-281

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Distinguishing viral and bacterial infections made easy through the food and drug administration approved technology-assisted diagnosis p. 205
Rajiv Mahajan
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Changing assessment scenarios: Lessons for changing practice Highly accessed article p. 206
Shaista Saiyad, Purvi Bhagat, Amrit Virk, Rajiv Mahajan, Tejinder Singh
Assessment is a process that includes ascertainment of improvement in the performance of students over time, motivation of students to study, evaluation of teaching methods, and ranking of student capabilities. It is an important component of the educational process influencing student learning. Although we have embarked on a new curricular model, assessment has remained largely ignored despite being the hallmark of competency-based education. During the earlier stages, the assessment was considered akin to “measurement,” believing that competence is “generic, fixed and transferable across content,” could be measured quantitatively and can be expressed as a single score. The objective assessment was the norm and subjective tools were considered unreliable and biased. It was soon realized that “competence is specific and nontransferable,” mandating the use of multiple assessment tools across multiple content areas using multiple assessors. A paradigm change through “programmatic assessment” only occurred with the understanding that competence is “dynamic, incremental and contextual.” Here, information about the students' competence and progress is gathered continually over time, analysed and supplemented with purposefully collected additional information when needed, using carefully selected combination of tools and assessor expertise, leading to an authentic, observation-driven, institutional assessment system. In the conduct of any performance assessment, the assessor remains an important part of the process, therefore making assessor training indispensable. In this paper, we look at the changing paradigms of our understanding of clinical competence, corresponding global changes in assessment and then try to make out a case for adopting the prevailing trends in the assessment of clinical competence.
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A comparative study of effects of 28-day exposure of bisphenol A and bisphenol S on body weight changes, organ histology, and relative organ weight p. 214
Parul Sharma, Maloy B Mandal, Richa Katiyar, Surya Pratap Singh, Hareram Birla
Context: Bisphenol A (BPA), a known endocrine disrupting chemical, is of widespread use in manufacturing of plastic products. Documenting ill health effects of BPA has led the plastic industrialists to replace BPA by its alleged safer alternative, bisphenol S (BPS). BPS belongs to the same chemical family and shares endocrine disrupting properties with BPA. Aims: We compared the effects of 28-day exposure of BPA and BPS on body weight changes, organ histology, and relative organ weight in rats. In addition, we detected BPA and BPS in the rat's blood serum. Settings and Design: Adult male albino rats were administered BPA (50 mg/kg/day) or BPS (50 mg/kg/day) or equivolume vehicle in different groups by oral gavage for 28 days. Subjects and Methods: The weight of each rat was noted at the commencement of the study and weekly afterward. On 29th day, the animals were sampled for whole blood and then sacrificed. The dissected out wet viscera were weighed and subjected to the standard protocol for histological examination. Serum samples were prepared and analyzed for the detection of BPA and BPS by high-pressure liquid chromatography. Statistical Analysis Used: Paired and unpaired Student's t-test, one-way ANOVA test, and Bonferroni test for multiple comparisons were used, as required for statistical analysis, and P < 0.05 was considered statistically significant. Results: Both BPA and BPS produced similar detrimental changes in body weight, histology of stomach, small intestine, lung, and kidney, and relative organ weight of lung and kidney. BPA and BPS detected in the serum of rats were nearly 45 times of the control. Conclusions: Present data suggest caution about the application of BPS as a substitute of BPA.
