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   Table of Contents - Current issue
July-December 2022
Volume 9 | Issue 2
Page Nos. 65-129

Online since Friday, December 23, 2022

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Revisiting cultural and biological perspectives on depression and antidepressants p. 65
Vikas Menon
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Arboviruses in human disease: An Indian perspective p. 69
Lakshmi Shanmugam, Mahalakshmi Kumaresan, Ramit Kundu, Anitha Gunalan, Rahul Dhodapkar
There has been a dramatic increase in the frequency of arboviral disease epidemics among humans and domestic animals worldwide in recent decades. Some of these infections have also undergone significant geographical expansion owing to uncontrolled urbanization leading to changes in vector distribution and/or adaptation of the etiologic agent to more anthropophilic vectors. Arboviral infections such as chikungunya have re-emerged in certain parts of the world, such as India (where chikungunya re-emerged in 2006 after 32 years of quiescence). Existing surveillance systems for arboviral infections in developing countries face several issues, such as being dependent on reporting of loosely defined clinical syndromes and infrequent laboratory confirmation. The recent re-emergence of Zika virus infections and its complications in South America underscore the urgent need for advancements in scientific knowledge on the biology of the arboviral agents and their vectors, innovations concerning diagnostic technologies, vector control measures, and therapeutic approaches. India, a tropical country, harbors an abundance of arthropod vectors capable of hosting and propagating viral infections. These vectors can transmit infections within humans, animals and also across species. This review focuses on viral infections in humans transmitted by arthropod vectors.
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Anatomy in a virtual small-group learning setting: A COVID revelation p. 78
John Kandam Kulathu Mathew, Priyanka Daniel, Pauline Shanthi, Supraja Srivatsava, Aby S Charles, Jenny Jacob, Mahasampath Gowri, Suganthy Rabi
Background: The benefits of small-group learning (SGL) in anatomy are well documented; however, the COVID-19 pandemic has seen the dynamics of SGL change in the online environment. In this study, we aimed to study the effects of the online platform and the content created on students' perception in the delivery of virtual SGL (VrSGL) in anatomy for 1-year medical students. Materials and Methods: VrSGL in anatomy was conducted for 6 weeks on Microsoft Teams as a meeting platform. Each group consisted of 10–12 1st-year medical students. Various aspects of VrSGL were analyzed with respect to technological factors, online content, online small-group teaching, and assessment modalities such as online viva, digital spotters, clinical cases, and short answer writing, through validated online feedback forms. Results: Of the 97 students (46 males and 51 females), 86% found the frequency of VrSGL optimal. There was a substantial positive correlation between connectivity issues and the quality of SGL. Majority of the students reported that VrSGL enabled them to learn anatomy well (72%), at their own pace (90%), and increased their accountability (85%). There was a significant positive correlation between the effectiveness of VrSGL sessions and quality of specimen demonstration videos (P < 0.001), assignments (P < 0.001), and online assessment (P < 0.001). A significant drawback of VrSGL was the lack of handling of cadaveric specimens as reported by 91% of the students. Conclusion: The most impactful factors on VrSGL were quality of specimen demonstration videos, frequency of the SGL sessions, assignments, and online assessment modalities.
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Evaluation of inhaler technique and asthma control among children in a low-resource setting p. 82
Harit Prasad, Sohini Ghosh, Sai Chandan Das, RV Manasa
Background: Inhalation has become the preferred route of drug administration compared to oral medication in managing Asthma due to its direct delivery to the airways, thus producing a faster onset of action and fewer systemic side effects at lower doses than would be required for other routes of administration. Aims and Objectives: This study aimed to evaluate the inhaler technique among children with asthma and its association with the level of asthma control and to identify factors associated with improper use of inhaler devices. Materials and Methods: This is a prospective cross-sectional study conducted at the Department of Pediatrics at B. P Koirala Institute of Health Science, university teaching Hospital in Nepal. The children with asthma were asked to use their inhaler device as usual and inhalational technique was assessed using inhaler device assessment tool and control of asthma level was assessed using the Childhood Asthma Control Test score. Results: One hundred and three asthmatic children of the age range of 4–11 years were enrolled in the study. The mean age of surveyed children was 6.3 ± 2.2 years and over half of the participants were boys (68.9%). Around 60% had moderate asthma. Among them, 50% had symptoms for <3 years; only 50% of children with asthma demonstrated good technique of inhaler medication. Forty-five percent of them showed optimal asthma control. Near about a quarter of the participants showed mistakes in one step and about a fifth of the children showed mistakes at more than one step. Almost 30% of children with asthma have not obtained inhaler technique education. Factors associated with poor inhaler technique and poor asthma control were younger age and irregular follow-ups. The most common errors in the proper use of inhalers were not shaking the inhaler before use (30%) and wrong breathing techniques (30%). Conclusions: Improper inhaler technique is common among children with asthma. Children with asthma should have their inhaler technique routinely checked, during visits and should be given detailed education on proper inhalation techniques. Health education programs on asthma control are recommended in countries like Nepal to improve proper asthma inhaler device use and treatment outcomes in children with asthma.
