India in Flattening the Curve of COVID-19 Pandemic - Triumphs and Challenges Thereof

We often see the term flattening the curve in newspaper and news but we often forget the very importance of this term which if considered seriously can be used to deal with various pandemic situations around the globe and one such condition is Covid-19 which is being dealt by each one of us in this World. The “Curve” which all the researchers in the world are commenting upon is the one which states the number of people that will come in contact with Covid-19 over a particular period of time. This curve will tell you about the theoretical spread of the virus and will help different governments around the world to predict the outcome of such a condition and plan various measures which can be used to deal with this situation we all are living with. The use of pandemic curve can be traced back in time and how it has benefitted mankind since time immemorial. The origin of the strategy of flattening the curve can be traced back in a newspaper named Interim pre pandemic planning guidance: community strategy for pandemic influenza mitigation in US: early, targeted, layered use of non-pharmaceutical interventions. The center for disease control and preventions published it in 2007, a paper which gave a preview about this impactful strategy and about how this could be used in a pandemic like situation. To win this battle against the novel coronavirus, infection Covid-19; epidemiologists are using this strategy of “Flattening the Curve”; but in this strategy in addition to social distancing there is a significant requirement to increase the surge capacity of hospitals. Different data is coming from different region’s which tells that diverse actions are being taken in different countries. This review will have a look at the Indian scenario of flattening the curve along with all the strategies applied and their success rate.

Neuroleptic Malignant Syndrome (NMS) after Treatment with Metoclopramide - A Rare Case Report

Neuroleptic Malignant Syndrome (NMS) is a medical emergency. It presents with mental status change, rigidity, fever, and autonomic dysfunction. It is caused by antipsychotics especially neuroleptic agents and certain antiemetic drugs like metoclopramide that block central dopamine pathways. We present a case of a 32-year-old male chronic alcoholic who presented to us with alcohol withdrawal symptoms and was given injection metoclopramide and developed neuroleptic malignant syndrome (NMS).Incidence rates for NMS range from 0.02 to 3 percent in patients treated with antipsychotic agents.1,2 Though it is commonly encountered in young adults, any age group can be affected.3,4 Males are two-fold more affected than females.4Metoclopramide, a commonly used anti-emetic agent has anti-dopaminergic properties and can give rise to development of NMS. The signs and symptoms of NMS include hyperthermia, altered mental status, muscular rigidity resembling extrapyramidal rigidity, autonomic instability, diaphoresis, hyper salivation, dysphagia, tachycardia, hypertension. NMS if left untreated, is usually fatal. So, early recognition and treatment is of great importance.

Methotrexate (MTX) Induced Pancytopenia - A Rare Serious Adverse Effect

A 65-year-old woman presented to us with complaints of fatigability and appearance of red spots on extremities since 6 days. She was a known case of rheumatoid arthritis since 5 years and was on tablet prednisolone 5 mg OD and tablet hydroxychloroquine 200 mg bid orally. Two months back she had exaggerated symptoms in the form of increased joint pains for which tablet methotrexate 7.5 mg was started weekly once and was increased to 7.5 mg bid (15 mg) per week 2 weeks back along with folic acid 5 mg per day.Methotrexate (MTX) is a folate antagonist used to treat various malignancies, and autoimmune disorders including rheumatoid arthritis. It enters cell by an active cellular uptake and inhibits dihydrofolate reductase (DHFR) enzyme that converts dihydrofolate (DHF) to tetrahydrofolate (THF) affecting purine and ultimately DNA synthesis. Cell with capability of polyglutamylation like myeloblasts and lymphoblasts are most susceptible to the effects of MTX because polyglutamylation prolongs its intracellular presence.1,2

In Search of an Ideal Obesity Assessment Tool : Is Body Mass Index Reliable Enough?

