Intestinal mucormycosis in a patient with COVID-19: A case report

The novel coronavirus disease (COVID-19) has spread to all the continents posing a serious threat to global health. It can present with myriad symptoms and complications including susceptibility to fungal co-infections. We hereby describe a case of mucormycosis in a 17 year old COVID-19 positive female with no known comorbidities presenting with abdominal pain and distention and ultimately developing intestinal perforation. Early identication of the symptoms is essential to make a correct and early diagnosis to prevent complications.

A Cross Sectional Study To Determine The Prevalance Of Occludable Angles In Hypermetropes

Background:Hypermetropic eyes are generally smaller in globe volume, resulting in crowding of anterior chamber when the lens size is normal.The aim of this study is to document the prevalence of occludable angles in hypermetropes visiting tertiary eye care centre of western region of India and to highlight the importance of screening for angle closure suspects inhigh risk groups. Material And Methods:This cross sectional study is based on clinical study of patients attended by M & J Western Regional Institute of Ophthalmology. The study group was divided into two subgroups: patients who are hyperopic on refraction and patients who are either emmetropic or myopic. Relative risk and Odd’s ratio was calculated for relation between refractive error and occludable angle. Result:Risk of Occludable angle in hypermetropes = 0.23.Risk of Occludable angle in myopes and emmetropes = 0.06. Relative risk in hypermetropes = 4.15 i.e. hypermetropes have nearly 4 times risk of developing occludable angle than myopes and emmetropes. Relative risk in myopes and emmetropes = 0.24 i.e. myopes and emmetropes have 0.24 times risk of de veloping occludable angle than hypermetropes.Odd’s ratio in the first group = 5.1 i.e. the possibility for a patient with occludable angle being a hypermetrope.Odd’s ratio in the second group = 0.2 i.e. the possibility for a patient with occludable angle being a myope or an emmetrope. Conclusion:When occludable angle is detected on gonioscopy in > 270 degrees, a peripheral iridectomy can be performed as a prophylactic measure and patients can be given a liberal follow up. A society like India where people have less awareness regarding glaucoma being a silent thief and not understanding the importance follow up examination in glaucoma, gonioscopy should be made a part of routine examination and peripheral iridotomy done as necessary.

Alcohol-based hand sanitizer-induced burns: A harsh reality in current times

ue to the recent coronavirus pandemic, there is a steep rise in the use of alcohol-based hand sanitizers (ABHSs) over the past few months. For them to be effective against microorganisms, the minimum recommended concentration of alcohol is 60%. This high alcohol content makes the sanitizers easily flammable. Although, they are extremely convenient to use, they can also prove to be a hazard if used in an improper manner. Guidelines have been published for safe manufacturing and distribution of these sanitizers. There are recommendations for storage and use, which should be adhered to in a strict manner. Their use by children should always be supervised. We report four cases of burn injuries caused by injudicious use of alcohol-based sanitizers. The flammable nature of ABHSs can also be exploited as witnessed in one of our cases. With this report, we wish to emphasize that judicious and correct use of these seemingly benign products is essential.

An Osteological Study Of Morphometric Variations Of Suprascapular Notch In South Gujarat Region

Background:The suprascapular notch is a depression in the lateral part of superior border of scapula. The suprascapular ligament bridges the notch. Thesuprascapular nerve passes below the ligament and corresponding artery above the ligament. Variation in size and shape of suprascapular notch is identified as one of the causes of suprascapular nerve entrapment.Aim Of Study:To study morphological variations of suprascapular notch in dry scapulae of South Gujarat (Indian) population and compare data with studies in other ethnic populations. Materials And Methods:Total 200 dry human scapulae were obtained from Anatomy departments of three medical collegesof south Gujarat. Three dimensions were defined and measured for each suprascapular notch (SSN) using classical osteometry: maximal depth (MD), superior transverse diameter (STD) and middle transverse diameter (MTD). Based on Micha? Polguj’s classification SSN was classified into five types. The results of the present study were compared with previous studies in different populations.Results:The proportion of Type III SSN is highest (46.5 %) followed by Type V (26 %), Type I (16 %), Type IV (6 %) and Type II (5.5 %). For Type III SSN, proportion of subtype III c is highest (36.5 %), followed by subtype III b (6 %) and subtype III a (4 %). For Type I SSN, proportion of subtype I c is highest (8.5 %), followed by subtype I a (4 %) and Subtype I b (3.5 %).Conclusion:The suprascapular nerve entrapment syndrome, in most cases is due to morphological variations of suprascapular notch particularly complete ossification of suprascapular ligament. So the knowledge of such variations is essential for clinicians,to make a proper diagnosis of shoulder pain and to plan the most suitable surgical intervention.