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Evaluation of health-related quality of life in adult patients on hemodialysis p. 221
Suman Sethi, Arshdeep Menon, Harmeet Pal Singh Dhooria, Vikas Makkar, Gurdeep Singh Dhooria, Rupesh Chaudhary
Background: Hemodialysis in end-stage renal disease patients causes disability in different domains of patient's lives, leading to impaired (quality of life [QOL]). Studies measuring the QOL in patients on renal replacement therapy are limited in the Indian scenario. Aims: To evaluate the QOL in adult patients on maintenance hemodialysis by applying the World Health Organization QOL (WHOQOL)-BREF scale. Material and Methods and Study Design: Health-related QOL was evaluated in 100 adult patients on maintenance haemodialysis for 3 months or more in Dayanand Medical College and Hospital, Ludhiana. The WHOQOL-BREF was applied in these patients and the physical, psychological, social, and environmental health domains were assessed. Results: Most common age group was 31–60 years (56%) with a mean age of 54.44 years, male: 74%. Patients with age more than 60 years had better QOL scores in the social domain which was statistically significant (P = 0.005). Male patients had better scores in all four domains and was significant in the social domain (P = 0.025). Married patients had better QOL scores in social domain. Duration of dialysis had a reverse correlation with QOL scores in physical domain with better scores in dialysis duration of <12 months. Frequency of dialysis did not significantly affect the QOL scores. QOL scores were directly related to the monthly family income in all four domains with the highest income group showing better scores (P < 0.05). Conclusion: The present study provided an insight into the factors that affect the QOL in hemodialysis patients. Patients with age >60 years had better QOL scores in the social domain. Female gender, low serum proteins, HD duration of more than 1 year, and low monthly income were found to be associated with impaired QOL domains in patients undergoing maintenance hemodialysis.
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Anemia and nutritional status in tuberculosis patients p. 226
Sandeep Chhabra, Anil Kashyap, Monica Bhagat, Rajesh Mahajan, Suman Sethi
Introduction: Anemia is a common complication of pulmonary tuberculosis (TB). Nutritional deficiency and malabsorption syndrome can deepen the severity of anemia. The aim of the present study was to study anemia and nutritional status in patients with TB at a tertiary care center. Materials and Methods: All patients diagnosed with TB (pulmonary and extrapulmonary), registered with Revised National TB Control Programme (RNTCP), taking DOTS regimen, attending the outpatient department as well as those admitted in the medicine and chest units of a tertiary care hospital, were enrolled in the present study. Results: Anemia was more common between the age groups of 51 and 60 years, with distribution of males (87 [58%]), patients with diabetes (49 [32%]), and hypertensive patients (29 [19.3%]). In our study, 48 (85.7%) out of 56 patients diagnosed with extrapulmonary TB were found to have anemia; similarly, 77 (88.5%) out of 87 patients diagnosed to have pulmonary TB were anemic. Anemia of chronic disease (128 [97.17%]) was higher when compared to that of those with iron-deficiency anemia (3 [2.29%]). According to body mass index (BMI), 135 (90%) patients were underweight; according to mid-arm circumference (MAC), 131 (87.3%) patients had severe malnutrition; and according to waist–hip ratio [WHR], 96 (64%) patients were underweight. Conclusion: Anemia was common in males and alcoholics, and there was a high prevalence of anemia of chronic disease. In addition, anemia was associated with high erythrocyte sedimentation rate and C-reactive protein. High proportions of TB patients (pulmonary and extrapulmonary) were classified as underweight and malnourished on the basis of different parameters (BMI, MAC, and WHR); in addition, the degree of malnutrition was higher in patients with anemia than in those without.
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Effect of women's and partners' education on maternal health-care services utilization in five empowered action group States of India: An analysis of 13,443 women of reproductive age p. 231
Arvind Kumar Yadav, Bhavna Sahni, Dinesh Kumar, Kiran Bala, Anuradha Kalotra
Background: Suboptimal utilization of maternal health-care services is a perennial problem in Empowered Action Group (EAG) states. This study examines role of women's and partners' education on usage of antenatal, postnatal care (PNC), and skilled birth attendance in these states. Methodology: National Family Health Survey-4 (2015–2016) data for 13,443 women in reproductive age group of 15–49 years in Bihar, Madhya Pradesh (MP), Odisha, Rajasthan, and Uttar Pradesh (UP) were analyzed using logistic regression. Results: Increasing level of education had a significant impact on utilization of antenatal services in all states, highest and lowest odds being observed with higher and primary level of partner's education, respectively. Skilled birth attendance universally showed rising trend with increasing women education, while it remained substantially low even at higher level of partner's education. For PNC, utilization increased with increasing level of maternal education. While significantly lower odds of PNC were seen with primary level of partner education in Rajasthan and UP, partner's secondary education showed positive and significant association in Bihar, Rajasthan, and UP. At higher level of partner education, positive and significant effects on PNC were observed only in Bihar, MP, and UP. Conclusions: Universal education is vital to attain sustainable development goals at the grassroot level, which is happening relatively slowly in the EAG states.
