Journal of the Association of Physicians of India

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Normative Cognitive Scores in Western India, Stratified by Age, Rurality, Cognitive Domains, and Psychiatric Comorbidity
(Journal of Indian Medical Association, 2024-07) Sundar, Uma; Mukhopadhyay, Amita; Sundar, Suresh; Shah, Nilesh
Background and objectives: Indian ethnic and educational diversities necessitate obtaining normative cognitive data in different populations. We aimed to evaluate cognitive scores using a Marathi translation of the Kolkata cognitive battery (KCB) and to study the association of KCB components with depression and sociodemographic variables. Materials and methods: We studied 2,651 individuals aged ?40 years without preexisting neuropsychiatric conditions from urban (Mumbai) and rural districts of Maharashtra. For each component of KCB, the lowest 10th percentile score was used to define cognitive impairment. Results: We studied 1,435 (54%) rural and 1,216 (46%) urban residents equally divided by gender (1,316 women and 1,335 men), average age 54 years. KCB scores were significantly lower with female sex, older age, illiteracy, and depression. The largest effect sizes attributable to these factors were in the domains of calculation (gender), visuoconstructional ability (VCA) (rurality), and verbal fluency (VF) (depression). Scores remained significantly lower in rural residents after controlling for age, sex, and education, particularly for VCA, immediate recall, and calculation. Conclusion: This Marathi KCB, having been validated on large urban as well as rural samples, may be used to study cognition in Marathi-speaking populations with appropriate cutoffs tailored to the degree of urbanization of the population.
Determination of Sample Size for Different Clinical Study Designs
(Journal of Indian Medical Association, 2024-07) Verma, Vivek; Mishra, Ashwani Kumar; Narang, Rajiv
Aim: This study illustrates parameters, procedures, and calculations for the statistical determination of sample size for different clinical study designs. Materials and methods: In any research process, the sample size is an important consideration for the implementation of the planned study. From time to time, literature on sample size has been documented in the medical literature. However, the situations covered under them lack comprehensiveness in terms of different study designs, demonstration of calculations, and overreliance on statistical software. Results: The present study provides various facets of sample size determination, such as prerequisite parameters, mathematical formulation, and calculations for clinical study designs [descriptive studies, randomized controlled trials (RCT), correlational studies, comparison of multiple outcomes, survival analysis, sensitivity, and specificity], which will be quite useful. Conclusion: This communication will be a good education and learning source for medical professionals to pick and choose a specific scenario and estimate the sample size.
Prevalence and Association of Risk Factors According to Liver Steatosis and Fibrosis Stages among Nonalcoholic Fatty Liver Disease Patients with Type 2 Diabetes Mellitus in India: A Cross-sectional Study
(Journal of Indian Medical Association, 2024-07) Panikar, Vijay; Gupta, Apoorva; Nasikkar, Nikhil; Joshi, Shashank; Walwalkar, Sanhita; Sachdev, Ishita; Tiwaskar, Mangesh; Panikar, Krish; Mahajan, Aditi; Deogaonkar, Narayan; Vadgama, Jimit; Tuteja, Harshpreet; Khan, Mujtaba; Kader, Parveen
Introduction: Type 2 diabetes mellitus (T2DM) and nonalcoholic fatty liver disease (NAFLD) are linked to the global diabetes epidemic, leading to increased disease progression and adverse health outcomes. The renaming of NAFLD to metabolic dysfunction-associated steatotic liver disease (MASLD) at the 2023 European Association for the Study of the Liver Congress highlights the complex relationship between metabolic disorders and liver health. Taking this into consideration, we aimed this study to identify prevalence and risk factors associated with the stages of NAFLD in individuals with T2DM in the Indian population. Materials and methods: This observational, cross-sectional study was conducted on 1,521 T2DM patients at Dr Panikar’s Speciality Care Centre, Mumbai, between September 1, 2022 and October 31, 2022. Demographic parameters such as age, gender, height, weight, and anthropometric parameters such as body mass index (BMI) and waist circumference were measured. Liver fibrosis and steatosis stages were identified by vibration-controlled transient elastography (VCTE) using FibroScan®. Results: The prevalence of liver steatosis was 75.1% among the 1,521 diabetes cases [S0 (24.9%), S1 (15.1%), S2 (24%), and S3 (36%)], whereas the prevalence of liver fibrosis was 28.0% [F0 (72%), F1 (19%), F2 (5%), F3 (1.5%), and F4 (3.4%)]. The S1 (p = 0.012), S3 (p = 0.001), F1 (p = 0.001), and F2 (p = 0.001) grades showed significant gender-related changes, demonstrating a positive connection. Furthermore, waist circumference was associated with disease severity in both liver steatosis and fibrosis stages (p = 0.001), but BMI was solely associated with the degree of steatosis (p = 0.001). The mean age differences between these categories, however, did not reach statistical significance (p-values of 0.149 and 0.078, respectively, for the steatosis and fibrosis grades). Conclusion: The study reveals a high prevalence of NAFLD (steatosis and fibrosis) in T2DM patients, increasing the risk of advanced fibrosis. In T2DM patients with risk factors including waist circumference and BMI, appropriate screening and intervention are required.