Hematopoietic stem cell transplantation in children with Griscelli Syndrome type 2: Experience and outcomes

Griscelli syndrome is a rare autosomal recessive inherited disorder characterized by hypopigmentation, silver colored hair, and associated immunological deficiency, which proves fatal in the absence of timely intervention. Our patients diagnosed with Griscelli syndrome-2 presented with fever, hepatosplenomegaly, and deranged hematological and biochemical parameters. Both cases underwent detailed investigations comprising of hair mount microscopic examination, degranulation assay, and mutational studies. Our cases showed defective degranulation activity by NK cells and gene mutation analysis revealed RAB27A mutation that causes defect of cytotoxic granule exocytosis from natural killer (NK) and T-cells, manifesting clinically as hemophagocytic lymphohistiocytosis (HLH). Hematopoietic stem cell transplantation in one of the patients resulted in stable chimerism; however, the second case relapsed within a month after SCT. Stem cell transplantation is the only curative therapeutic option for GS2; thus, improvement in posttransplantation management may reduce mortality and posttransplant complications. Hence, any child who presents with partial albinism and clinical features suggestive of HLH, a peripheral blood, hair shaft mount examination along with basic immunological NK and T-cell cytotoxicity assay by flow cytometry will help clinch the diagnosis early. It can subsequently be confirmed by molecular study. Timely therapeutic intervention can prevent relapses and severe infection and improve outcome in these cases.

“Dear Peers! Are You “Free to Learn” For Your Kin?”

I have stories to tell. More than a decade ago and ironically almost a decade after my graduation from medical school, I trained and got certified in basic life support (BLS) skills because I did NOT want to fail my family, my friends and my patients as I had desired to NOT fail my conscience as a physician. I will tell you this that you will never regret honing BLS skills whenever you will see the smiles on the faces of revived and you will never forget when not forgiven – by else and/or by self – for your reluctance in knowing what’s expected from you especially as a physician. Even though my natural desire to hone BLS skills was born in the times when it was NOT mandated, my free will to care for my family, my friends and my patients had always brought me back to BLS training centers for revisiting my skills again and again, years after years. Essentially, I have recognized Brain-Heart-Lungs as the Trinity of Life and hereafter I plead to all my peers irrespective of which stage of career they are in: “Please hone your BLS skills, at least be a Heartsaver®, for your kin so that when your kin, your beloved, needs your help, you don’t delay providing help compared to leaving “To go find one”

Comparative Evaluation of Efficacy of Interscalene Block vs. Interscalene Block and Superficial Cervical Plexus Block for Fixation of Clavicular Fractures

Introduction: Regional anaesthesia is seldom used forclavicle fractures considering the anatomical location of thebone. We aim to compare the efficacy of two techniques ofregional anaesthesia as sole anaesthesia technique for fixationsof clavicular fractures.Material and methods: 60 Adult patients with claviclefractures were divided randomly in two groups (1 and 2) andwere administered interscalene block (ISB) only or interscaleneblock and superficial cervical plexus block(ISB+SCPB) assole anaesthetic, respectively. Patients were monitored forefficacy of block and adequacy of anaesthesia and analgesiaat the surgical site. Side effects and hemodynamic parameterswere also monitored.Results:. ISB+SCPB provides excellent anaesthesia forclavicle fixation. Only 1 patient in group 2 required GeneralAnaesthesia(GA) whereas in Group 1, 8 patients required someform of supplemental anaesthesia. There was no statisticallysignificant difference in side-effects and hemodynamic profilein both the groups.Conclusion: ISB+SCPB is significantly better than ISB onlyfor anaesthesia for fixation of clavicular surgeries.

Clinical-ophthalmological profile of patients undergoing cataract surgery following their identification in screening eye camps

Background: Senile cataract constitutes about 50–70% of preventable blindness in the year 2000 in India. >3/4th of Indian populations live in rural areas which are away from medical facilities. Conducting of outreach camps forms an integral part in decreasing the visual morbidity due to cataract, etc., in rural areas, thus the unrecognized rural and poor population is benefited. Objective: The objective of this study was to see demographic and clinical-ophthalmological profile of patients undergoing cataract surgery. Materials and Methods: The present cross-sectional observational study which was conducted in a tertiary care hospital involved 72 cataract patients who were assigned to undergo extra capsular cataract extraction surgery (SICS with PC-IOL) following their identification in various screening eye camps of Jammu province. Results: The maximum prevalence was seen in the age group of >60 years, i.e., 76.39%. Males outnumbered females, i.e., 63.89%. Housewives comprised 36.11% followed by farmers who were 34.72%. About 37.5% among studied subjects were smokers and 38.89% were hypertensives while 19.44% had blood sugar level above normal value. Mature cataract was the most common seen in 72.22%. Majority of the patients, i.e., 59.72% had visual acuity of <1/60. Conclusion: Increasing age, housewives, and smoking were the most important risk factors, whereas mature type of cataract was more commonly seen in camp patients.

