Iron Deficiency Anemia as a Potential Risk Factor for Unprovoked DVT in Young Patients: A Case Series.

Deep vein thrombosis (DVT) is a serious and potentially life-threatening condition due to the occurrence of pulmonary embolism (PEs) in the acute phase. DVT can be provoked or unprovoked. Provoked DVT can be associated with transient or persistent causes. Iron deficiency anemia (IDA) with reactive thrombocytosis can act as a prothrombotic condition. We present two case reports of lower limb DVT which was associated with moderate anemia. Association between IDA and thrombosis has been reviewed.

Role of Ambulatory Glucose Profile in Precision Medicine in Type 2 Diabetes Mellitus.

Assessment of diabetes with daily blood glucose fluctuations including peaks and nadirs forms the crux of the modern management. Use of glycemic variability (GV) as a parameter to assess these fluctuations is emerging. It is important to determine the hyperglycemic and hypoglycemic episodes which are the culprits for increasing glycemic variation. Diabetes mellitus patients follow different clinical trajectories which can be traced by the ambulatory glucose profile (AGP) obtained from flash glucose monitoring system (FGMS). MATERIAL: This comparative observational study enrolled 106 adult (>18 years) type 2 diabetes patients with HbA1c<8%. Patients were divided into two groups (group A & group B) with 53 patients each. Group A included patients on OAD's (oral antidiabetic drug) with insulin and Group B included patients on OAD's without insulin. The patients were put on FGMS for 14 days and their AGP was analysed. Hyperglycemic episodes (level 1- >180 mg/dl, level 2- >250 mg/dl) and hypoglycemic episodes (level 1- 54-70 mg/dl, level 2- <54 mg/dl) were determined between the groups. OBSERVATION: Group A patients had significantly higher (29.99%) total number of hyperglycemic episodes (Level 1+ Level 2) as compared with group B (9.08%) (p <0.0001). Amongst group A, proportion of patients with total number of hyperglycemic episodes was significantly higher in insulin only subgroup (58.11%) followed by insulin +metformin+ 1 OAD (29.14%) & insulin+ metformin (26.82%) (p <0.0001). Amongst group B, total number of hyperglycemic episodes were found to be significantly higher with metformin only subgroup (10.19%) followed by metformin + 1 OAD (9.72%) & metformin + >1 OAD (8.1%) (p<0.0001). Amongst the add on OAD's, sulfonylurea contributed to 61.07% hyperglycemic episodes in group A & 11.63% in group B which was statistically more than DPP-4 inhibitors with 14.91% & 2.84% respectively (p <0.0001). Total number of hypoglycemic episodes seen in group A patients (8.66%) were significantly less as compared with group B (13.27%) (p<0.0001). Sulfonylurea contributed to 7.5% hypoglycemic episodes in group A & 13.2% in group B which was statistically more than DPP-4 inhibitors with 6.49% & 12.35% respectively when added to metformin (p<0.0001). CONCLUSION: Amongst the OAD's used in type 2 diabetes mellitus patients in this study, total number of hyperglycemic and hypoglycemic episodes were found to be more in patients taking sulfonylurea as compared with DPP4 inhibitors when used in combination with metformin with or without insulin.

A case of Weil's disease presenting as Stevens-Johnson syndrome.

Leptospirosis presents in a biphasic manner: an early leptospiraemic phase and a late immune phase. In its severe form, it presents with multi-organ failure, also known as Weil's disease. Stevens-Johnson syndrome (SJS) is an autoimmune hypersensitive reaction leading to diffuse fluid filled vesicle formation with detachment of skin and mucous membrane. Though SJS is triggered by different infections and drugs, its association with leptospirosis is not frequently reported. Here we present such a case.

A cross-sectional evaluation of communication skills and perceived barriers among the resident doctors at a tertiary care center in India.