An Observational Study of Various Risk Factors and Etiological Profile in Patients with Lower Back Pain at Tertiary Care Center
(Journal of Indian Medical Association, 2024-07) Kumawat, Banshi Lal; Kaur, Inderjot; Parashar, Vasudev Sharan
Objectives: The study aimed to analyze the risk factors and etiological profile of lower back pain (LBP) among patients attending a neurology outpatient department at a tertiary care center. Materials and methods: A cross-sectional observational study was conducted, involving 170 patients, aged over 18, presenting with LBP between March and August 2023. Sociodemographic and lifestyle data were collected, and diagnostic investigations, including X-ray and magnetic resonance imaging (MRI), were performed. Patients were categorized into acute and chronic LBP groups for analysis. Results: Age—acute LBP was more prevalent in younger patients (<35 years), while chronic LBP was predominant in older age-groups (?55 years). Gender—females showed a higher prevalence of LBP compared to males, with chronic LBP more common among females. Triggering events—heavy weightlifting was a significant trigger for chronic LBP, while coughing/sneezing was common in acute LBP. Occupation—patients with physically exerting jobs were more prone to acute LBP, while chronic LBP was prevalent among homemakers and those with no work. Body mass index (BMI)— obesity and overweight were associated with chronic LBP. Medication—chronic LBP patients were more likely to be on medication compared to acute LBP patients. MRI findings—prolapsed intervertebral disk (PIVD) was the most prevalent etiology, more common in chronic LBP patients. Other etiologies included vertebral fracture, tumor, tuberculosis, and various spinal conditions. Conclusion: Lower back pain is a multifaceted condition influenced by age, gender, BMI, and lifestyle factors. Effective management and prevention strategies should consider these risk factors to improve patients’ quality of life. A comprehensive approach is essential to address the complex etiology of LBP.
Study of Diagnostic Yield of Nucleic Acid Amplification Test among Tuberculous Cervical Lymphadenitis in Immunocompetent Patients
(Journal of Indian Medical Association, 2024-07) Sisodia, Jitendrakumar A; Dedun, Amit R; Patel, Priyanka K; Muhammad, Yoosuf TSS
Background: The most common form of extrapulmonary tuberculosis (TB) is tuberculous lymphadenitis, which constitutes about 30–40% of all extrapulmonary TB cases. A new diagnostic method like the nucleic acid amplification test (NAAT) is a very sensitive and rapid test for diagnosing tuberculous cervical lymphadenopathy. It also detects rifampicin sensitivity among positive patients. Objectives: (1) To evaluate the diagnostic yield of TrueNAT for detecting Mycobacterium tuberculosis bacteria in the fine-needle aspirated samples of cervical lymph nodes compared with Ziehl– Neelsen (ZN) staining; (2) to evaluate the diagnostic yield of TrueNAT for diagnosis of tuberculosis through comparison with the cytology report of fine-needle aspiration (FNA) sample of cervical lymph node and with necrotic cervical lymph node on ultrasonography (USG) neck. Materials and methods: A total of 50 patients enrolled in this prospective study from January to December 2022. Demographic profile and clinical history were noted. Fine-needle aspirate samples were sent for TrueNAT assay, cytological examination, and ZN staining. USG neck was done for necrotic findings in the cervical lymph nodes. Results: The TrueNAT positivity rate was 70%. TrueNAT sensitivity and specificity were assessed according to the cytology report, acid-fast bacilli (AFB) positivity on ZN stain, and the finding of necrosis in the cervical lymph node on the USG neck. The sensitivity and specificity of the TrueNAT assay were 80.49 and 77.78%, respectively, in accordance with necrosis on FNA cytology; 17.14 and 93.33%, respectively, in accordance with AFB positivity on ZN stain; and 74.29 and 33.33%, respectively, in accordance with lymph node necrosis on USG neck. Conclusion: The TrueNAT assay should be used as an adjunctive test in addition to the conventional cytological examination of the FNA sample of lymph nodes for the rapid diagnosis of tuberculosis. It also detects rifampicin resistance simultaneously.