Obesity, a global pandemic, has become a chronic health problem within a modern western society. Obesity mimics the iceberg phenomenon wherein there is more to it than what we perceive resulting in various physical and psychological problems. Obesity is defined as surplus body weight for given height. . Obesity has been triggered by the growth of economy caused as an effect of industrialization, and urbanization, associated sedentary lifestyle, and transition of nutrition to canned foods. In the last few years, globally, countries have witnessed the spike in the rate of obesity. The endangering effects presented by obesity lead to numerous comorbidities that are being masked by the body dysmorphism. Metabolic disorders like diabetes mellitus type 2 and various cardiovascular risks hamper the regular metabolism of the body. Exploring the cascading effects in changing sedentary lifestyles draws many parallels to the surge in overweight and obesity among the people following such lifestyles. Increased adoption of sedentary lifestyles has resulted in a cascading effect on various metabolic disorders associated with obesity, globally. To address this surging concern, researchers around the globe have come up with multiple indices and parameters such as BMI, ABSI, VAI, BIA, DEXA, waist-hip ratio, and waist circumference, to quantify obesity in one final equation. However, these parameters have failed to give a conclusive summation that helps to identify the pre-symptoms of obesity. Similarly, variations in physical size and different body compositions for different weight categories usually pose tremendous challenges to quantify obesity. To make things more complicated various forms of obesity are being described and each has got its implication as far as the development of cardiovascular burden is concerned.This challenge presents the need to derive and identify a much robust, accurate and explicit index that would apply universally to all forms of obesity and would guide preventive and therapeutic strategies thereoff. In this article, an effort is being made to compare various parameters available globally to tail off the better and more reliable indicator available.

Assessment of Cytokeratin Expression in Carcinoma Breast

Breast cancer is the most common malignancy in females and an important cause of cancer deaths worldwide. With advances in oncopathology, breast cancers are now diagnosed and treated at a molecular level. To distinguish and subdivide the type of cancer with the suitable markers and to foresee its prognosis and therapeutic approach, cytokeratin can be used which is prognostic tumour marker and has a number of different advantages as it is an important IHC marker, cytokeratin (Ck) is epithelial intermediate filament, which is expressed in a tissue specific manner. Expression of the intermediate filaments, predominantly cytokeratins (Ck) reflects the epithelial cell type. In breast, the luminal epithelial cells express CK 8 / 18, CK 7 and CK 19, while basal cell expresses CK 5 / 6, CK 14 and CK 17. Bloom Richardson grading (BR) system has a powerful prognostic value. It is also incorporated in the algorithm for the determination in the use of adjuvant chemotherapy. Moreover, as a tumour marker cytokeratin can accurately predict disease status as it is easy, inexpensive and a reliable tool for efficient management. CK and BR grading can be used as cost effective diagnostic tools in hormone positive breast carcinoma for diagnosis as well as treatment. Very early detection of breast cancer reduces the mortality and morbidity.

Spectrum of Lesions on Upper Gastrointestinal Endoscopy and Its Correlation with Histopathological Evaluation.

Gastrointestinal (GI) diseases present with symptoms of abdominal pain, heartburn, diarrhoea, nausea, vomiting, flatulence, difficulty in swallowing, dysphagia, bloated abdomen, significant weight loss, fullness after having very little meal, and melena. Taking into account of just the upper GI bleed incidence, it ranges from 50 to 150/100,000 population annually, and time trend analyses suggest that aged people constitute an increasing proportion of those presenting with acute upper GI bleed.1An upper GI endoscopy or oesophagogastroduodenoscopy/ EGD aids in diagnosing and treating disorders of upper GIT. Endoscopy gives a visual look of GI mucosa and allows tissue sampling, for further assessment by pathologist. Abnormal endoscopic appearance indicates a disease, where biopsy will confirm.2 Histopathological examination (HPE) is the best confirmatory tool to confirm and find the diagnosis.3Various lesions affecting THE GIT are classified organ wise i.e. oesophageal, gastric and duodenal lesions. Clinical history remains central in evaluating oesophageal symptoms. Chief oesophageal symptoms are pyrosis, reflux, chest pain, dysphagia and odynophagia. Heartburn/pyrosis, is most frequent intermittent oesophageal symptom, presenting as an uneasiness/ burning sensation in retrosternum radiating toward neck. It occurs mostly after eating/while lying recumbent.4

Hashimoto s Encephalopathy (HE) - Early Manifestation of Impending Thyroid Storm.

Dear Dear HyperthyroidismiHyHyperthyroidism may be associated with various neuropsychiatric manifestations like anxiety, irritability, restlessness, decrease in concentration, dementia, lack of judgement and planning.[1] Rarely, seizures, myoclonus, chorea, or catatonia can occur. Encephalopathy may be present in only 1% of cases.