Suicide: Managing self-directed violence?

The Centers for Disease Control and Prevention have put forth recommendations to document events in terms of well-defined categories of self-directed violence even though the evolution of terminology for decriminalization and de-stigmatization from “self-murder” to “suicide” to “self-directed violence” may be just avoiding calling a spade a spade. Suicide causes mortality (and morbidity if suicide attempt) in an individual leading to (a) physical suffering to others by injuring them during-and-after the act, (b) psychological toll on the next-of-kin, and (c) isolation of society due to its suicide-statistics and economic losses with overall loss of spirit to pursue happiness potentially resulting more mortality if morbidity becomes too severe for the affected. What is the story (myth) instigating an individual to commit (or think of committing) the act of self-directed violence? And what is the story (myth) in the society that is allowing the act in some instances while prohibiting and sometimes even punishing the act in other instances? We believe that Switzerland can provide an apt example to understand suicide. Swiss ideology may inspire societies around the world to recognize their stories (myths) when they scientifically decipher prevalence of self-directed violence “suicide” even in nonhuman animals. Consequently, astounding statistics of physician suicide call for action from physicians’ community to understand peers when none can remain untouched by harsh reality of unique stress which physicians’ workspace entails. One of the possible remedies may be thoughtlessness (a form of meditation) which may require strenuous practicing; however, the first step towards achieving it may possibly involve mindfulness (another form of meditation) inspiring peers to learn the need to refocus onto whatever good there is over whatever better there could have been. Essentially, the conception of birth and the birth itself is always planned to be joyful; and the embrace of death itself and the life after death is always purported to be peaceful.

Role of DPP-4 inhibitors in the management of type 2 diabetes

Among various insulinotropic agents used in treatment of Type 2 DM, inclusion of DPP4 inhibitors are considered as major breakthrough as far as new drug development is concerned. In this review article we have discussed in detail about the pathogenesis of diabetes mellitus especially the role of incretin, DPP4 enzyme and implication of its inhibitors in treatment of DM. Also, various clinical studies regarding use of DPP4 inhibitors as monotherapy and as combination therapy with other antidiabetic agents were discussed. DPP-4 inhibitors control glucose in fasting as well as in postprandial state both in monotherapy and in combination with other oral antidiabetic agents. Significant reduction in HbA1c observed with DPP4 inhibitors as monotherapy. On combining DPP 4 inhibitor as add-on therapy to metformin, glitazone or sulphonylurea therapy in patients with type 2 diabetes not reaching therapeutic goals, DPP-4 inhibitors reduce HbA1c, fasting plasma glucose and 2-h postprandial plasma glucose up to the desired level. Various DPP-4 inhibitors have been proven to be as safe and tolerable both as monotherapy and combination with other antidiabetic agents. Inhibition of DPP-4 enzyme has been proven as a promising aspect in the treatment of type 2 diabetes and various drugs inhibiting DPP4 enzymes have been developed now. They are highly recommended in the treatment of Type 2 DM both as monotherapy as well as combination therapy.

Assessment of arterial stiffness in stable patients of chronic obstructive pulmonary disease: a prospective case control study

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide and represents a substantial socioeconomic burden. Co-morbidities are more in COPD patients. Cardiovascular disease is one of the co-morbid conditions in COPD. Arterial stiffness has a strong predictive value for cardiovascular events, which can be assessed non-invasively. Various predictors of arterial stiffness between stable COPD patients and healthy volunteers were measured and compared.Methods: COPD patients attending pulmonary medicine outpatient services were screened for enrolment. It was a prospective case control study with enrolment of fifty COPD stable cases and fifty healthy control, who were matched for their age and sex. All eligible participants were subjected to focused history and physical examination as per structured questionnaire, followed by spirometric examination, periscope test, arterial blood gas analysis and six- minute walk test (6MWT).Results: Increased arterial stiffness was observed in COPD patients over a wide range of severity of airway obstruction. Distance walked in 6MWT and spirometric values were significantly lower in COPD group as compared to healthy group.Conclusions: It was concluded that vascular changes, which are predictive of cardiovascular disease remain as cardiovascular risks in mild or early lung disease. A strong relationship between COPD, systemic inflammation, arterial stiffness and cardiovascular disease had been found which needs to be explored further. It was finally concluded that targeted therapeutic approach has broad aspect in reducing cardiovascular risks and has potential for improved prognosis in COPD.