Drug-induced Kidney Disease: Revisited
(Journal of Indian Medical Association, 2024-01) Ganguli, Anirban; Singh, Narinder Pal
Drug-induced kidney disease (DIKD) is a frequent cause of acute and chronic kidney disease (CKD) that leads to high morbidity, hospitalization, and increased healthcare costs. There is a need to constantly update our knowledge in this field, given the ever-burgeoning list of newer treatments that are emerging, especially in the field of cancer immunotherapy. Generalizing the complex pathways causing DIKD from different agents, the common mechanisms include direct toxicity, immune-mediated injury, and drug-induced alterations in renal blood flow. Proper management of this condition involves risk minimization, early detection of renal damage, and timely discontinuation of potential agents to avoid irreversible renal damage.
Dynamics of Antibody Response to Covishield Vaccine after 6 Months: A Longitudinal Prospective Study
(Journal of Indian Medical Association, 2024-07) Chavhan, Smita Santosh; Dhikale, Prasad Tukaram; Adsul, Balkrishna B; Kinge, Kirti V; Ingale, Aniket R; Gokhale, Chinmay N; Jadhav, Nilam
Objectives: To study the dynamics of antibody responses in the real world up to 6 months following two Covishield vaccination doses and evaluate its correlation with age. Materials and methods: From March 2021 to February 2022, a prospective, longitudinal study of healthcare workers (HCWs) from a dedicated COVID-19 hospital was conducted. Institutional Ethics Committee permission was obtained. HCWs were divided into two groups. The first group consisted of individuals who had received the first dose of the COVID-19 vaccine, with at least 3 weeks elapsed since the dose, and who had not received the second dose until the initial blood sample for antibody testing was obtained. The second group consisted of individuals who had received both COVID-19 doses and had at least 2 weeks between the administration of the second dose and the collection of the first sample for antibody testing. In March 2021, after undergoing phlebotomy for serum collection, the participants responded to the survey. Electrochemiluminescence immunoassay (ECLIA) was used to perform a quantitative test for antibodies to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike (S) protein receptor domain [receptor binding domain (RBD)]. The test used had a 98.8% sensitivity and a 99.9% specificity. If the antibody titer was 0.80 U/mL or higher, it was deemed positive; if it was lower, it was deemed negative. Two follow-ups were conducted for both groups, 3 and 6 months following the first sample collection. During both follow-up visits, a blood sample was obtained for testing the amount of antibody response, and the history of COVID-19 disease following the initial sample was taken. Results: Every HCW had received the Covishield vaccination. After the vaccine’s first dosage, 61 HCWs in the first group underwent antibody testing. The information about the 43 HCWs in the first group who attended the two follow-ups is as follows. There were 14 (32.6%) nurses and 5 (11.6%) doctors among the 43 HCWs. The age range was 21–55 years, with the median [interquartile range (IQR)] age being 26 (22–40) years and 20 (60.5%) being females. The vaccination series had a median (IQR) of 34 (29–49) days between doses. There was a statistically significant difference in immunoglobulin G (IgG) levels of the three samples, ?2 = 13.579, p = 0.001. Median (IQR) IgG levels of the three samples at 1 month after the first dose, 3 and 6 months after the second dose were 8511 (51–15400) U/mL, 1471 (249–5050) U/mL, and 978 (220–2854) U/mL, respectively. The antibody titer was negative for two HCWs in the first sample, positive in the rest of the samples, and positive in all samples in both follow-ups. In the second group, following two COVID-19 dosages, a total of 65 HCWs had tested positive for antibodies. The information of the 56 HCWs in group II who attended both follow-ups is as follows. Of the 56 HCWs, 15 (26.8%) were doctors, 27 (48.2%) were nurses, and 14 (25%) were others. The age range was 20–64 years, with a median (IQR) of 29.5 (22–37.7) and 31 (55.3%) female participants. The vaccination series had a median (IQR) interval of 32 (29–35) days between doses. There was a statistically significant difference in IgG levels of the three samples, ?2 = 31.107, p < 0.0001. Median (IQR) IgG levels of the three samples at 20 days, 3.8 months, and 7 months after the second dose were 2377.5, 1345.5, and 1257 U/mL, respectively. Spearman’s rank order correlation was used to assess the association between IgG level and age in both groups. The relationship between IgG levels and age was weakly correlated and not statistically significant. Conclusion: There is a waning of antibody titer over time postimmunization. A lower antibody titer can be a contributing factor for infections that emerge later. IgG levels postvaccination do not differ according to age.