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Out-of-pocket expenditure for the diagnosis of cervical, breast, and oral cavity cancer: A cross-sectional study from a tertiary care hospital in South India p. 88
Shahana Singh, Mahalakshmy Thulasingam, Bharathnag Nagappa, Chitrita Singh, Vishnu Rajan, Gunaseelan Karunanithi
Background: Cancer as a disease has widespread financial impact on patients. Most public funded government schemes provide insurance only after the diagnosis is made. Patients incur a substantial out-of-pocket expenditure even before the diagnosis. Objectives: The study was done with the objective of determining the total cost (direct out-of-pocket expenditure and indirect cost) incurred from the symptom onset to diagnosis among patients diagnosed with cancer of the uterine cervix, oral cavity, and breast. Materials and Methods: In this hospital-based study conducted in the Regional Cancer Center of a tertiary hospital in South India, 100 patients were interviewed using a predesigned, pretested questionnaire. For cost calculation, the reference period was duration between the first contact to the health facility for the symptoms suggestive of cancer, and the histopathological diagnosis. The total direct (out-of-pocket expenses) and indirect (income lost) costs were determined by interviewing the participants. The Mann-Whitney and Kruskal-Wallis test were used to compare the out-of-pocket expenses across age, gender, and tumor type categories. Results: The median (first quartile [Q1] and third quartile [Q3]) cost incurred while diagnosing the three cancers was Indian rupees (INRs) 3660 (1280, 12,660); the median (Q1, Q3) direct cost was INR 1710 (350, 10,930) and the median (Q1, Q3) indirect cost was INR 250 (0, 2000). Those who visited a private health facility for their symptoms incurred a significantly higher direct cost (P < 0.05). Further, those aged 15–44 years, above the poverty line, male, who had completed more than primary education, or were diagnosed with cervical cancer incurred higher costs, although this was not statistically significant. Conclusion: Patients of common cancers incur a high out-of-pocket expenditure even before initiation of treatment. Measures such as providing all diagnostic modalities under a single roof and adopting a standardized protocol for various investigation procedures may help in reducing the costs incurred by patients.
