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.

Acute Transient Hemiparesis - An Unusual Pseudo Exacerbation of Multiple Sclerosis

Multiple sclerosis is a chronic demyelinating disease characterised by inflammation and plaque formation. Multiple sclerosis has many variants. It presents as four clinical forms, Relapsing Remitting Multiple Sclerosis (RRMS), Primary Progressive Multiple Sclerosis (PPMS), and Secondary Progressive Multiple Sclerosis (SPMS) and Primary Relapsing Multiple Sclerosis (PRMS). RRMS can present as acute attacks. They should be differentiated from pseudo-exacerbations. True exacerbation is when a new lesion appears in the brain or spinal cord, with a neurological episode lasting for more than 24 hours, with a period of clinical stability over the last 30 days.1 Any flaring up of symptoms of multiple sclerosis due to external factors such as fever, heat or infection is called pseudo-exacerbations. Pseudo-exacerbation episodes do not last for more than 24 hours and should resolve with treatment of the underlying fever or infection.2

Subdural Haematoma (SDH) Leading to Subfalcine Herniation in a Case of End Stage Renal Disease

Subdural haematoma (SDH) is characterized by bleeding into the sub dural space surrounding the brain. It is mostly associated with atraumatic brain injury. It usually results from tears in bridging veins that cross the subdural space. ESRD is a risk factor for SDH. Coagulation abnormalities, volume overload, haemodialysis and platelet dysfunction predispose to SDH in ESRD and increase the morbidity and mortality.1 We report a case of a 44-year-old female, a known case of chronic kidney disease on maintenance haemodialysis who developed SDH with resulting subfalcine herniation.

Atypical Presentation of Gitelman Syndrome (GS) Masquerading as Hypokalaemic Periodic Paralysis

Gitelman syndrome once considered to be a subset of Barter’s syndrome, is a disorder of the distal tubule.1,2 It is an inherited disorder of the thiazide sensitive sodium-chloride transport channel. It is characterised by its main clinical features of metabolic alkalosis, hypomagnesemia, hypokalaemia and hypocalciuria. It’s an infrequently diagnosed condition where there diagnosis is made based on the clinical and the biochemical parameters of the disease. We present a case of Gitelman syndrome in a young male who presented with recurrent episodes of weakness to different private hospitals with documented hypokalaemia and labelled as hypokalaemic periodic palsy (HPP), presented to us with quadriparesis and on investigation diagnosed as GS.

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

Clinical Application of Fasting and Post-Prandial Lipid Profile in Patients of Chronic Kidney Disease.

Dyslipidemia is a traditional risk factor for cerebrovascular disease and cardiovascular disease (CVD). CKD is associated with dyslipidemia. Patients with CKD will be more prone to the CVD and cerebrovascular disease as compared to normal healthy individuals. Thus, it is important to cover the postprandial lipid profile for better assessment and treatment of dyslipidemia. We wanted to study the postprandial lipid profile in patients of CKD. MethodsThis is a case control study conducted in Acharya Vinoba Bhave Rural Hospital (AVBRH) Sawangi (Meghe), Wardha, Maharashtra, between September 2016 and September 2018. In this study, we enrolled 150 cases and 75 controls. ResultsFasting lipid profile in CKD patients was higher as compared to controls and was found to have similar post-prandial lipid profile. When we compared the fasting and post-prandial lipid profile in patients with CKD, we found that a substantial difference existed. We found a considerable difference in the fasting and post-prandial lipid profiles even in the controls. ConclusionsPatients with CKD and diabetes mellitus had a significant increase in the total cholesterol, triglycerides, low density lipoprotein and very low-density lipoprotein in the fasting and post-prandial state. In clinical practice, the implementation of standardized methodologies and biomarker profiles would allow for the early and reliable detection of those at risk.

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.

Splenic Abscess Complicating Scrub Typhus Induced Splenic Infarct - A Rare Case Report

Any condition leading to the interruption of blood flow to the spleen, such as blockage in the splenic artery due to a plaque or a clot in one of its branches leads to Splenic Infarction. It could also be due to infection, trauma, disseminated intravascular coagulation and vasculitis. The complications of splenic Infarct include pseudocyst, haemorrhage, rupture, aneurysm and rarely abscess formation due to infection of the infarcted region. Splenic abscess is a rare and potentially lethal clinical condition. We present a case of a 24-year-old male who was diagnosed with splenic infarct because of scrub typhus and later developed splenic abscess.Spleen is a lymphatic organ present in the left hypochondrium of the abdomen. It filters and stores the red cells, produces white blood cells and scavenges microorganisms like bacteria. Any condition leading to the interruption of blood flow to the spleen could cause an infarct. The infarction could be classified as partial or complete based on the extent of involvement. The area of the spleen which had loss of blood supply leading to the death of the area is called splenic Infarct. It could also be due to infection, trauma or certain diseases. Rarely splenic infarcts may lead to formation of abscess. The most commonly occurring symptoms of a splenic abscess pain in the abdomen, fever and nausea are not specific to splenic abscess.[1] Hematogenous spread is the most common cause of splenic abscess.[2]

