Magnetic Resonance Guided Focused Ultrasound Thalamotomy for Treatment of Severe Essential Tremor in a Lung Transplant Recipient-A Case Report.

Calcineurin inhibitor-related tremors occur in up to 50% of solid organ transplant recipients and are disabling in severe cases. We describe a bilateral lung transplant recipient with essential tremors that significantly worsened after tacrolimus initiation. She did not have improvement with the change to extended-release tacrolimus, the use of everolimus as a calcineurin inhibitor-sparing agent, or the addition of primidone, clonazepam, or propranolol. She underwent magnetic resonance-guided focused ultrasound thalamotomy with significant improvement in her tremor and activities of daily living.

COVID-19 and tuberculosis co-infection in pregnancy - A case series and review.

Various guidelines are in place for management for COVID-19 and pulmonary tuberculosis (PTB) in pregnancy. However, to the best of our knowledge, there are no significant guidelines for the management of COVID-19 and PTB co-infection in pregnancy. Pregnancy being an altered physiological state, the use of various drugs and their outcomes are altered. Here we present two cases of COVID-19 and PTB co-infection in pregnancy which were managed successfully.

Encephalopathy in the Setting of COVID-19: A Case Report.

We present an interesting case of encephalopathy in a patient diagnosed with COVID19 pneumonia describing the clinical course and recovery. We hope this unique presentation can contribute to the ever-growing evidence and literature on COVID-19 encephalopathy.

COVID-19 and Management of Severe Acute Respiratory Infection (SARI): A Questionnaire-Based Study Among Indian Healthcare Professionals.

BACKGROUND: COVID-19 presenting as SARI (severe acute respiratory syndrome) mandates the need for ICU (intensive care unit) hospitalization, increasing healthcare burden. This study aims to determine knowledge of healthcare professionals towards management of SARI in COVID-19 suspected cases. METHODS: A total of 313 healthcare professionals from the state of Maharashtra, India completed a questionnaire-based survey study adapted from the WHO interim guidance for management of SARI in COVID-19 suspected cases. Convenience sampling method was used and the distribution of responses was presented as frequencies and percentages. Sub-groups were classified on the basis of gender, age, profession and ICU vs. Non-ICU setting. Descriptive statistics were performed for all groups based on percentage of correct responses and individual pairwise comparisons were done using the Chi-Square test. RESULTS: The median and mean percentage of correct responses for all sub groups was only 66.80% and 58.62% respectively. A higher percentage of total correct responses were those from the ICU setting with a higher overall performance from medical postgraduates. The nursing and allied healthcare professionals had a poor overall performance. CONCLUSIONS: The findings indicate lacunae in several aspects of SARI management which calls for nationwide studies and implementation of comprehensive training programmes. A uniform structured training program with team-oriented crisis resource management suitable for all healthcare professionals irrespective of prior training in COVID-19 management must be implemented. Furthermore, the findings of this study can serve as a baseline to develop training resources for healthcare professionals for COVID-19 management.

COVID-19 Awareness Among Healthcare Students and Professionals in Mumbai Metropolitan Region: A Questionnaire-Based Survey.

Background and objectives The rapid and extensive spread of the COVID-19 pandemic has become a major cause of concern for the healthcare profession. The aim of this study is to assess the awareness of COVID-19 disease and related infection control practices among healthcare professionals and students in the Mumbai Metropolitan Region. Materials and methods A total of 1562 responders from the Mumbai Metropolitan Region completed a questionnaire-based survey on the awareness, knowledge, and infection control practices related to COVID-19 infection in the healthcare setting. The questionnaire was adapted from the current interim guidance and information for healthcare workers published by the US Centers for Disease Control and Prevention (CDC). Convenient sampling method was used for data collection and the distribution of responses was presented as frequencies and percentages. Descriptive statistics were performed for all groups and subgroups based on the percentage of correct responses. Individual pairwise comparisons were done using the median test for the percentage of correct responses. Results The overall awareness for all subgroups was adequate with 71.2% reporting correct answers. The highest percentage of correct responses were from undergraduate medical students and the lowest was from non-clinical/administrative staff. Less than half of the total respondents could correctly define "close contact." More than three-fourths of the responders were aware of the various infection control measures like rapid triage, respiratory hygiene, and cough etiquette and having a separate, well ventilated waiting area for suspected COVID-19 patients. However, only 45.4% of the responders were aware of the correct sequence for the application of a mask/respirator, and only 52.5% of the responders were aware of the preferred hand hygiene method for visibly soiled hands. Conclusion There is a need for regular educational interventions and training programs on infection control practices for COVID-19 across all healthcare professions. Occupational health and safety are of paramount importance to minimize the risk of transmission to healthcare students and professionals and provide optimal care for patients.

