Effectiveness of Yoga in Modulating Markers of Immunity and Inflammation: A Systematic Review and Meta-Analysis

Chronic inflammation is central to the pathogenesis of many chronic inflammatory conditions. This review aims to analyze whether the practice of yoga, or yogic meditation and breathing, has any effect on the levels of inflammatory cytokines and other inflammatory markers in patients with various chronic inflammatory diseases such as rheumatoid arthritis, neoplastic disorders, and asthma, as well as in healthy subjects, compared to usual care or sham interventions. A comprehensive search of databases (PubMed, CENTRAL, Embase, and CINAHL) was performed. Randomized controlled trials (RCTs) that evaluated the effects of yoga as an intervention on inflammatory markers were analyzed. A total of 26 studies were included. Only two studies had a low risk of bias (RoB); 24 other studies had a high RoB. Most studies (n=24) reported a favorable outcome with yoga, irrespective of the type of yoga used, the condition studied, and the duration of the intervention. The commonly reported inflammatory markers included IL-6 (n=17), tumor necrosis factor-alpha (TNF-a) (n=13), and C-reactive protein (CRP) (n=10). Most studies showed a significant reduction in inflammatory markers in the yoga group (YG) compared to the control group (CG). Few studies also showed significant improvement in markers of cellular immunity (interferon gamma (IFN-g), IL-10, and transforming growth factor-beta (TGF-b); n=2 each) and improved mucosal defense (IgA, IL-6, and IL-2; n=2 each). A meta-analysis of IL-6, TNF-a, and CRP showed yoga had a favorable effect on the levels of these markers, but it was not statistically significant. Current evidence suggests that yoga can be a complementary intervention for various chronic inflammatory conditions. However, the quality of the evidence is poor, along with considerable heterogeneity. In the future, investigators should describe the intervention better, with a uniform assortment of outcome measures and treatment conditions, to generate high-quality evidence.

Otolaryngologists' Initiative for Collaborative Tracheostomy Care: Knowledge, Attitude and Skill in Tracheostomy Care Among Nurses - An Interventional Study from India

Introduction: Tracheostomy-related adverse events are a global problem, requiring coordinated approach for care of tracheostomised patients. The concept of 'collaborative tracheostomy care' was introduced by Global Tracheostomy Collaborative in 2012. For successful post tracheostomy outcome, nursing care is vital. Data on their knowledge, attitude and skills regarding tracheostomy care including outcome of a structured interventional workshop is not available from India. Methods: A validated questionnaire with items pertaining to knowledge, attitude and skills regarding tracheostomy care was administered to nurses working in intensive care units and wards. Following this, a workshop was conducted for hands-on training in tracheostomy care using didactic lectures, videos and simulation-based training. The participants took a post-test immediately and after three months. Skills were assessed before and three months after the workshop using a checklist. Results: Among 386 participants who attended the pre-test and workshop, 285 (74.2%) underwent post-test immediately and three months later. Overall mean knowledge score (± SD) of the participants in pre-workshop was 6.8 ± 3.5, immediate post-test score was 15.9 ± 2.7 and three months later was 11.6 ± 3.5 (p < 0.001) out of total score 20. The baseline score was significantly higher among ICU nurses. Three months post workshop skill assessment revealed no statistically significant increase in the proportion of participants who performed skills related to suctioning procedure. Conclusion: Knowledge, attitude and practice regarding tracheostomy care is inadequate among nurses. Otolaryngologists-driven structured intervention with didactic lectures, videos and hands-on training can improve all three domains to positively impact outcomes in post tracheostomy patient care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03682-9.