Acute Exacerbation of COPD Triggered by Pneumonia, and Secondary Spontaneous Pneumothorax (SSP).

Secondary Spontaneous Pneumothorax (SSP) can rarely complicate Chronic Obstructive Pulmonary Disease (COPD). Infections are common triggers for exacerbations of COPD. COPD with acute exacerbation presents with increasing dyspnoea. We present a rare case of a 75 year old female, who was a known case of COPD and developed right middle lobe pneumonia with partial collapse of the middle lobe along with a secondary spontaneous pneumothorax.

Correlation of ECG Changes with Coronary Angiographic Findings in Patients of Coronary Artery Disease.

Coronary Artery Disease (CAD) is the most common type of heart disease. Assessment of coronary artery disease (CAD) is the starting point of determination of prognosis of patients presenting with clinical symptoms. ECG reflects the physiology of the myocardium during ischemia, while Coronary Angiography identifies vessel anatomy. In the present study, we aimed to correlate ECG changes with coronary angiographic findings along with prediction of number of vessels involved in patients of coronary artery disease. This study also intended to determine sensitivity and specificity of ECG for diagnosis of coronary artery disease using CAG as gold standard. MethodsThis cross-sectional study was carried out for a period of 2 years at Acharya Vinobha Bhave Rural Hospital, a tertiary rural health institute. 200 patients above 18 years of age who presented with or without symptoms and were willing for ECG and Angiography were included in study. Patients with valvular and congenital heart disease were excluded. Patients were divided into groups according to ECG changes and correlated with coronary angiography findings. ResultsIn the present study, the sensitivity and specificity of ECG to diagnose myocardial infarction or ischemia (AWMI / AWI, IWMI / IWI, and LWMI / LWI) ranged from 87.50% to 96.63% and 91.30% to 95.45%, respectively. Diagnostic accuracy of ECG to detect myocardial infarction or ischemia (AWMI / AWI, IWMI / IWI, and LWMI / LWI) ranged from 89.36% to 96.40%. ConclusionsECG is used as reliable tool for the diagnosis of coronary artery disease due to its high sensitivity and specificity, though CAG is the Gold Standard method for the diagnosis of CAD.

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.

Sickle Cell Retinopathy (SCR) in a Patient with Sickle Cell Trait - A Rare Case Report.

Sickle cell trait is an inherited hematologic anomaly that affects 1 million to 3 million Americans and 8 to 10 percent of African Americans. It also affects other races like Hispanics, south Asians, Caucasians from southern Europe, and people from Middle Eastern countries. Evidence based estimations suggests that more than 100 million people worldwide have sickle cell trait. Unlike sickle cell disease, where two genes that cause the production of abnormal haemoglobin, individuals with sickle cell trait carry only one defective gene and typically live normal lives. Extreme conditions such as severe dehydration and high-intensity physical activity can lead to serious health issues, including sudden death, for individuals with sickle cell trait. We present a case of a young female with sickle cell trait who presented with overt retinopathy which is a rare phenomenon.

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.

Co-Existence of Chronic Lymphocytic Leukaemia and Malignancy of Uterine Cervix

Chronic Lymphocytic Leukaemia (CLL) is the most common variety of leukaemia. In this disease B-lymphocytes which would normally respond to antigens by transformation and forming antibodies, fail to do so. Patients with chronic lymphocytic leukaemia have up to a threefold risk of site specific secondary cancers. However, the co-existence of chronic lymphocytic leukaemia with gynaecological cancers is a rare phenomenon. Expert clinical and pathological review is warranted for proper diagnosis and management. Here we report a case of 57 year old patient with co-existent CLL and squamous cell carcinoma of the uterine cervix.Chronic Lymphocytic Leukaemia (CLL) is the most common leukaemia affecting the western world. It occurs mostly in the elderly.[1] It is less frequent in the Asian population. CLL is characterized by clonal proliferation and accumulation of mature, typically, CD5 positive B-cells within the bone marrow, spleen, blood and lymph nodes.[2]