Hypomagnesemia in Patients with Type 2 Diabetes Mellitus
(Journal of Indian Medical Association, 2024-07) S, Ram Kumar; KG, Sajeeth Kumar; R, Gayathri
Background: Recent research has shown that low serum levels of magnesium are often linked to both microvascular and macrovascular complications in individuals with diabetes mellitus. Hence, monitoring of serum magnesium levels is needed in diabetic patients. Furthermore, the addition of magnesium through supplementation may present a novel therapeutic strategy for mitigating vascular complications in individuals with diabetes. Objectives: To assess the prevalence of hypomagnesemia in type 2 diabetes mellitus patients and to assess the association between hypomagnesemia and microvascular complications of diabetes mellitus in a tertiary care hospital in North Kerala. Materials and methods: An analytical cross-sectional study was conducted at a tertiary care hospital involving 230 diabetic patients receiving outpatient and inpatient care in the Department of Internal Medicine at Government Medical College, Kozhikode, Kerala. The study took place from January 2018 to December 2018, during which serum magnesium levels were assessed and analyzed in relation to the patients’ microvascular complications and glycemic control. Results: We observed that 19.13% of the participants had hypomagnesemia. This condition was found to be more common among older individuals with diabetes, as indicated by a p-value of 0.022. However, there were no significant differences in serum magnesium levels based on gender (p-value 0.18), body mass index (BMI) (p-value 0.223), or the duration of diabetes (p-value 0.36). The prevalence of diabetic retinopathy, diabetic neuropathy, and diabetic nephropathy was higher in diabetics with hypomagnesemia than their counterparts with normal magnesium, with a p-value of 0.001, 0.001, and 0.001, respectively. There was a significant negative correlation obtained between serum magnesium and glycated hemoglobin (HbA1C) values (Pearson coefficient = –0.240 and p-value = <0.01) and fasting blood sugar (FBS) values (Pearson coefficient = –0.265 and p-value = <0.01). Conclusion: Hypomagnesemia is negatively correlated with HbA1C and FBS but not related to duration of diabetes and gender. The prevalence of microvascular complications was higher among the diabetics with hypomagnesemia.
Connecting the Dots: Hydration, Micronutrients, and Immunity
(Journal of Indian Medical Association, 2024-06) Vora, Agam; Kalra, Sanjay; Thakor, Priti; Malve, Harshad; Chamle, Vijay; Patil, Amol
Dehydration, often unnoticed, can occur in adults due to heat-related illnesses, viral infections, and upper respiratory tract infections, leading to deficits in fluids, electrolytes, and energy (FEE), even without diarrhea. This fluid deficit, in turn, impairs immunity at cellular and molecular levels. Physiologically, the immune system rapidly reacts to threats by adjusting its structural permeability, allowing water and small solutes to be passed, facilitated by proteins like aquaporins (AQPs). These AQPs are also essential for immune cell communication and adjustments of the cytoskeleton for functions like chemotaxis and phagocytosis. Apart from hydration, maintaining an optimal intake of essential micronutrients, including vitamins C and E, copper, zinc, and selenium, is also critical for supporting immune function and acting as antioxidants. Transient alterations in immune function caused by acute stressors or nondiarrheal conditions heighten vulnerability to coexisting illnesses, particularly cold and upper respiratory tract infections, while also elevating the likelihood of recurrent health issues. Supplementing fluids with known FEE content according to quality standards and enhanced taste is recommended during acute illness and until complete recovery. Thus, dehydration, caused by various acute conditions, can impair immunity and delay recovery. Prioritizing hydration and nutrition in healthcare and general settings is imperative, even when diarrhea is absent.