Are We Educating, Our Children, About Hygiene? Are We Talking, With Them, About It?

Cancer screening has always focused on screening lone individuals even when sexually transmitted diseases (STDs) have been traditionally known to require concurrent treatment of all current sexual partners. This shared responsibility towards the sexual partners cannot be limited only to the prevention and treatment of STDs, especially when human papillomavirus (HPV), which is a STD, has been implicated in the etio-pathogenesis of cervical, penile and anal cancers besides other perineal cancers. Consequently, educating Indian population about our personal perineal hygienic practices is of utmost importance to help curtailing the non-“contagious” spread of cancers.

Diminished CD40L expression on T-cells in a case of disseminated cryptococcosis

X-linked hyperimmunoglobulin M (HIGM) syndrome may increase the susceptibility of patients to disseminated cryptococcal infections primarily due to CD40L deficiency that causes defective cross talk between T- and B-cells, thus preventing class switching. In HIGM syndrome, serum IgM levels are elevated with severe reduction in serum immunoglobulin G (IgG) and IgA levels. In addition, the expression of CD40L (CD154) on in vitro-activated T-cells is severely reduced or absent. Here, we describe a rare, and perhaps, the first reported case in India of a 3-year-old male child with X-linked HIGM immunodeficiency syndrome who developed disseminated Cryptococcosis. Evaluation of the serum IgG profile of the patient revealed increased serum IgM levels with reduced IgG and IgA levels. Both the frequency and the function of T-cells, primarily CD40L on activated T-cells, showed weak expression suggestive of HIGM syndrome.

Invasive cutaneous mucormycosis in a preterm neonate presenting as a vesicobullous lesion

Mucormycosis is a relatively rare fungal infection seen in immunocompromised patients. Very few cases of invasive cutaneous mucormycosis occurring in neonates have been reported in literature. It is an aggressive disease with a mortality rate of around 64% in neonates, so a high index of suspicion is essential for rapid diagnosis and definitive treatment with broad-spectrum antifungals such as Amphotericin B. We present a case of a premature infant born at 25 weeks of gestation who developed vesicobullous lesions all over the body on day 5 of life. Biopsy from the vesicles confirmed the presence of angioinvasive fungal hyphae of mucormycosis which were highlighted on Periodic acid-Schiff and Grocott stain.

Impact of awareness about hypertension on compliance to antihypertensive medication

Background: Hypertension, a common cardiovascular disorder accounts for 20-50% of all deaths. This risk can be greatly ameliorated by creating awareness about disease and its effective treatment alongside regular medical check-ups. Therapeutic failures result from patient non-compliance, manifested as intentional or unintentional errors in dosage or schedule, overuse or underuse of prescribed drugs and early termination of therapy. Adherence is helpful for management of hypertension and cost minimization. Non-adherence to the drug treatment is an important factor for uncontrolled hypertension and its complications.Methods: Patients were interviewed individually after taking informed consent, using pretested, predesigned, self- administered and closed ended questionnaire both before and 4 weeks after creating awareness about hypertension and its complications. Compliance measured by self-reporting in which knowledge of the patient about number of antihypertensive drugs being used, formulations of drugs, frequency of administration, duration of taking the drugs and knowledge of complications due to uncontrolled and untreated hypertension were assigned 1 score each. Patient having score of at least 4 out of total 5 was considered compliant.Results: No significant association of compliance with demographic and other variables like age, sex, marital status, economic status, education, urbanization, duration of treatment and drug procurement were noted. A significant increase in compliance in patients on antihypertensive medication was found 4 weeks after creating awareness about hypertension and its complication. A significant increase in compliance scores was also seen in non-compliant patients showing their shifting from non-compliance to compliance group. Overall compliance increased from 59.38% to 84.38%. A percentage decrease from 58.82% to 25% in patients having uncontrolled hypertension was also observed after the awareness about hypertension.Conclusions: Demographic variables, duration of hypertension and drug procurement have no significant effect on compliance to antihypertensive medication. There is persistence and improvement in compliance to antihypertensive medications after an education of the patients about hypertension and its complications.

Does the presence of Klebsiella pneumoniae carbapenemase and New Delhi metallo‑β‑lactamase‑1 genes in pathogens lead to fatal outcome.