BACKGROUND: The study was conducted to assess the different components of communication skills and barriers to practicing good communication skills among resident doctors in a health care setting. MATERIALS AND METHODS: A web-based cross-sectional survey was performed, and data were collected using a pre-validated questionnaire with a Cronbach's alpha (0.88). A total of 431 responses were statistically analyzed. Chi-square test was used to associate the socio-demographics and communication skills. Regression analysis was conducted to analyze the association between various communication domains and barriers, which were adjusted for potential confounders such as age and gender. RESULTS: Resident doctors have differential levels of competencies in each domain of communication skills. Around two-thirds of the residents did not practice good communication skills while breaking the bad news and reported poor para-verbal skills. Some of the most common barriers to practicing good communication skills were found to be an infrastructural deficit, lack of time, and long working hours. These barriers significantly affected the communication skills such as para-verbal skills {[-0.32; P < 0.01; C.I (-0.54 to -0.09), [-0.27, P < 0.05, C.I (-0.54 to. 004)], [-0.32, P < 0.01, (0.07-0.56)]}, the ability to break bad news {[-0.42, P < 0.01, (-0.73 to -0.11)], [-0.35, P < 0.05, (-0.75 to -0.35)], [0.48, P < 0.01, (0.12-0.84)]}, and communication with patients/attendants {[0.39, P < 0.01, C.I (-0.71 to -0.06)], [-0.88, P < 0.001, C.I (-1.2 to -0.48)], [-0.88, P < 0.001, C.I (-1.2 to -0.48)]} after adjustment for confounding such as age and gender. CONCLUSION: There is a scope for improvement in practicing good communication skills with patients, among the residents doctors in India. Structured modules for training and evaluation should be implemented in the medical curriculum.

A rare case of abdominal cocoon caused by brucellosis.

Brucella is the most common zoonosis in the world and is also included among the neglected endemic zoonoses by the World Health Organization. Its clinical presentation is often vague and it is not frequently suspected. A thorough history of social-economic status and animal exposure is often missed. We present a case of abdominal cocoon in a young patient residing at a dairy farm who tested positive for Brucella serology. Timely diagnosis and management prevented the progression of this debilitating condition to intestinal obstruction.

Post-COVID Interstitial Lung Disease - The Looming Epidemic.

INTRODUCTION: As India recovers from the two waves of the Covid-19 pandemic, its sequelae are posing a new challenge to the physician. These may vary from fatigue and myalgia to persistent, and even worsening breathlessness, due to pulmonary fibrosis. Management of post-COVID-19 pulmonary fibrosis is currently limited to symptomatic management and largely an unexplored aspect. OBJECTIVES: To draw attention to the imminent threat of post-COVID-19 interstitial lung disease (PC-ILD) in COVID survivors through a case series. METHODS: A retrospective analysis of data was done in patients admitted with severe COVID in December 2020 at our tertiary care hospital, and who had a prolonged stay with symptoms and signs suggestive of pulmonary fibrosis. HRCT was done to make a diagnosis of pulmonary fibrosis or ILD. Three such patients were identified. RESULTS: All the three cases were laboratory proven SARS CoV-2 positive cases and had developed pulmonary fibrosis, with traction bronchiectasis, termed here as PC-ILD (Post Covid-Interstitial Lung Disease). Two of them survived and had improved oxygen saturation on room air at three-month follow-up, while one patient had developed arrhythmia and died. CONCLUSION: PC- ILD is one of the emerging complications of COVID-19 pneumonia. A proactive follow-up programme should be undertaken to identify and manage this looming epidemic.

Measles in immunized medical residents: Case series with brief review.

Measles is a vaccine-preventable disease that continues to be a major cause of morbidity and mortality in children and young adults across the world. Immunization efforts have reduced the incidence of measles over the last 3 decades, but outbreaks are seen in high-transmission areas with susceptible populations, as is seen in hospitals and student campuses. The protection offered by prior vaccination may wean off over time making vaccinated individuals susceptible to infection. Hence, catch-up immunization drives should be undertaken for vulnerable populations such as healthcare personnel, along with routine immunization programs, with the goal to eliminate measles in the future. This case series presents measles in two of our medical residents who got infected despite being vaccinated in childhood.

COVID-19 and Tuberculosis: A Meeting of Two Pandemics!

Coronavirus disease 2019 (COVID-19), causes serious respiratory illness manifesting as pneumonia, adult respiratory distress syndrome and respiratory failure. Amidst the rising number of cases and deaths, it is imperative to not forget Tuberculosis (TB) which is another pandemic existing since centuries. There could be dire consequences for tuberculosis patients globally especially in low and middle income countries with a high burden of disease and overwhelmed health care systems. Tuberculosis is still the leading infectious killer worldwide, and therefore, it is crucial to reflect on the interaction between the two diseases. Evidence suggests that both COVID-19 and tuberculosis have a synergistic relationship, boosting detrimental effect of each other, disrupting existing health care models, and also worsening the clinical outcomes in terms of morbidity and mortality. This review aims to draw attention towards this pertinent clinical issue, and tries to unravel the intricate relationship between COVID-19 and tuberculosis, as also the role of BCG vaccination to combat the COVID-19 pandemic.

Serum Vitamin D Level in Patients with Coronary Artery Disease and Association with Sun Exposure: Experience from a Tertiary Care, Teaching Hospital in India.