Assessment of Hydration Status Using Conventional Method and Salivary Osmolarity as a Point-of-care Tool
(Journal of Indian Medical Association, 2024-06) Kalra, Sanjay; Sharma, Sourabh; Verma, Suneet Kumar; Thakor, Priti; Malve, Harshad; Chamle, Vijay; Patil, Amol; Meer, Tarique; Naik, Isha
Dehydration is a well-known problem worldwide, and its assessment can be challenging due to confusing physical signs. The most effective way to assess hydration status is through the costly stable isotope methodology, but this approach has practical limitations. More commonly accepted and utilized indicators of hydration status are hematological and urinary parameters. However, hematological markers require invasive methods, and urinary markers have varying degrees of success in tracking hydration changes. While alterations in body weight can serve as a means of promptly evaluating hydration status, various factors such as food consumption, fluid intake, fecal losses, and urine production can impact these changes. Researchers have turned their attention to saliva as a potential marker and point-of-care (POC) testing to address the limitations of existing biomarkers. Saliva is appealing due to its easy collection process and similarities to extracellular fluid in terms of water and ion concentrations. Recent studies have shown that saliva flow rate, osmolarity/osmolality, and total protein concentration can effectively monitor changes in body mass during acute dehydration. Misdiagnosing dehydration can have severe clinical consequences, leading to morbidity and even mortality. This narrative review focuses on recognizing the significance of hydration assessment, monitoring, and the potential of salivary osmolarity (SOSM) as an assessment tool. Healthcare professionals can improve their practices and interventions to optimize hydration and promote overall wellness using such tools.
Thyroid Disorders among Type 2 Diabetes Mellitus: A Cross-sectional Study from a District Hospital in West Bengal
(Journal of Indian Medical Association, 2024-07) Bhattacharyya, Arnab; Rao, Arravelli Venkateshwar; Halder, Susovan; Sadhukhan, Sanjoy Kumar; Pal, Jyotirmoy
Introduction: The coexistence of diabetes mellitus (DM) (both type 1 and type 2) and thyroid dysfunction, two common endocrine problems, is scientifically predictable. The prevalence of thyroid disorders among type 2 diabetics (more prevalent in India) was studied among patients visiting the outpatient department (OPD) of a district hospital in West Bengal to assess its relation with different characteristics of type 2 DM. Materials and methods: A total of 120 patients suffering from type 2 DM (already diagnosed and on treatment) were randomly selected from the OPD (irrespective of their glycemic status). The thyroid status of all those patients was assessed. All diabetic patients were studied with a predesigned schedule and lab investigations for the prevalence of thyroid dysfunction and its association with pertinent variables from January to December 2019. Results: This study found a 28.3% prevalence of thyroid dysfunction among diabetics. It was significantly associated with poor glycemic control [rising hemoglobin A1c (HbA1c) level] (actual p-value for HbA1c vs abnormal thyroid status = 2.4 E–21) but not with other variables, including the duration of diabetes. Conclusion: Screening for thyroid dysfunction among diabetic persons should be routine, and strict glycemic control is essential.
Neuroparacoccidioidomycosis
(Journal of Indian Medical Association, 2024-06) Kulkarni, Shilpa S; Wadia, Rustom S; Kharawade, Datta; Nandedkar, Mrunal; Munshi, Neeta; Sathe, Prachee
Paracoccidioidomycosis (PCM) is caused by a dimorphic fungus Paracoccidioides Brasiliensis and is endemic to subtropical areas of Central and South America. CNS involvement of PCM is extremely variable. NeuroPCM is found in 9.65% to 27.18% of PCM cases .Most neuro PCM patients presents with simultaneous involvement of other organ but isolated or initial CNS involvement may be a feature in 21%. Here we report a case of CNS PCM and this appears to be first reported case of PCM and CNS PCM in India.