Coexistence of Miliary Tuberculosis with Tubercular Sacroiliitis in a Young Immunocompetent Female.

The incidence of musculoskeletal tuberculosis accounts for about one-third of all cases of tuberculosis occurring in extra pulmonary sites. The involvement of sacroiliac joint is rare and is commonly seen in immunocompromised young adults. Here we report the case of a 22-year-old immunocompetent female who presented to us with breathlessness, cough, lower back pain on right side and high-grade fever of 15 days duration. HRCT showed miliary mottling of both the lungs. MRI hip with sacroiliac joints revealed sacroiliitis. A Mantoux test was positive with 22 mm induration after 48 hours. Sputum AFB was positive for Mycobacterium tuberculosis. Sputum CB-NAAT test was positive. Sacroiliac joint aspiration sample was positive for CB-NAAT. The patient was administered with antituberculous drugs after which her symptoms began to subside and CXR was found to be normal on subsequent follow ups.Tuberculosis (TB) is one of the world’s most devastating infectious diseases caused by Mycobacterium tuberculosis, affecting nearly one-third of the world’s population.(1) India accounts for about 27% of total Global TB burden.(2) Tuberculosis of the musculoskeletal system, though accounts for only 1-3% of total TB cases,(3) of which approximately 10% occurs at the sacroiliac joint.[4-7]The majority of cases of hip TB presents as painful, restricted movements of the hip and there comes, the dilemma of accurate diagnosis as several pathologies may mimic this presentation.

Acute Liver Failure and Intravascular Haemolysis in Zinc Phosphide Poisoning.

A 37-year-old male presented with symptoms of nausea, vomiting, abdominal pain, jaundice, lacrimation and reddish brown urine discoloration since 2 hours after ingestion of 30 gms of zinc phosphide with suicidal intent 4 hours before arriving at the hospital. There was no history of hematemesis, melena, convulsions. On examination blood pressure: 140/90 mmHg, Pulse: 120 beat per minute, RR: 24 cycles/minute, temperature: 37.5°C and O2 saturation: 91 percent in room air. Visible icterus was present. Diffuse tenderness was reviled by abdominal tests. Organomegaly was not present. The neurological examination was not important. There were flapping tremors. With 0.9 percentage of NaCl solution added with activated charcoal, the patient was given gastric lavage. Table 1 displays laboratory tests in the emergency department.

The Pandemic of 21st Century: COVID – 19

The novel coronavirus or COVID – 19 as it has been namedhas transformed into a pandemic ravaging the world. As thedays pass, the number of cases seem to be increasing at analarming rate and few regions have managed to escape theclutches of this deadly virus. With no visible cure beingavailable at the moment, the healthcare sector of nations isworking against the clock in the hunt of a solution to thispuzzling problem. Belonging to family Coronaviridae, it isgenetically most similar to the Severe Acute RespiratorySyndrome (SARS) virus but manifestation of symptoms inboth the diseases is somewhat different. This portion of thearticle aims to elaborate the different methods employed fordetection and testing of COVID.This review deals with various statistics pertaining to thepandemic which have been reported and for whom, studiesand research has been carried out with a string of predefinedvariables included. It involves anaccount of the number ofcases reported, both in India and the World.While the fight against the pandemic is far from over, witheach day comes the hope, that our healthcare workers shall beable to find a resolution to this seemingly relentless problem.

Acute Disseminated Encephalomyelitis (ADEM) versus Multiple Sclerosis (MS)- A Diagnostic Challenge in an Adult.