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Role of 4-H serum lipase level in predicting postendoscopic retrograde cholangiopancreatography pancreatitis p. 238
Sultana Parvin, Md Samiul Islam, Md Golam Azam, Touhidul Karim Majumdar, Shireen Ahmed, Taslima Zaman, Rajib Dutta
Introduction: Serum amylase level can rise asymptomatically after endoscopic retrograde cholangiopancreatography (ERCP). Thus, its assay can lead to overprediction of post-ERCP pancreatitis (PEP). Lipase assay is used to diagnose other forms of pancreatitis but usually not for PEP. Objectives: The aim of this study was to predict whether lipase may be of better use for the early prediction of PEP. Methods: One hundred and twenty-five consecutive ERCPs performed over a period of 1 year and 9 months were observed. On admission (baseline) and after ERCP at 4 and 24 h, serum amylase and lipase were measured. Based on sensitivity and specificity from the receiver operator characteristic (ROC) curve, optimal cutoff levels for the enzyme, serum lipase, and amylase levels were employed to predict PEP. Results: Out of 125 patients, 26 (20.8%) developed PEP. In multivariate analysis, young age, suspected sphincter of Oddi dysfunction, recurrent pancreatitis, and needle papillotomy were significant risk factors. Considering the optimum cutoff level (single value with the best sensitivity and specificity), both the enzyme amylase and lipase evaluated at 4 h were significant (Chi-square test: P =0.0001 for both the enzymes). However, multivariate regression analysis and levels of enzymes at different cutoff values in the ROC found that 4-h lipase levels were more (about 4 times) increased of the upper limit of normal range than amylase levels (1.19 times). Conclusion: The enzyme, serum amylase, and lipase evaluated at 4 h after ERCP were satisfactory predictors for PEP. However, when compared, serum lipase was more reliable than amylase.
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Role of glutathione s-transferase M1 and glutathione S transferase theta 1 gene polymorphism, histopathological, and immunohistochemistry in carcinoma breast p. 243
Vijay Kumar Bodal, Medhavi Dhir, Kuldip Singh Ahi, Sarbhjit Kaur, Malkiat Singh, Lachhima Bandhari
Background: Breast cancer is the most common invasive cancer in females in developing countries such as India. It is the most common malignancy in females in the Punjab state. Objectives: (1) The purpose of this study was to calculate the prevalence of the four subtypes of breast cancer based on molecular classification and (2) to determine the association of polymorphisms in Glutathione S-Transferase M1 (GSTM1) and Glutathione S transferase theta 1 (GSTT1) gene in carcinoma of the breast with histopathological grading. Materials and Methods: This study analyzed histologically confirmed 100 cases of carcinoma breast; immunohistochemistry and reverse transcription polymerase chain reaction molecular tests were performed for further grading, molecular typing, and gene polymorphism. Results: Out of 24 Grade I tumors, 18 (75.00%) expressed the GSTM1 gene and 6 (25.00%) were negative. Out of 48 Grade II tumors, 30 (62.50%) expressed the GSTM1 gene and 18 (37.50%) were negative. Out of 28 Grade III tumors, 8 (28.57%) expressed the GSTM1 gene and 20 (71.43%) were negative. Out of 24 Grade I tumors, 17 (70.83%) expressed the GSTT1 gene and 7 (29.17%) were negative. Out of 48 Grade 2 tumors, 28 (58.33%) expressed the GSTT1 gene and 20 (41.67%) were negative. Out of 28 Grade III tumors, 8 (28.57%) expressed the GSTT1 gene and 20 (71.43%) were negative. Conclusion: Our study shows that polymorphism of both GSTM1 and GSTT1, either individually or in combination, influences the risk of developing carcinoma due to DNA damage caused by many factors including environmental and genetic.