Diabetes Mellitus and Fluid Imbalance: The Need for Adequate Hydration
(Journal of Indian Medical Association, 2024-06) Mohan, Viswanathan; Kalra, Sanjay; Zargar, Abdul Hamid; Tiwaskar, Mangesh; Thakor, Priti; Malve, Harshad
The effect of hydration in modulating metabolic disease risk is a comparatively recent concept. Diabetic patients are at increased risk of dehydration due to osmotic diuresis. Undiagnosed or undertreated hyperglycemia may lead to electrolyte imbalance and elevated renal burden of glucose excretion, which may alter fluid reabsorption in the kidney. Also, the presence of one or more contributory factors, such as inadequate fluid intake, strenuous exercise, high temperatures, alcohol consumption, diarrhea, acute illnesses, fever, nausea, and vomiting, may put diabetic patients at increased risk of dehydration and electrolyte imbalance. Certain antidiabetic agents used by diabetic patients may cause fluid retention/deficits and/or electrolyte abnormalities in a few patients. Thus, drinking ample amounts of water and fluids with appropriate electrolyte composition is important to prevent dehydration. Successful management of dehydration in patients with diabetes is an unmet need and can best be accomplished by maintaining adequate hydration status.
Effectiveness of ORSL® Variants as an Adjuvant along with Standard-of-care Treatment in the Restoration of Oral Fluid, Electrolytes, and Energy in Patients with Fever and/or General Weakness in Indian Patients in an Outpatient Setting
(Journal of Indian Medical Association, 2024-06) Reddy, B Ravinder; Bhatia, Sumeet; Gogia, Atul; Hughes, Alison; Tian, Sandy; Thakor, Priti; Malve, Harshad; Chamle, Vijay
Background: Dehydration due to reduced intake or increased losses including insensible losses in patients with acute nondiarrheal diseases may lead to fluid, electrolytes, and energy (FEE) deficits. The impact of oral FEE supplementation adjuvant to standard of care (SOC) treatment on recovery in patients with acute nondiarrheal diseases is yet to be evaluated. Aim: To determine the effectiveness of ORSL® variants (ORSL® Apple Drink and ORSL® PLUS Orange Drink), fruit juice-based electrolyte drinks as an adjuvant along with SOC in the restoration of oral FEE in patients with acute nondiarrheal disease with fever and/or general weakness who attended an outpatient department (OPD). Materials and methods: This was a prospective, interventional, open-label, multicenter, real-world, study conducted at eight sites across India. Patients with fever and/or general weakness due to an acute nondiarrheal illness were given either ORSL® Apple Drink or ORSL® PLUS Orange Drink as an adjuvant along with SOC treatment per physician’s discretion. The primary endpoint of the study was to assess improvement from baseline in energy or hydration levels after ORSL® variants consumption at 6, 24, and 48 hours measured by a new aided recovery scale (ARS). Secondary endpoints were to assess the improvement in energy and hydration levels at 20, 40, and 60 minutes, as well as energy levels and hydration levels at 20, 40, and 60 minutes, 6, 24, and 48 hours after the consumption of ORSL® Apple Drink or ORSL® PLUS Orange Drink. The patient’s consumption of ORSL® variants and treatment experience, physician’s experience of recommending ORSL® variants, and product safety were evaluated. Results: In total, 612 patients were enrolled with mean age 38.3 years, of whom 62.9% were male. The mean baseline level of energy and hydration was 1.59 (range 1.0–2.0) on ARS. Statistically significant (p < 0.0001) improvements were observed in energy or hydration 6 hours after first consumption of ORSL formulations. Furthermore, improvement was observed from 40 minutes, and in levels of energy, hydration, and both energy and hydration from 60 minutes. Patients and physicians reported a positive experience with ORSL® variants. Conclusion: ORSL® Apple Drink and ORSL® PLUS Orange Drink are clinically proven to provide hydration and/or energy to patients with fever and/or general weakness.
Surgical Management in a Medical Emergency: Disseminated Extensive Tissue Damage Due to Snake Envenomation
(Journal of Indian Medical Association, 2024-06) Jha, Vijoy Kumar; Deshpande, Sanjeev Kumar; Arora, Rahil; AK, Ajin Anto
Many snakebite deaths in India may remain unreported as these patients still seek treatment from traditional healers or quacks. Though local and systemic toxicity due to snake envenomation is quite common, the clinical presentation as disseminated extensive tissue damage and ulceration is not seen. We present a lady who presented with extensive skin erosions with tissue necrosis in all four limbs and the trunk. The case was successfully managed with antisnake venom, wound debridement, and split skin grafting. Early antisnake venom halts the progression of tissue damage effects of snake venom. The future treatment of these extensive ulcerations may be the use of drugs that can inhibit the hydrolyzing enzymes of snake venom. The case also stresses the need for excellent wound care after the management of systemic envenomation with antivenom treatment
Adult Partial Anomalous Pulmonary Venous Connection: Case Reports (Including a Case of Scimitar Syndrome)
(Journal of Indian Medical Association, 2024-06) Gupta, Rekha; Udupi, Pranav K; Sharma, Ankita; Uppal, Lipi
Partial anomalous pulmonary venous connection (PAPVC) is a congenital heart defect in which one or more pulmonary veins drain abnormally into the systemic venous circulation, leading to the development of pulmonary arterial hypertension. It can be supracardiac type, draining into the superior vena cava or right atrium (also called cardiac type) and infracardiac type with drainage into the inferior vena cava (IVC). We present two cases—supracardiac and infracardiac types of PAPVC in this case report.