Acute Disseminated Encephalomyelitis (ADEM) is a demyelinating disease of Central Nervous System (CNS). It usually is followed by infection and vaccinations. It commonly occurs in the paediatric age group. Its occurrence in adults is rare. When present in adults, a diagnostic dilemma always occurs between ADEM and Multiple Sclerosis (MS), because of overlapping clinical, and neuroimaging features. We present a case of a 46 year old female who presented to us with variable neurologic manifestations and later was diagnosed with ADEM. This case tries to embark on arguments so as to differentiate ADEM from MS while dealing with such cases.Acute Disseminated Encephalomyelitis (ADEM) and Multiple Sclerosis (MS) are both considered as immune mediated inflammatory demyelinating diseases of the central nervous system.1,2 Although considered as different conditions, the clinical presentation of both these conditions may overlap. The only gold standard differentiation is pathologically determined. Perivenous demyelination is a feature of ADEM and discrete confluent demyelination (plaque) is signature of MS. Still hybrid cases showing pathological features of both ADEM and MS may co-exist.ADEM, typically though not always is preceded by some infection or vaccination. The course of ADEM is usually monophasic and prognosis is better than MS which commonly presents with a relapsing and remitting course. Each exacerbating event worsens the clinical course in MS. Different clinical and/or radiological criteria to differentiate between the two spectrums of diseases have been proposed, but none of those unequivocally differentiate them.Hartung and Grossmann hypothesized that ADEM may be a part of the MS spectrum, rather than a different entity.3 The characteristic demyelination in ADEM is perivenous as opposed to MS where the demyelination is confluent. 4Acute Disseminated Encephalomyelitis (ADEM) is a demyelinating disease associated with inflammation and demyelination of the Central Nervous System (CNS) in a monophasic pattern. ADEM occurs commonly in paediatric age group often following viral infections, bacterial infections, or vaccinations.[5,6] The clinical characteristics include a sub-acute development of focal neurologic deficits, accompanied by encephalopathy. 5,6 It can rarely occur in middle-aged or elderly adults. The course is usually fulminant, but typically there is recovery in 50–75% of cases, with progression to multiple sclerosis in up to 20% of cases.[5,6]

Self-Examination of Scrotum- Need of the Hour to Create Awareness Regarding Testicular Pathologies- A Cross Sectional Study.

Although nowadays people are very much concerned when it comes to cancer, still they are not aware about the process and advantages of early detection. Testicular cancer is the most common cancer among males in the age group 18-50 years. Still people are not aware of self-examination of scrotum and testicular self-examination (TSE). Knowledge deficits and sociocultural norms contribute towards increased incidence of testicular pathologies. This study was aimed to assess knowledge and attitude of young male medical students regarding self-examination of scrotum/testis and various testicular pathologies.METHODSA cross sectional study was conducted in a rural tertiary care hospital attached to medical college. After getting approval from institutional ethics committee, 149 medical students were included in the study. A self-administered validated online questionnaire was made for pre-test and post-test consisting of 10 questions. The students were educated after pre-test and intervention was done in post-test. The data was collected through Google forms and data analysis was done using chi square test.RESULTSIn pre-test it was revealed that 39.5% of subjects didn’t have knowledge about self-examination of scrotum or testicles. Amongst 60.5% who knew about it, only 26.5% knew the procedure for performing the self-examination, and 24% knew the frequency for self-examination. The main barrier for 22.4% people was social and mental hindrance. In post-test, it revealed that still 11.41% didn’t have clear idea about procedure of self-examination and still after knowing all the advantages 12.08% people had social or mental hindrance.CONCLUSIONSThis study concluded health care professionals lack the necessary knowledge about TSE. Still the main problem lies in their perspective and attitude towards TSE as even after educating them regarding TSE and various testicular pathologies and its early detection and its advantages, 12.08% of students had social or mental hindrance. This study highlighted the various hindrances the educated, young, health care students have, where the real problem lies, and brings out the most important hindrance which is mental and social inhibition.

The World- After COVID-19 Apocalypse

Corona virus disease which originated from Wuhan in China has engulfed the whole globe. Covid-19 is leading the list of diseasespeople are extremely concerned about, followed by cancer and HIV/AIDS, according to the study by market research and analysiscompany Velocity MR. This disease has brought around many changes in the lives of people. The medical officials and scientistsare working all day long to find a cure for this disease or to create a vaccine. But the question that rises is will there ever be acure?. Will the world be normal again? For how long will this disease cause a havoc in the life of the people? And many suchquestions which still remain unanswered. But in this article we have discussed about how will the world change after COVID-19pandemic.