BACKGROUND: Vitamin D, a fat-soluble vitamin, has various extraskeletal effects, and several human and animal studies have suggested that vitamin D deficiency may be a contributory factor in the pathogenesis of coronary artery disease (CAD). However, such studies in the Indian subcontinent are either lacking or have shown conflicting results. METHODS: This was a descriptive cross-sectional study involving 121 patients with CAD from a tertiary care center and their 80 age-matched healthy controls. Serum vitamin D levels along with serum and urine chemistries were measured in both the groups. The average duration of sun exposure/day and use of sunscreen were also considered in the study cohort using a questionnaire. Serum vitamin D levels were categorized into deficient (<30 nmol/lit), insufficient (30-75 nmol/lit), and sufficient (>75 nmol/lit) groups. RESULTS: Among the cases, 51.2% of the patients were vitamin D deficient and 44.6% patients had insufficient vitamin D levels, whereas among controls, 40% and 31% of the population had deficient and insufficient levels of vitamin D, respectively. However, the mean value of the serum vitamin D level was not statistically different in the cases as compared to that of the controls (34.06 vs 40.19 nmol/lit) (P=0.08). Corrected serum calcium (9.26 vs 9.59 mg%) (P ≤ 0.0001) and serum albumin levels (4.21 vs 4.75 gm%) (P ≤ 0.0001) were lower in the cases than those of the controls. The average sun exposure/day was higher among the cases than that among the controls (2.93 vs 1.85 hours) (P=0.001). CONCLUSION: Vitamin D deficiency is widely prevalent in Indian population despite abundant sunshine, and the duration of sun exposure is not correlated with serum vitamin D levels. Vitamin D deficiency is not associated with CAD. However, serum calcium is deficient in CAD patients as compared to the controls. Large-scale studies are required to explore the association further to evaluate the benefits of screening and correction of vitamin D deficiency in patients with CAD.

Laparoscopic splenic pseudocyst management using indocyanine green dye: An adjunct tool for better surgical outcome.

Splenic cysts are not so common in incidence. Only 800-850 cases have been reported till now in the literature. Splenic cysts can be further classified into parasitic and non-parasitic cysts. Non-parasitic cyst is further subdivided into true and false or pseudocyst. Pseudocysts are those who are lacking any epithelial lining. Splenic pseudocysts are usually a result of trauma, infection or infarction. We present a case of splenic pseudocyst that was diagnosed incidentally on routine check-up, and we managed this case with minimally invasive approach with complete preservation of spleen and only removal of pseudocyst. We used indocyanine green dye that helped us in complete delineation of splenic parenchyma and vascular structure adjacent to it. In our view, as in this study also, adopting a new technique that can be helpful in better treatment of the patient and if it can change the surgical outcome of the disease in favour of the patient, it should be encouraged.

Coronary artery disease and its association with Vitamin D deficiency.

Coronary artery disease (CAD) has become the latest scourge of humankind and referred to in this article as CAD, is the end result of the accumulation of atheromatous plaques within the walls of coronary arteries that supply the myocardium, a process also known as atherosclerosis and manifests mostly in the form of chronic stable angina or acute coronary syndrome. Vitamin D has attracted considerable interest recently due to its role in a number of extraskeletal disease processes including multiple sclerosis, malignancies, diabetes mellitus, and CAD. It is also known as sunshine vitamin due to its production in the body following exposure to ultraviolet rays, and it is a unique vitamin as it acts like a hormone with its receptor present in a wide range of tissues including endothelium, which is the important mediator of atherosclerosis and subsequent CAD. A large number of studies conducted in the past have provided the basic scientific framework and this article attempts to explore the role of Vitamin D deficiency in the pathogenesis of CAD and stresses the need for further research to fill up gap in our knowledge.

A new genus and species of arboreal toad with phytotelmonous larvae, from the Andaman Islands, India (Lissamphibia, Anura, Bufonidae).

A new bufonid amphibian, belonging to a new monotypic genus, is described from the Andaman Islands, in the Bay of Bengal, Republic of India, based on unique external morphological and skeletal characters which are compared with those of known Oriental and other relevant bufonid genera. Blythophryne gen. n. is distinguished from other bufonid genera by its small adult size (mean SVL 24.02 mm), the presence of six presacral vertebrae, an absence of coccygeal expansions, presence of an elongated pair of parotoid glands, expanded discs at digit tips and phytotelmonous tadpoles that lack oral denticles. The taxonomic and phylogenetic position of the new taxon (that we named as Blythophryne beryet gen. et sp. n.) was ascertained by comparing its 12S and 16S partial genes with those of Oriental and other relevant bufonid lineages. Resulting molecular phylogeny supports the erection of a novel monotypic genus for this lineage from the Andaman Islands of India.