An Indian Expert Group Review of Acanthosis Nigricans with Recommendations for Early Detection and Timely Management
(Journal of Indian Medical Association, 2024-06) Tyebkhan, Gulrez; Velaskar, Sangeeta; Yadav, Preeta; Phiske, Meghana; Shah, Duru
Introduction: Acanthosis nigricans (AN) is a visible cutaneous manifestation of several underlying systemic conditions, such as prediabetes, diabetes mellitus (DM), polycystic ovarian syndrome (PCOS), metabolic syndrome (MS), and malignancy. AN is commonly seen in obese individuals and is a proven skin marker of insulin resistance (IR). Its typical clinical presentation and location, especially on the nape of the neck, allows for easy visual identification. Obesity, IR, and other noncommunicable diseases (NCD) are on the rise in India, with many cases being undiagnosed or missed. Every sixth diabetic in the world is Indian. AN can thus play a vital role in screening, early identification, and reduction of morbidity, especially of IR-related disorders. Currently, there are no national or international multidisciplinary guidelines or recommendations for AN. Objective: To review published current literature and evidence on AN, its associations, and management. To recommend an approach to clinical identification of AN, associated/underlying disorders, investigations, and management, including lifestyle modifications. To sensitize and familiarize clinicians and healthcare workers across India with AN presentations. This will enable early detection of conditions such as IR, prediabetes, DM, PCOS, malignancy, etc., in practice and in the community. Materials and methods: The PCOS Society of India constituted a multispecialty Expert Working Group with representation from various national societies to review all published scientific evidence. Expert group meetings were conducted to provide recommendations. Conclusion: Acanthosis nigricans is a simple, non-invasive, cost-effective screening tool for early identification of IR. It is important to integrate and disseminate information and training on AN across medical specialties. The government of India has launched several National Health Programmes to help address the rising burden of NCD in the population. AN would provide a simple screening tool to pick up undiagnosed or missed cases.
To Access Knowledge Regarding Organ Donation among Healthcare Workers and Their Willingness toward Organ Donation
(Journal of Indian Medical Association, 2024-01) Zirpe, Kapil; Gurav, Sushma; Dixit, Subhal; Pote, Prajakta; Deshmukh, Abhijeet; Tiwari, Anand; Suryawanshi, Prasad; Joshi, Surekha; Khatib, Khalid; Jadhav, Lochana; Gole, Manasi; Mathew, Sinu; Shaikh, Raeena L
Background: In India, critical shortage of organ donations, particularly deceased donations, has led to a dire situation in India, with thousands of patients waiting for transplants and a significant number of them succumbing. One of the reasons for the shortage of organs for transplantation is unawareness and prejudiced information about organ donation. Being direct or indirect stakeholders, the knowledge regarding organ donation among healthcare workers may play an important role in the donation process. Aim: To assess the knowledge regarding cadaver organ donation among healthcare workers and their willingness toward organ donation. Materials and methods: It is a cross-sectional offline self-administered questionnaire-based survey conducted among healthcare professionals at tertiary care teaching institutes. Survey was carried out between the months of August to December 2019. A structured questionnaire was used to assess knowledge and willingness toward organ donation. Statistical analyzed was done by using statistical package for social sciences (SPSS) 20.0. All p-values were considered significant at <0.05. Results: A total of 1,039 healthcare professionals participated in the survey. Out of them, 362 (34.8%) were males and 675 (65%) were females. Average age of the healthcare workers participating in survey was 30.81 years, and age ranged from 18 to 60 years. Awareness regarding corneal donation after brain death was found to be maximum (89.7%) and was comparable to that of kidney (86.6%) and heart (83.7%). Participants were unlearned of donation of lungs, pancreas, hands and unaware of heart valve donation. About 45% respondents considered that age affected the donors. About 40% respondents considered younger patients as ideal recipients, while 18.7% respondents considered waiting list patients as ideal recipients. Doctors had highest willingness (78. 3%) for organ donation, followed by nurses (69.9%) and support staff (59.3%) (p < 0.001). Only 119 (11.5%) participants received organ donation cards as against 68.7% willingness toward organ donation (p < 0.01). Conclusion: We have observed fair awareness regarding overall cadaver organ donation concept among healthcare workers. There is a need to improve knowledge of extended age criteria and which organs can be retrieved from deceased donor. Authorities have to work hard on delivery of organ donation pledging card to promote donation program.