Primary Sjogren s Syndrome Presenting as Hypokalaemic Periodic Paralysis- A Rare Case Report

Sjogren’s syndrome is “an autoimmune disorder which is characterized by lymphocytic infiltration of salivary and lacrimal glands”. The commonest presenting symptoms are dryness of eyes, mouth and parotid gland enlargement. SS also has extra glandular manifestation in the form of RTA (renal tubular acidosis) seen in one-third cases. RTA presenting as hypokalaemic periodic paralysis is described in few cases in the literature as a rare presentation

High-Sensitivity C-Reactive Protein in Metabolic Healthy Obesity (MHO)..

Metabolically Healthy Obesity/Metabolic Healthy Obesity (MHO) is a paradox in scientific medical literature and discussion is still on regarding the safety status of MHO phenotype. It is an obesity phenotype where the subjects have BMI more than or equal to 30 Kg/m2 but are devoid of conventional metabolic complications such deranged lipid profile, altered glucose tolerance, or metabolic syndrome as they have less adverse inflammatory profile, low visceral fat, less disturbed insulin signalling, and lipid metabolism. But recently studies are coming up with robust evidence that MHO is not a benign condition. It may lead to metabolic syndrome in future and it is also associated with cardiometabolic risks.METHODSThis cross-sectional study was done in a tertiary care hospital conducted for a period of two years from October 2017 to October 2019. After obtaining institutional ethical clearance, this cross-sectional study was conducted on 120 MHO subjects, 120 metabolic syndrome (MS) and 120 Metabolic Healthy Non-Obese (MHNO) subjects. Anthropometric data was obtained, and hs-CRP was estimated and compared with MS and MHNO group. The data was analysed using appropriate statistical significance tests.RESULTSIn one-way Analysis of Variance (ANOVA), anthropometric determinants and metabolic variables differed significantly across the groups (p<0.0001). The mean hs-CRP in MHO was; 4.45 ± 1.46 and in the control group it was 1.84 ± 0.77 (p<0.0001). Using Pearson’s correlation coefficient, significant positive correlation was found between hs-CRP with other anthropometric and metabolic parameters. In multiple regression analysis, Body Mass Index (BMI), Waist Circumference (WC), were significantly associated with elevated hs-CRP. Adjusted odd’s (AOR) of abnormal hs-CRP in MHO was 1.9 times that of MHNO subjects.CONCLUSIONSMHO phenotype is associated with increased hs-CRP levels as compared to MHNO phenotype suggesting that obesity even if associated with a healthy metabolic profile, still harbour subclinical inflammation. So, subjects with MHO should be targeted for appropriate preventive strategies in the form of health education, lifestyle alterations to avoid future cardiovascular morbidities. MHO phenotype with evidence of subclinical vascular inflammation should not be considered a benign condition.

Study of Morphological Patterns of Leprosy in a Rural Setup.

Leprosy is a chronic disease of ancient world and is still afflicting patients in many parts of world mainly Asia and Africa. Leprosy is one of the most dreaded diseases of humankind. We wanted to study the various microscopic patterns and subtypes of Leprosy. We also wanted to study the Bacterial Index in the region of Sawangi, Meghe.METHODS80 skin biopsies after adequate fixation in 10% of formalin, were routinely processed and were stained with H and E, Fite-Faraco stain and Modified Rapid Acid-Fast Bacilli (MRAFB staining) method, were studied microscopically and bacterial index was calculated.RESULTSA total of 80 skin biopsies were obtained from patients of department of dermatology over a period of two years from 2017 to 2019. Among them Lepromatous leprosy were 43 cases, Tuberculoid leprosy were 23 cases, Borderline lepromatous leprosy were 09 cases, Borderline tuberculoid leprosy were 03 cases, histoid leprosy were 01 case and ENL were 01 case. With an age range of 6 - 85 years, majority were in 31-40 years of age group, with male to female ratio of 2.47:1. LL was the most common type of leprosy (53.75%).CONCLUSIONSAccurate diagnosis of leprosy purely on clinical grounds is extremely difficult. Hence, there can be false positive and false negative diagnosis. Since histopathology is confirmatory, with application of Fite-Faraco and MRAFB staining it can also evaluate the bacterial load. Hence in all suspected cases of leprosy, histopathology along with Fite-Faraco and MRAFB staining should compulsorily be done.

Acute B Virus Hepatitis with Fulminant Hepatic Failure Precipitating Crisis in Sickle Cell Disease.