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Comparison of Nutrition Risk Screening 2002 and Subjective Global Assessment for predicting postoperative complications among patients undergoing elective abdominal surgery p. 94
Hemamalini Raghuraman, M Kavyashree, Gurushankari Balakrishnan, TP Elamurugan, Gomathi Shankar, Nivedita Nanda, Mahalakshmy Thulasingam, Vikram Kate
Introduction: Malnutrition leads to poor outcomes in surgical patients, leading to negative impact during the postoperative period. Nutrition Risk Screening (NRS) 2002 and Subjective Global Assessment (SGA) are novel tools to assess nutrition risk which have the potential to predict the postoperative complications in surgical patients. Aim: This study was carried out to determine the efficiency of the NRS 2002 and SGA in predicting postoperative complications. Materials and Methods: A prospective cohort study was conducted to assess the nutritional risk of patients aged 18 years and above who underwent elective abdominal surgery. NRS 2002 and SGA were used for nutritional screening. Univariate analysis was carried out to determine the relative risk (RR) of complications for each variable. Receiver operating characteristic (ROC) and area under curve (AUC) were plotted for NRS 2002 and SGA to identify the score for the former and grade for the latter that predicted complications postoperatively. The correlation of malnutrition with surgical outcomes was performed to determine their association. Results: A total of 320 patients were included in the study. Among the patients who underwent elective abdominal surgeries, 39.4% of the total number developed postoperative complications. The most prevalent were Grade 2 complications, which accounted for 69.1% of all such events. Postoperative complications were recorded in 75.5% of the patients identified as at risk by NRS 2002, with a RR of 5.3 (95% confidence interval [CI]: 3.7–7.6; P < 0.001). Complications were found among 68.3% of those who were malnourished by SGA, with a RR of 4.2 (95% CI: 3.0–6.0; P < 0.001). The ROC curve for NRS 2002 to determine the complications had an AUC of 0.80. A score of 3 was the optimal cutoff of NRS 2002 for predicting complications with a maximum sensitivity of 93.6%. Similarly, the ROC curve for SGA grades to determine complications had an AUC of 0.79. Grade B was the best cutoff, with a sensitivity of 77.0%. Conclusion: Patients with NRS 2002 scores higher than or equal to 3 and SGA Grades B and above had a higher incidence of postoperative complications in patients undergoing elective abdominal surgeries. Hence, NRS 2002 and SGA are reliable nutrition risk assessment tools for predicting postoperative outcomes.
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Chronic cough etiology within a tertiary care center: A retrospective chart review Highly accessed article p. 101
Krittin J Supapannachart, Amanda S Fryd, Sandeep Shelly, Anjali Warrier, Andrew Tkaczuk, Jeanne L Hatcher, Adviteeya N Dixit, Keriann M Van Nostrand, Anand S Jain, Amanda I Gillespie, Merin K Kalangara, Adam M Klein
Purpose: Chronic cough occurs in 12% of the population and is associated with significant morbidity and healthcare utilization. Little is known about chronic cough patients requiring referral to higher level care facilities; such knowledge may improve primary care physician chronic cough referral algorithms. Methods: A retrospective study was conducted on patients with primary complaints of chronic cough presenting to Emory Healthcare, Atlanta between 2009 and 2020. Data on socio-demographics, etiology, treatment, and health behavior were extracted from the electronic medical records of patients with chronic cough that had been seen by at least by 1 cough specialist at a tertiary care center. The Chi-square test and analysis of variance helped determine differences in socio-demographic variables between patients with different primary cough etiologies. Results: A total of 1152 patients met the inclusion criteria for this study. Common etiologies of chronic cough were found to be neurogenic (n = 196, 17%), gastroesophageal reflux disease (n = 114, 9.9%), asthma (n = 93, 8.1%), and chronic obstructive pulmonary disease (n = 80, 6.9%). A multifactorial etiology was found in 213 (18.5%) patients and 99 (8.6%) patients were still undergoing further work up. Significant differences in age, sex, race, smoking status, and chronic cough duration were noted based on the underlying etiology. Interestingly, although nonsignificant, patients with pulmonary etiologies tended to live in areas with higher poverty rates. Conclusion: The most common etiology was neurogenic cough, typically a diagnosis of exclusion that goes undiagnosed in primary care settings. Primary care physicians should have a low threshold for referral to otolaryngologists and academic institutions should consider establishing multidisciplinary cough clinics to facilitate work up and treatment.
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Association of clinicopathological features with DNA mismatch repair status among colorectal cancer patients presenting to a Tertiary Care Cancer Hospital p. 107
Gayathri G Nair, Vijayalakshmi Nair, Usha Mary Abraham
Background: About 12%–15% of sporadic colorectal cancers (CRCs) display a defect in the DNA mismatch repair (MMR) system resulting in microsatellite instability (MSI). Many authors have described certain clinicopathological predictors of MSI and confirmed with ancillary studies. The purpose of this study was to determine the clinicopathological features and their association with MMR deficiency (dMMR) among CRC patients. Materials and Methods: A cross-sectional study was designed among patients presented with CRC. A predesigned proforma was used to document the particulars of the patient along with histological parameters to be assessed. Cases were analyzed for dMMR using MLH1 and MSH2 immunostains and categorized into dMMR and MMR-proficient. The association of clinicopathological features with MMR status was statistically analyzed. Results: Sixty-four CRC cases were analyzed in the study. Thirteen out of 64 cases showed dMMR. Most of the dMMR tumors were located in the right-sided colon (P < 0.001). Three patients with a family history of CRC exclusively had dMMR (P = 0.01). Mucinous (P = 0.04), signet ring cell differentiation (P = 0.04), and lack of dirty necrosis (P < 0.001) showed a significant difference between deficient and proficient MMR categories. Gender, mean tumor-infiltrating lymphocytes per hpf, Crohn's-like reaction, and tumor stage did not show any significant difference between the two categories. Conclusions: Clinicopathological features such as family history, tumor location, tumor size, histologic type, tumor differentiation, mucinous, signet ring cell component, and dirty necrosis are associated with MMR status in CRC.