Primary Aortoenteric Fistula Due to Salmonella typhi-related Mycotic Aneurysm
(Journal of Indian Medical Association, 2024-06) S, Divyashree; Premkumar, Prabhu; Rupali, Priscilla
Primary aortoenteric fistulas (AEF) are rare. The majority of these are due to atherosclerotic aortic aneurysms. Mycotic aortic aneurysms leading to primary AEF are exceedingly uncommon. Here we report a rare case of primary AEF secondary to Salmonella-related mycotic aneurysm and discuss the diagnostic and therapeutic issues.
Declining Trend in Antimicrobial Sensitivity in Respiratory Tract Bacterial Pathogens against Commonly Used Drugs at a Tertiary Care Hospital
(Journal of Indian Medical Association, 2024-06) Sharma, Swati; Khedar, Raghubir Singh; Dixit, Tripti; Kumar, Pawan; Singh, Surendra; Sharma, Krishna Kumar; Gupta, Rajeev
Objectives: Antimicrobial resistance (AMR) is a major health issue. To determine trends in bacterial organisms in respiratory tract infections (RTIs) and their antibiotic sensitivity at a tertiary care center in India, we performed this study. Methods: Successive samples received from January 2017 to December 2021 from the respiratory tract (sputum, endotracheal secretion, and bronchoalveolar lavage) from intensive care units and medical inpatients were processed for bacterial growth. The identification of isolates and antibiotic sensitivity patterns was performed using an automated VITEK-2 system. Descriptive statistics are reported. Results: We received 7,204 respiratory samples. Significant bacterial growth was in 3,000 (41.6%), and 2,992 (41.5%) were gram-negative. Klebsiella pneumoniae was the most prevalent, followed by Pseudomonas aeruginosa, Acinetobacter baumannii, Escherichia coli, and Enterobacter aerogenes. Increasing secular trends were observed for Klebsiella and Pseudomonas and declining trends for Acinetobacter and Escherichia (p < 0.05). Antimicrobial sensitivity patterns showed that Klebsiella, Pseudomonas, Acinetobacter, E. coli, and Enterobacter had a high sensitivity with colistin and polymyxin (99–100%). Moderate sensitivity was observed with carbapenems (Acinetobacter: 47.5%, Enterobacter: 62.0%, Escherichia: 76.5%, Klebsiella: 72.3%, Pseudomonas: 66.7%) and tigecycline (Acinetobacter: 50.4%, Enterobacter: 68.0%, Escherichia: 81.1%, Klebsiella: 66.6%, Pseudomonas: 0%). Aminoglycosides had <50% sensitivity for various organisms, and <25% sensitivity was observed with third-generation cephalosporins and quinolones. Trend analysis showed persistent sensitivity of various pathogenic bacteria to colistin and polymyxin and declining pharmacological sensitivity in Acinetobacter (carbapenems and tigecycline), Escherichia (carbapenems, quinolones, and tigecycline), Klebsiella (carbapenems, quinolones, aminoglycosides, and tigecycline), and Pseudomonas (carbapenems and aminoglycosides) species (p < 0.05). Conclusion: Common respiratory tract gram-negative bacterial pathogens at a tertiary care hospital are K. pneumoniae, P. aeruginosa, A. baumannii, and E. coli. All these bacteria demonstrate high sensitivity only with colistin and polymyxin. Significant AMR is observed to carbapenems, tigecycline, aminoglycosides, and third-generation cephalosporins. Secular trends show declining antimicrobial sensitivity among various bacterial pathogens.

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