Alternate day versus daily oral iron for treatment of iron deficiency anemia: a randomized controlled trial

Oral iron is the mainstay of treating iron deficiency anemia. Recent studies indicate better fractional iron absorption with alternate day supplementation. However, the optimal supplementation strategy is unclear. We compared effectiveness of daily versus alternate day supplementation of oral iron for treatment of iron deficiency anemia. This double blind, active control, randomized controlled trial was conducted on two hundred adults having hemoglobin 10 g/dL or less with microcytic hypochromic anemia and/or serum ferritin below 50 ng/mL. They were randomized to receive either two Ferrous sulfate tablets containing 60 mg elemental iron (120 mg total) on alternate days or single tablet of 60 mg elemental iron daily for 8 weeks. Primary outcome was mean change in hemoglobin at week 8 from baseline. Mean hemoglobin was 6.53 (± 1.89) and 6.68 (± 1.89) g/dL in the alternate day and daily arms respectively. Mean change in hemoglobin was + 1.05 ± 1.34 g/dL in alternate day arm and + 1.36 ± 1.51 g/dL in daily arm (p = 0.47) at week 8. There were no statistically significant differences between the arms with respect to any secondary outcome. There is no significant difference between alternate day and daily iron administration in improving hemoglobin. Randomized controlled trials enrolling more participants for longer periods of supplementation and evaluating clinically relevant outcomes like change in hemoglobin may be useful in identifying the ideal dosing strategy.Trial Registration: Clinical Trial Registry of India (CTRI/2019/01/017169).

Expression profiling of IL-1β, IL-6 and IL-8 genes in lung tissues of Aseel, Crossbred Naked neck, and White Leghorn chicken challenged with H9N2 Influenza virus

Aseel and Naked neck are major chicken breeds of the tropics and well-known for their thermotolerance and robustness. However, both of them especially Aseel are very susceptible to Avian Influenza (AI) which cause huge mortalities. The role of cytokines in relation to the pathology and severity of the disease caused by the endemic strain (H9N2) of AIV in these breeds remained thus far unclear. The aim of this study was to investigate the effects of H9N2 AIV on the expression level of IL-1β, IL-6 and IL-8 in the lung tissues of Aseel, crossbred Naked Neck, and White Leghorn (WLH). In total 60 birds, 20 from each breed, were used in this study, whereas 30 birds (10 from each breed) were challenged intranasally with H9N2 virus with a concentration of 106 EID50 at 6wk of age and other half were treated as control. The lung tissues were sampled at 5th day post-infection to study the differential expression of IL-1β, IL-6, and IL-8 using qRT-PCR. Our data revealed a significant difference (P<0.001) in the gene expression levels among all the breeds in response to viral challenge. It was also observed that after exposure to H9N2 virus, Aseel birds showed the highest increase in their expressions of interleukin (IL-1 β, IL-6, and IL-8) genes followed by Naked Neck and WLH respectively suggesting greater susceptibility of Aseel to AIV compared with other breeds. However, these results are in agreement with the severity of disease and incidence of mortality caused by AI in these breeds.

Cold antibody autoimmune hemolytic anemia following varicella infection

Introduction

Autoimmune hemolytic anemia (AIHA) is a rare complication of chicken pox. In adults, such AIHA is due to warm antibodies. We report a case of cold antibody AIHA following chicken pox in a young female.

Case Report

A 24-year-old female presented with clinical and laboratory features consistent with hemolytic anemia 5 days after the onset of chicken pox. Her hemoglobin levels dropped rapidly during the course of admission from 7.9 to 3.8 g/dL with evidence of ongoing haemolysis in the form of rising total and indirect bilirubin. Peripheral smear revealed red cell agglutinates and erythrophagocytosis. Direct Coomb's test (DCT) was positive for C3d suggesting a cold antibody AIHA. Since test for Donath Landsteiner antibody was negative, and all other tests for common causes of hemolytic anemia were noncontributory, it was presumed to be due to chicken pox. The fulminant course necessitated a short course of oral steroids to which she responded with rise in hemoglobin and no further hemolysis. Two weeks later, her peripheral smear was normal and DCT negative.

Conclusion

In patients presenting with acute onset anemia following chicken pox, possibility of cold antibody AIHA must be considered and appropriate testing pursued. Despite lack of empiric evidence, short course of steroids may be beneficial if drop in hemoglobin is rapid with evidence of fulminant hemolysis, showing no abatement after first week.