Sickle cell disease (SCD) is a hemoglobinopathy which involves multiple organs in the body. Hepatobiliary manifestations in SCD are many. Acute and chronic HBV infection may be transmitted through multiple blood transfusions in SCD. We report the case of a 36-year-old male with sickle cell disease who presented to us in acute liver failure and sickle cell crisis due to acute hepatitis B virus infection. Sickle cell disorder is a broad category under which all the patients who have a point mutation (haemoglobin S-HbS) on at least one Beta chain due to substitution of valine in place of glutamic acid at position 6 are included. Due to this substitution, HbS molecules have a sticky site allowing the molecules to aggregate. This aggregation worsens in deoxygenated state leading to the development of long polymers, sickling of erythrocytes and haemolysis. The most commonly affected site in SCD is the hepatobiliary system. The presentation due to this involvement varies from benign hyperbilirubinemia to a spectrum of manifestations termed “sickle cell hepatopathy”.1

Smart phones for medical undergraduates: friend or foe?

Background: Smart phones are truly a boon for us in all aspects of our life. It helps mankind to lead a faster and easier life, but the same devices used to get things done are now the gatekeepers of an infinite number of distractions and sources of instant gratification. Even though, there is an ocean full of information a click away, we fail to utilize it for something resourceful. Increased media consumption, multi screening and social media usage reduce the ability to focus on tasks and duties which have a much higher priority.Methods: A cross sectional study was conducted with a validated questionnaire among 200 undergraduate MBBS students of a deemed to be medical university.Results: Among the ninety-eight per cent of the students who own a smartphone, all have access to the internet. Seventy-seven per cent of the students use these gadgets on a very regular basis throughout the day and among them only forty-six per cent were found to be using it for academic purposes.Conclusions: Through this study, it has become more discernible that smart phones have paved its way for a reckless future, though if used wisely it would become a blessing in disguise. The ever-changing medical fraternity could really benefit from this discovery but alas, a tool made to make our lives easier is weighing us down with its addictive and time-consuming features.

Carotid and femoral intima-media thickness in adults with sickle cell disease

Background: This study was conducted to evaluate Carotid Intima Media Thickness (CIMT) and Femoral Intima Media Thickness (FIMT) in adults with SCD.Methods: The present prospective cross-sectional study with control group was carried out in Department of Medicine at Acharya Vinoba Bhave rural hospital over a period of 6months from January to June 2018. A total of 100 (50 cases of SCD, 50 normal subjects) were studied. In the SCD group, 35 cases were patients regular follow up cases and 15 patients were in sickle cell crisis. CIMT of both left and right carotids were taken and the mean of the two values were recorded. The IMT was also measured in the right common femoral artery (RCFA) and left common femoral artery.Results: SCD patients in steady state had significantly decreased Hb%, increased WBC counts and platelet counts as compared to healthy controls. The mean right FIMT, left FIMT, right CIMT and left CIMT the patients with SCD with crisis were significantly higher than that of the patients without SCD (P<0.001). One way showed that there were significant differences in duration of disease in mean level of Hb%, WBC count, platelet count of the patients in the three groups (p<0.01).Conclusions: CIMT and FIMT can pick up the macrovascular involvement early and can be utilized as screening tools to predict vascular injury so that at risk individuals would be subjected to proper treatment protocols, especially hydroxyurea therapy early on.

A Rare Case Of Fenoxaprop-P-Ethyl Poisoning: Presenting As Acute Myocardial Infarction

Fenoxaprop-P-ethyl (FPPE) is a phenoxy herbicide and exerts its herbicidal action by interfering with fatty acid biosynthesis through inhibition of acetyl-CoA-carboxylase in plant chloroplast and thereby hampering fatty acid synthesis. It also inhibits this enzyme in the mammalian liver and has produced reversible hepatic toxicity in laboratory studies. Poisoning with this herbicide is uncommon, and herbicide product appears to be safe in patients with an acute self-poisoning, particularly in comparison with other herbicides and causing few clinical features. Here, we report the case of a 35-year-old male patient presented with FPPE poisoning. He came with an altered sensorium and later on developed acute myocardial infarction. Even after appropriate management, the patient deteriorated and succumbed.