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Chronic pancreatitis associated with pancreatic stone impaction at the ampulla and subsequent gallbladder perforation Highly accessed article p. 113
Oseen Hajilal Shaikh, Uday Shamrao Kumbhar, Chellappa Vijayakumar, Sunitha V Chakkalakkoombil, Naveen Kumar Gaur
Obstructive jaundice due to pancreatic stone is very rare. We report a case of obstructive jaundice in a patient with chronic pancreatitis, occurring due to the pancreatic stone getting impacted at the ampulla and subsequently, leading to gallbladder perforation, without any dilatation of the biliary tree. This could be explained due to the lower insertion of the cystic duct. Such instances can be managed with percutaneous tube cholecystostomy, endoscopic retrograde cholangiopancreatography, pancreatic stone extraction, and stenting of both the main pancreatic duct and the common bile duct.
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Virchow-Robin space enlargement associated with borderline intelligence and behavioral problems in a young male p. 117
KP Lakshmi, Prerna Maheshwari, Bindu Menon, Subhash Chandra
A 22-year-old male presented with borderline intelligence, visual and auditory hallucinations, and an obsessive urge to bite. He was investigated for organic pathology in view of visual hallucinations and his magnetic resonance imaging study showed enlarged Virchow-Robin Space, which are fluid-filled spaces that surround small blood vessels and capillaries in the brain. He had no facial dysmorphic features or autistic features. Literature reports that this finding is associated with dementias in elderly, obsessions, and auditory hallucinations, but there is little data on its association with visual hallucinations, or intellectual impairment in the young. He responded well to a combination of medications and psychosocial approaches. Neuroimaging offers a noninvasive, reproducible method to better understand the clinical associations and accumulate evidence base in young patients presenting with intellectual impairment and behavioral problems.
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How to handle a manuscript rejection? p. 120
Raja Kalayarasan, Chandrasekar Murugesan
Biomedical researchers desire recognition of their scientific work as a publication in a reputed journal. On the other hand, editors who intend to bring quality work to their readers scrutinize the manuscripts through many checks and peer-review processes. Hence, manuscript rejection is a common phenomenon, and every researcher will have to experience it in their academic career. The manuscript could be rejected at the editor's desk level without peer review or after peer review by experts in the field. Understanding the common reasons for rejection at various levels would help to approach manuscript rejection effectively. The present article aims to provide an overview of the manuscript evaluation process and tips for handling manuscript rejection effectively so that the research work is eventually published.
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The art and science of writing narrative reviews p. 124
Aneesh Basheer
In this age of evidence-based medicine, systematic reviews are considered the highest level of evidence. However, traditional narrative reviews continue to have an important role in medicine. While narrative reviews have inherent shortcomings in terms of nonstandardized literature search, potential bias in the appraisal of retrieved articles, and interpretation of findings, they serve as sources of quick up-to-date reference for specific areas of interest of readers. Well-conducted reviews could inform readers about gaps in existing literature and areas that need new primary research. Crafting a narrative review requires a blend of good scientific approach and the skillful art of presentation. This article aims to provide an overview of the need for narrative reviews and strategies to equip potential review authors complete an effective narrative review.
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Perils of injudicious use of alternate forms of medicine: Toxic encephalopathy in a neonate p. 127
Tissa John, Femitha Pournami, Ajai Kumar Prithvi, Anila V Panackal, Jyothi Prabhakar, Naveen Jain
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Thanks to Reviewers 2022 p. 129

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