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Gender variations in pharmacokinetics of paracetamol in hausa/fulani ethnic group in Northwest Nigeria – A two-stage approach p. 248
Umar Muhammad Tukur, Shaibu Oricha Bello
Background: Paracetamol is one of the most commonly used drugs worldwide and has been linked to drug-related liver damage, even when taken at recommended doses. Ingesting the upper limit of recommended doses of the drug produced a doubling of mortality when compared to not taking the drug. Acetaminophen ingestion has been implicated in the development of angioedema, the exasperation of asthma, and urticaria in patients with aspirin intolerance. Aim: This study aimed at assessing gender variations in the pharmacokinetics of paracetamol in Hausa/Fulani, the most populous ethnic group in Nigeria and determines a possibility of toxicity in the group. Methods: It was an exploratory study involving twenty participants selected by criterion sampling who satisfied inclusion criteria. They were fasted 11-h preceding acetaminophen administration to 3 h after administration. A single dose of acetaminophen, 1 g orally with 300 ml of distilled water, was administered at 8 A. M. Blood was obtained before the administration and 15, 30, and 45 min, and 1, 2, 3, 4, 5, and 6 h after the administration. Acetaminophen plasma concentrations were determined by validated reverse-phase high-performance liquid chromatography Food and Drug Administration guidelines. Results: Six out of 19 (31.6%) participants have higher than maximum therapeutic plasma concentration (>20 μg/ml). Pharmacokinetics parameters were higher in males except for clearance and volume of distribution. Conclusion: Clearance from the plasma tends to be more for females than their male counterparts. A good proportion of Hausa/Fulani is prone to acetaminophen toxicity at a therapeutic dose.
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Evaluation of salivary alpha-amylase levels for determining stress variations in patients undergoing spinal anesthesia for infra-umbilical surgery p. 253
Shagufta Bano, Renu Garg, Meenu Agrawal, Ruchi Agarwal, Ashutosh Kumar, Praveen Prashant
Aims and Objectives: To evaluate salivary alpha-amylase (sAA) levels for determining stress variations in patients undergoing spinal anesthesia for infra-umbilical surgery. Materials and Methods: One hundred and twenty subjects (age 18–65 years) planned for infra-umbilical surgery under spinal anesthesia were included and allocated to Groups A and B ensuring age and sex matching. In both groups, sAA levels (S1 to S4) were assessed sequentially at different times (E1 to E4). S1 and S2 were collected on the evening before surgery (E1) and in the preoperative room on the day of surgery (E2), respectively. Thereafter, in Group A, S3 and S4 were collected before (E3) and 15 min after spinal anesthesia (E4), following which intravenous Midazolam was given. In Group B, intravenous Midazolam was administered first, S3 was collected 5 min later (E3), spinal anesthesia was administered and S4 was collected after15 min (E4). Results: In both groups, sAA levels showed a mild increase from E1 to E2 (not significant). Thereafter from E2 to E3 and E3 to E4, a significant sharp rise in sAA levels in Group A and a significantly acute decline in Group B was noted. Mean sAA levels in Group A were higher as compared to group B (P < 0.005) in E3 and E4. Conclusion: Sequential documentation of increase in sAA levels in our study, starting with the baseline levels, presents a comprehensive report of the stress that the patients experience during preoperative period and reinforces the need of anxiolytic before spinal anesthesia.