Public Awareness of the Emergency Medical Services in Maharashtra, India: A Questionnaire-based Survey.

Background and objectives The most widely used emergency medical services (EMS) model in India is the '108' emergency service which primarily functions as an emergency response system to attend patients in need of critical care, trauma and accident victims. This is an observational cross-sectional study which was conducted using a questionnaire that asks the participants about their awareness and opinion of the current EMS system. The results of this study will enable us to ascertain the level of awareness of EMS among the population and address any misconceptions if they exist. Materials and methods All participants had to complete a 24-item self-administered questionnaire consisting of eight socio-demographic questions and 16 questions based on the EMS system. Questions regarding the development of the '112' unified emergency service were also included. The convenient sampling method was used for data collection. The distribution of responses was examined using frequencies and percentages. Further analysis was done using the Chi-square test to compare responses between various subgroups based on the age, gender, profession, and level of education. Results A total of 1220 people from the state of Maharashtra responded to the survey and the maximum responses were from Mumbai. Majority of the respondents (59.2%) were from the age group of 15 to 30 years and, most of our responders had received education at the graduate level or above (78.2%). Only 17.5% of the respondents said that they will try to check for responsiveness if they saw a person lying unconscious by the side of the road with the scene being free of any danger. Interestingly, 78.9% of the healthcare professionals who participated in this survey would not check for responsiveness. Only 76.2% of the respondents knew that '108' is the number to dial in case of a medical emergency and about a quarter of them was not aware of it. It may seem that a good number of people are aware of the number. However, with the high number of fatalities occurring every day due to lack of medical facilities and a high current annual death toll on the roads, 100% of the population should know the emergency number. Only 20.2% of the respondents had called the EMS and asked for an ambulance. 68.5% of the respondents would immediately move out of the way and 27.5% of them would move out of their way if the ambulance's lights and sirens were on. About two-thirds of the respondents were unaware of the development of a unified emergency number (112). However, a large majority (82.9%) were in favor of having a unified emergency number instead of a different number for each emergency. Only 43.8% of the respondents were of the opinion that the current EMS coverage was inadequate. 24.9% of the participants rated the current EMS as good, whereas 53.5% rated the EMS average and 16.9% rated it poor. Conclusions An effort should be made to make 100% of the population aware of this service. The first step for increasing awareness would be starting various advertisement campaigns. The next step would be to implement the unified emergency number (112) to address all kinds of distress calls such as police, fire, and ambulance. A very small proportion of the population is trained in first-aid or basic trauma life support. Awareness campaigns and training sessions for the general public should be conducted for the same. It is also necessary to spread awareness and help the populace know about the Good Samaritan law.

Hand Hygiene Practices Among Indian Medical Undergraduates: A Questionnaire-Based Survey.

Background and objectives To prevent the spread of infections in all healthcare settings, hand hygiene must be routinely practiced. Appropriate hand hygiene techniques can go a long way in reducing nosocomial infections, cross-transmission of microorganisms and the risk of occupational exposure to infectious diseases. World Health Organisation (WHO) has taken an incredible approach called "My Five Moments for Hand Hygiene" which defines the key moments when health-care workers should perform hand hygiene. We thus carried out a survey to assess knowledge of hand hygiene practices among undergraduate medical students.  Materials and methods A cross-sectional survey was conducted among 523 Indian medical undergraduates. The questionnaire used was adapted from the WHO hand hygiene knowledge questionnaire for health-care workers and was distributed both, in print and online formats. The response to each question was examined using percentages. Results Nearly 57% (n=298) of medical students who participated in this study did not receive any formal training in hand hygiene. Only 27% (n=141) students knew that the most frequent source of germs responsible for health-care associated infections were the germs already present on or within the patient. Nearly 68.6% (n= 359) students were unaware of the sequence of hand washing and hand rubbing. Although 71.9% (n=376 ) students claimed that they use an alcohol-based hand rub routinely, only 36.1% (n=189 ) students knew the time required for a hand rub to kill the germs on the hands. Overall hand hygiene knowledge was low in 6.9% (n=36), moderate in 80.9% (n=423) and good in 12.2% (n=23) of respondents.  Conclusions The awareness about hand hygiene practices among medical students is low. Nearly 57% (n=298) of the respondents never received any formal training in hand hygiene throughout their course of medical undergraduate study. To prevent the spread of infections in healthcare settings, medical students should be given proper training in hand hygiene practices right from the first year of the medical curriculum. This should be done by running workshops and annual seminars on hand hygiene practices and making it a requisite for clinical skills assessment.