Importance of high-quality evidence regarding the use of Bacopa monnieri in dementia

Background

Bacopa monnieri (BM), a commonly used herb, has shown neuroprotective effects in animal and in vitro studies; but human studies on patients with Alzheimer's Disease (AD) have been inconclusive. Further high-quality trials are required to conclusively state the utility of BM in AD and other neurodegenerative dementias.

Methods

In the present study, we did a narrative review of the current challenges in designing clinical trials of BM in dementia and their evidence-based recommendations.

Results

Many facets of the BM trials need improvement, especially effect size and sample size estimation. Current assessment and outcomes measures need a more holistic approach and newer scales for diagnosing and monitoring prodromal AD. The stringent guidelines in CONSORT and STROBE are often considered difficult to implement for clinical trials in ayurvedic medications like BM. However, adherence to these guidelines will undoubtedly improve the quality of evidence and go a long way in assessing whether BM is efficacious in treating AD/prodromal AD patients and other neurodegenerative dementias.

Conclusion

Future studies on BM should implement more randomized controlled trials (RCTs) with an appropriate sample size of accurately diagnosed AD/prodromal AD patients, administering a recommended dosage of BM and for a pre-specified time calculated to achieve adequate power for the study. Researchers should also develop and validate more sensitive cognitive scales, especially for prodromal AD. BM should be evaluated in accordance with the same rigorous standards as conventional drugs to generate the best quality evidence.

Impact of COVID-19 on Guillain-Barre Syndrome in India: A Multicenter Ambispective Cohort Study

Introduction/Aims

Studies conducted during the coronavirus disease 2019 (COVID-19) pandemic have reported varied data regarding the incidence of Guillain-Barre syndrome (GBS). The present study investigated demographic and clinical features, management, and outcomes of patients with GBS during a specified period of the COVID-19 pandemic, and compared these features to those of GBS in the previous year.

Methods

A multicenter, ambispective cohort study including 26 centers across India was conducted. Data from a pre-COVID-19 period (March 1 to August 31, 2019) were collected retrospectively and collected ambispectively for a specified COVID-19 period (March 1 to August 31, 2020). The study was registered with the Clinical Trial Registry India (CTRI/2020/11/029143).

Results

Data from 555 patients were included for analysis: pre-COVID-19 (n = 334) and COVID-19 (n = 221). Males were more commonly affected during both periods (male:female, 2:1). Gastroenteritis was the most frequent antecedent event in 2019 (17.4%), whereas fever was the most common event in 2020 (10.7%). Paraparesis (21.3% versus [vs.] 9.3%, P = 0.001) and sensory involvement (51.1% vs. 41.3%; P = 0.023) were more common during COVID-19 in 2020, whereas back pain (26.3% vs. 18.4%; P = 0.032) and bowel symptoms (20.7% vs. 13.7%; P = 0.024) were more frequent in the pre-COVID period. There was no difference in clinical outcomes between the two groups in terms of GBS disability score at discharge and 3 months after discharge. Independent predictors of disability in the pre-COVID period included areflexia/hyporeflexia, the requirementfor intubation, and time to bulbar weakness; in the COVID-19 period, independent predictors included time from onset to admission, intubation, and intubation requirement. The mortality rate was 2.3% during the entire study period (13/555 cases).

Discussion

Results of this study revealed an overall reduction in the frequency of GBS during the pandemic. The lockdown likely reduced the risk for antecedent infections due to social distancing and improved hygiene, which may have resulted in the reduction of the frequency of GBS.

Thrombotic thrombocytopenic purpura as an acute complication of COVID-19

Introduction

While disseminated intravascular coagulation (DIC) is a serious complication of COVID-19, a close differential in critically ill patients with thrombocytopenia is Thrombotic thrombocytopenic purpura (TTP).