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Emergence of OXA-833 in Proteus species at a tertiary care hospital in Dhaka, Bangladesh p. 258
Hasnatul Jannat, SM Shamsuzzaman, Md Abu Faisal
Context: Proteus species are liable for multitude of infections and associated with resistance to routinely used antibiotics even to reserve drugs such as carbapenems. Aims: The aim of this study was to detect the presence of MBL producers, including blaOXA-833 gene in Proteus spp. along with their antibiotic resistance pattern. Settings and Design: This cross-sectional study was conducted in the Department of Microbiology of a tertiary care hospital of Bangladesh during July 2018 to June 2019. Subjects and Methods: Proteus spp. was isolated from a total of 500 samples. Antibiotic susceptibility was performed by disk-diffusion technique. Minimum inhibitory concentration (MIC) of imipenem was determined by agar dilution method. Carbapenemase producers were phenotypically detected by double disc synergy (DDS) test, combined disc (CD) assay, and modified Hodge test (MHT). Carbapenemase genes (blaKPC, blaVIM, blaIMP, blaNDM-1, blaOXA-23, blaOXA-48-like/blaOXA-833, and blaOXA-58) among imipenem-resistant Proteus spp. were detected by polymerase chain reaction (PCR). Sequencing was performed to differentiate OXA-833 from OXA-48-like gene by capillary method, and the nucleotide sequence of OXA-833 has been deposited to GenBank. Results: Ten (25%) imipenem-resistant isolates were detected during disk-diffusion technique, among them 60%, 70%, 50% carbapenemase producers were detected by DDS test, CD assay, MHT, respectively, and 70% by PCR. A significant increase in MIC was found between 8 and ≥128 μg/ml to imipenem. PCR revealed that 40% imipenem-resistant isolates were positive for blaNDM-1 and blaVIM followed by 20% for blaOXA-48-like/blaOXA-833 and blaOXA-23, respectively. Sequencing of blaOXA-48-like gene established the OXA-833 variant of class D carbapenemase encoding gene. Conclusion: The results of this study showed the presence of high proportion of carbapenemase enzyme-producing Proteus spp. in Bangladesh. blaOXA-833 is emerging in Bangladesh.
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Comparison of tocilizumab and high-dose methylprednisolone pulse on outcomes in severe corona virus disease-2019: TAME-COVID, a retrospective multicentric study p. 263
Vipin Kumar, Anil Kumar Kashyap, Simran Kaur, Mary John, Raminderpal Singh Sibia, Vishal Chopra, Tanvi Singla, Jyoti Jindal, Suman Sethi, Sandeep Chhabra, Amit Berry, Harmeet Singh Dhooria, Akashdeep Singh, Vikas Garg, Dinesh Jain, Rajesh Mahajan, Parshotam Lal Gautam, Vandana Midha, Bishav Mohan
Background: India recently encountered fierce second wave of coronavirus disease (COVID-19), and scarcity of novel medications added to the management challenges. Various studies have highlighted the effectiveness of tocilizumab and high-dose steroids in severe COVIDs, but none has compared their efficacy. Materials and Methods: This retrospective multi-centric analysis compares intravenous tocilizumab (8 mg/kg/day, maximum dose-800 mg), and intravenous Methylprednisolone Pulse (MPS-1 g/day for 3 days) in severe COVID-19. Both the groups had additionally received the standard of care COVID treatment as per protocol. Outcomes were assessed at 30 days. Results: A total of 336 patients, with 249 receiving MPS and 87 receiving tocilizumab were compared. Majority of these were males (72.9%) with a mean age of 57.4 ± 13.6 years. Diabetes was the most common comorbidity. Patients in both groups had comparable age distribution, comorbidities, presenting mean-arterial pressures, d-Dimer levels, serum ferritin, serum leukocyte-dehydrogenase, and procalcitonin. However, the tocilizumab group had more number of males, higher incidence of coronary artery disease, more tachypnea and leukocytosis, more number of patients with severe acute respiratory disease syndrome (PaO2/FiO2 ratio <100), and higher C-reactive protein levels at presentation. Both groups had comparable adverse events' profile. Tocilizumab group had lesser requirement of invasive ventilation than MPS group (17% vs. 29%, P = 0.038), however mortality at the end of 30 days follow-up was similar (36% vs. 34% respectively; P = 0.678). Conclusions: Tocilizumab decreased the need for invasive ventilation in severe COVID-19; however, it did not translate to improved survival. A planned prospective randomized study is recommended in this respect to compare their efficacy.