Clinical and Radiological Improvement Following Ozone Disc Nucleolysis: A Case Report.

The results of traditional open surgery for herniated intervertebral disc are often limited by complications and failed back surgery syndrome (FBSS). Over the past few decades, a considerable amount of research has been done in the field of minimally invasive procedures as a treatment option for herniated intervertebral disc disease. Ozone disc nucleolysis is one such procedure which has results equal to or better than traditional surgery with virtually no complications. A 27-year-old post-partum female presented to the clinic with acute onset of severe lower back pain radiating to the left lower limb for one month. The pain started suddenly during labor and gradually increased over a period of few weeks post-partum. A magnetic resonance imaging (MRI) scan showed a large herniated disc bulge at the L4-L5 level causing severe radiculopathy. There was no bladder or bowel involvement. The patient was managed conservatively for three weeks. However, she failed to show any signs of improvement. She opted to undergo ozone disc nucleolysis under local anaesthesia. She showed significant improvement immediately after the procedure and there was further improvement in symptoms over a period of six weeks. Post-procedure follow-up at three months and six months showed significant improvement on the visual analogue scale (VAS), which was used to measure pain intensity and pain affect, along with the Oswestry Disability Index (ODI), which was used to measure the degree of disability due to the lower back pain. Her VAS score improved from nine to two at three months and finally to one at six months, whereas the ODI score improved significantly from 46 to 10 at three months and eventually to four at six months. Ozone disc nucleolysis is an efficacious, safe, durable, and cost-effective treatment option for mild to moderate cases of herniated intervertebral disc which are resistant to conservative management. However, randomized control trials are required to build a long-term database regarding the efficacy and durability of ozone disc nucleolysis as compared to other minimally invasive procedures and surgery. We strongly believe that the availability of long-term data on ozone disc nucleolysis would make it a more acceptable form of treatment for disc herniation as compared to traditional surgery.

Burnout Syndrome Among Medical Practitioners Across India: A Questionnaire-Based Survey.

BACKGROUND AND OBJECTIVES: Excessive and prolonged work-related stress has always been a cause for burnout among healthcare professionals. This has led to emotional, mental, and physical exhaustion. This survey was conducted to assess the burnout among medical practitioners using the abbreviated Maslach Burnout Inventory (aMBI) and Burnout Clinical Subtype Questionnaire (BCSQ-12) scales. MATERIALS AND METHODS: A cross-sectional survey was conducted among 482 registered medical practitioners across India. A questionnaire consisting of 25 socio-demographic and occupational questions related to aMBI and BCSQ-12 scales was used to assess the burnout. The distribution of responses for each variable was examined using frequencies and percentages among the subgroups to find out the burnout levels of various components of the scales. RESULTS: High burnout levels were uniformly recorded for the entire population. For the aMBI, 45.02% (n = 217) and 65.98% (n = 318) of the participants scored high on the emotional exhaustion and depersonalization scales, respectively, whereas 87.14% (n = 420) scored low on the personal accomplishment scale and 62.86% (n = 303) and 11.41% (n = 55) had medium and low scores on the satisfaction with the medical practice scale. The BCSQ-12 scale showed the mean values of 15.89, 11.56, and 10.28 on a scale of 28 for overload, lack of development, and neglect subtypes, respectively, whereas, satisfaction with the financial compensation item showed a mean value of 3.79 on a scale of seven. All these values indicate high levels of burnout. CONCLUSION: The results suggest high levels of burnout in all domains of aMBI and BCSQ-12 scales in all the occupational and socio-demographic groups of medical practitioners and warrant immediate actions to address this issue.