Introduction: Infections due to multidrug‑resistant (MDR) pathogens are a medical challenge. There is considerable apprehension among clinicians regarding pathogens reported as carrying New Delhi metallo‑β‑lactamase‑1 (NDM) and Klebsiella pneumoniae carbapenemase (KPC) genes from their patients. In the face of extremely high rates of antimicrobial resistance, it is essential to gauge the clinical significance of isolation of pathogens carrying these genes from clinical samples. This study compares the outcome of patients infected with pathogens carrying NDM/KPC genes versus those without these genes. Methods: The study was conducted over a 1‑year period at a Level‑1 trauma centre. Hospital‑acquired infections were diagnosed on the basis of CDC’s criteria. The correlation of isolation of a multi‑resistant pathogen carrying KPC or NDM genes with the clinical outcome was ascertained. Results: A total of 276 consecutive patients admitted to the Intensive Care Units/wards of the JPNA Trauma Centre were included in this study. Of the 371 isolates recovered from these patients, 116 were from patients who had a fatal outcome. The difference in prevalence of blaNDM and blaKPC was not significant in any genera of Gram‑negative pathogens isolated from patients who survived versus those who had a fatal outcome. Conclusion: Isolation of MDR pathogens carrying NDM/KPC genes from clinical samples is not always a harbinger of a fatal outcome. Efforts should be made to prevent cross‑transmission of these pathogens.

Knowledge, attitude and practice about breast cancer and breast self‑examination among women seeking out‑patient care in a teaching hospital in central India.

BACKGROUND: Breast cancer (BC) continues to be a major cause of morbidity and mortality throughout the world. Early detection of BC and early treatment increases the chance of survival. According to Breast Health Global Initiative guidelines for low and middle income countries, diagnosing BCs early by promoting breast self‑awareness; clinical breast examination (CBE) and resource adapted mammographic screening will reduce BC mortality. There is a paucity of data on the knowledge and awareness of BC and self‑breast examination in India. We designed this hospital based cross sectional descriptive study to evaluate the current status of knowledge, awareness and practices related to BC and breast self‑examination in the female rural population attending a teaching hospital. MATERIALS AND METHODS: We did a random sampling to identify and enroll 360 women and their female relatives. We excluded a participant from the study if she had already undergone a screening mammography or had had a BC. The data was collected by a self‑administered questionnaire in vernacular language. RESULTS: Our study population included 360 women with a mean age of 45.81 (±10.9) years. Only 5 (1.38%) females had a family history of BC. A whopping 81% of women did not have any knowledge about BC. All the women thought that CBE by doctors was the only way for screening BC. CONCLUSIONS: We concluded that with the results of this study, it is imperative to increase awareness about BC and its detection methods in the community through health education campaigns. We should have major policy changes to increase future screening programs and health education programs which would have an overall positive impact on reducing the disease burden.

Perception of quality in a Radiation Oncology Department: Is it different for patients and health care providers.

AIM: Patient satisfaction is increasingly being identified as an important benchmark in health care industry. Studies addressing patients’ perceptions of quality are available but there is paucity of data regarding the perception of health care providers towards their own services. This study was undertaken to compare the satisfaction level between the patients and the staff from a Radiation Oncology Department. MATERIALS AND METHODS: A common 16‑item questionnaire addressing various aspects of patient care was served to 40 patients and 40 staff members. The responses were statistically evaluated to assess the satisfaction level among the two groups and the scores were compared to assess the agreement between two groups. RESULTS: Overall, satisfaction level of both groups regarding quality of services ranged from “good” to “excellent”. A high level of agreement was observed between the two groups. The physician’s ability to give an explanation to patients, helping attitude of the staff and the staff’s concern for patient safety were the most satisfying features of the department while inconvenience during scheduling of appointments, billing and registration process, status of the changing rooms and inter‑department coordination were the least satisfying features. CONCLUSION: A high level of satisfaction may be achieved from the consumers if service providers are trained to assess the needs and expectations of consumers and to critically evaluate themselves. The service provider’s perception regarding their own services may serve as a preliminary indicator of overall quality. Future studies with more participants in different setting may further explore this hypothesis.

Rare yeasts causing fungemia in immunocompromised and haematology patients: Case series from Delhi.

Systemic fungal infection related to fluconazole‑resistant yeasts are emerging in immunocompromised patients. In this case‑series, we report eight cases of fungemia caused by Trichosporon spp. (2), Stephanoascus ceferrii (1), Kodamaea ohmeri (1), Pichia kutrawersi (2), Candida rugosa (1) and Candida lusitianae (1) in immunocompromised patients. All the yeasts except (Trichosporon asahii) were sequenced. As these rare species are inherently resistant to antifungal agents and they may lead to the development of nosocomial outbreaks, therefore, accurate identification followed by antifungal susceptibility testing is crucial for proper treatment and management.