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Angle closure with patent laser peripheral iridotomy - An unusual complication p. 270
Saswati Sen, Matuli Das, Tej Mehar Singh Chugh
A 41-year-old female presented with diminished vision in both eyes with recurrent episodes of pain, redness, and watering. With a provisional diagnosis of primary angle-closure glaucoma in the left eye and primary angle closure in the right eye, anti-glaucoma medications were started in the left eye and laser peripheral iridotomy was done in both eyes. Follow-up showed patent iridotomy in both eyes and dilated fundoscopy revealed total cupping in the left eye. Next day, the patient had angle closure in the right eye. On medical management, symptoms subsided but intraocular pressure (IOP) was still raised. Right eye trabeculectomy with cataract surgery was done. Vision was restored to 6/9 with IOP of 12 mmHg after 2 weeks. The event was considered to be precipitated because of plateau iris configuration which is an anatomical variant of angle in angle-closure patients. This proves patent laser iridotomy is not always a ticket to dilatation and one should be aware of all possible complications.
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Recurrent ST-Elevation myocardial infarction in a single coronary artery: A rare anomaly p. 273
Monika Bhandari, Shweta Vohra, Pravesh Vishwakarma, Akshyaya Pradhan
Single coronary artery anomalies are those where the entire myocardium is supplied by an artery arising from one ostium. It is a rare coronary anomaly and has been there in literature ever since 1867. Over the years, this has intrigued anatomists and physicians whether its presence has life-threatening consequences or is mere a benign entity. Most of the cases are generally silent except for the interarterial course variants which are associated with sudden deaths. We report the case of a patient presenting with recurrent inferior wall ST-elevation myocardial infarction who was found to have a single coronary artery on angiography. The patient underwent primary percutaneous coronary intervention and uneventful further course.
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Dandy-Walker variant associated with bilateral congenital cataract p. 277
Gopal Singh Charan, Gursharan Singh Narang, Arshpuneet Kaur, Ekamjot Kaur
Dandy-Walker Syndrome (D-WS) is a rare disorder with an incidence of 1%–2% of all central nervous system anomalies. The diagnosis can be challenging, especially in the prenatal period. Here, we present an extremely rare case of D-WS associated with bilateral congenital cataracts. A 36 weeks and 6 days old male baby presented with a Dandy-Walker variant associated with bilateral congenital cataract. Ophthalmological examination revealed microphthalmos and congenital cataracts present in both eyes with sclerocornea, iris coloboma, and zone 3 retinopathy of prematurity involving only the right eye. However, the right eye was salvageable. Skull transillumination was negative with no cranial bruit. He was admitted to the neonatal intensive care unit with breathing difficulties, maintained SpO2 with oxygen through prongs, and noninvasive continuous positive airway pressure for 7 days. He had two episodes of hypoglycemia with hypothermia. There was no significant finding in sepsis evaluation. The abdominal ultrasonography was normal. Echocardiogram was suggestive of patent foramen ovale. Mother's torch panel tested positive for cytomegalovirus immunoglobulin G antibodies. Magnetic resonance imaging brain suggested variant D-WS with dilation of cerebellar fossa and occipital lateral ventricle horn and lack of usual corpus callus structure. Intravenous antibiotics cefotaxime and amikacin were administered along with fluid supplementation. He was shifted to mother feed. The neonate was referred to the pediatric surgery department for further management.
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Practical manual of pharmacology for medical students: Book review p. 280
Rajiv Mahajan
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