Crohns disease with central nervous system vasculitis causing subarachnoid hemorrhage due to aneurysm and cerebral ischemic stroke.

Cerebral vasculitis secondary to Crohn's disease (CD) seems to be a very rare phenomenon. We report a 39-year-old male who presented with headache, vomiting, and left-sided weakness in the known case of CD. Cross-sectional imaging (computed tomography and magnetic resonance imaging,) showed right gangliocapsular acute infarct with supraclinoid cistern subarachnoid hemorrhage (SAH). Cerebral digital substraction angiography (DSA) showed dilatation and narrowing of right distal internal carotid artery (ICA). Left ICA was chronically occluded. His inflammatory markers were significantly raised. Imaging features are suggestive of cerebral vasculitis. Arterial and venous infarcts due to thrombosis are known in CD. Our case presented with acute subarachnoid hemorrhage in supraclinoid cistern due to rupture of tiny aneurysm of perforator arteries causing SAH and infarction in right basal ganglia. Patient was treated conservatively with immunosuppression along with medical management of SAH.

Role of local thrombolysis in cerebral hemorrhagic venous infarct.

BACKGROUND: Chemical thrombolysis in cerebral venous thrombosis (CVT) is one of the treatment options and the data is limited. SETTINGS AND DESIGN: Prospective observational nonrandomized study. SUBJECTS AND METHODS: This is a prospective study of 10 patients (six females and four males) admitted between May 2007 and June 2013. Grading system proposed by Department of Interventional Neuroradiology (INR), King Edward Memorial Hospital (KEM), Mumbai was used to grade the clinical status at admission. There were six patients with clinical Grade 3, two with Grade 4, and two with Grade 5. Patients with either Grade less than 3 or more than Grade 5 were excluded. Those patients, who were diagnosed with Cerebral venoussinous thrombosis (CSVT) but without hemorrhagic venous infarct and treated  according to INR KEM criteria, were excluded from the study. Average duration of thrombolysis was 13 hours (range 10-18 hours). Average dose of urokinase was 12.2 lakh units (range 9.2-16.8 lakh units). RESULTS: Six patients presented with clinical Grade 3 had modified Rankin Scale (mRS) sore of 1 at 30-day follow-up. Of the two patients with Grade 4, one had mRS 1 and the other had mRS 2 at 30-day follow-up. Of the two patients with Grade 5, one had mRS 2 at 30-day follow-up and the other did not respond to local thrombolysis and succumb to intracranial hemorrhagic infarct within 48 hours. CONCLUSION: This small prospective single-center study showed local dural venous thrombolysis significantly improves clinical and radiological outcome in patients with CVT. A randomized control trial with large sample size is needed to substantiate our findings.

Anomalous connection of superior vena cava to the left atrium masquerading as epilepsy: a case report with review of literature.

An 11-year-old girl who presented with recurrent epileptic fits was eventually found to have a superior vena cava draining into the left atrium. There was no atrial septal defect. The patient underwent a successful surgical correction.

Anticoagulation for pregnant patients with mechanical heart valves.

Management of a pregnant patient with mechanical heart valve is a complex issue for all health care providers involved in the care of such patients. Complications may arise at any stage due to the increased haemodynamic load imposed by pregnancy or because of impaired cardiac performance often seen in these patients. In addition, the use of various cardiovascular drugs in pregnancy (especially anticoagulants) may lead tofoetal loss or teratogenic complications. Additionally, the risk of thrombo-embolic complications in the mother is increased by the hypercoagulable state of pregnancy. In this review, we have attempted to draw inferences to guide management of such patients based on the available literature. It seems that in pregnant women with mechanical heart valves, recent data support warfarin use throughout pregnancy, followed by a switch to heparin and planned induction of labour. However, the complexity of this situation demands a cafeteria approach where the patient herself can choose from the available options that are supported by evidence-based information. Unfortunately there is no consensus on such data. An overview of the available literature forms the basis of this review. In conclusion, a guideline comprising pragmatic considerations is preffered.