Case Report

We describe the case of a middle-aged lady admitted with COVID-19 pneumonia who developed progressive thrombocytopenia, altered sensorium and renal failure. The absence of coagulation abnormalities alerted to the possibility of TTP, strengthened by presence of schistocytes in peripheral smear.

Conclusions

This case highlights the need for high index of suspicion and to pay attention to normal tests as well that might give clues to the diagnosis. New onset thrombocytopenia in COVID-19 need not always indicate DIC. A careful examination of peripheral smear may help diagnosing TTP especially if coagulation profile is normal.

Bacopa monnieri in the treatment of dementia due to Alzheimer's disease: A systematic review of randomised controlled trials

Background

Bacopa monnieri, a herb that has been used for many centuries in India, has shown neuroprotective effects in animal and in vitro studies; human studies on patients with Alzheimer disease have been inconclusive.

Objective

The primary objective of this review was to determine the clinical efficacy and safety of B. monnieri in persons with mild, moderate, or severe dementia, or mild cognitive impairment, due to Alzheimer disease.

Methods

We searched PubMed, Embase, Cochrane Library, clinical trial registries (World Health Organization, Australia-New Zealand, United States, and South Africa), the metaRegister of Controlled Trials, and CINAHL. We intended to include all randomized and quasi-randomized controlled trials that compared B. monnieri, its extract or active ingredients (at any dosage), with a placebo or a cholinesterase inhibitor among adults with dementia due to Alzheimer disease and in those with mild cognitive impairment due to Alzheimer disease.

Results

Our comprehensive search yielded 5 eligible studies. A total of 3 studies used B. monnieri in combination with herbal extracts while the remaining 2 used B. monnieri extracts only. Two studies compared B. monnieri with donepezil while the others used a placebo as the control. There was considerable variation in the B. monnieri dose used (ranging between 125 mg to 500 mg twice daily) and heterogeneity in treatment duration, follow-up, and outcomes. The major outcomes were Mini-Mental State Examination scores reported in 3 trials, Cognitive subscale scores of the Alzheimer’s Disease Assessment Scale in 1 study, and a battery of cognitive tests in 2 studies. Using the Cochrane risk-of-bias tool, overall, we judged all 5 studies to be at high risk of bias. While all studies reported a statistically significant difference between B. monnieri and the comparator in at least one outcome, we rated the overall quality of evidence for the Alzheimer’s Disease Assessment Scale-Cognitive Subscale, Postgraduate Institute Memory Scale, Mini-Mental State Examination, and Wechsler Memory Scale to be very low due to downgrading by 2 levels for high risk of bias and 1 more level for impreciseness due to small sample sizes and wide CIs.

Conclusions

There was no difference between B. monnieri and the placebo or donepezil in the treatment of Alzheimer disease based on very low certainty evidence. No major safety issues were reported in the included trials. Future randomized controlled trials should aim to recruit more participants and report clinically meaningful outcomes.

Trial Registration

PROSPERO CRD42020169421; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=169421

Immunoglobulin G Antibodies to SARS-CoV-2 Among Healthcare Workers at a Tertiary Care Center in South India

Introduction

Healthcare workers (HCWs) are at risk of exposure to SARS-CoV-2. Seroprevalence in this group may offer insights into trends to monitor and revise strategies to prevent transmission.

Methods

A cross-sectional study was conducted in two phases among healthcare workers at a tertiary care center to detect IgG antibodies to SARS-CoV-2. Seropositivity was calculated during both phases, and possible associations were determined using regression analysis.

Results

A total of 382 and 168 HCWs took part in the two phases, respectively. IgG antibodies were detected in 13 of 382 (3.4%; 95% confidence interval (CI): 2%-5.7%) and 71 of 168 (42.3%) participants in the first and second phases, respectively. Receiving at least one dose of vaccine (p < 0.001) and age (p = 0.028) were factors associated with the presence of antibodies, while gender, job type, exposure to COVID-19 cases, and comorbidities were not associated with seropositivity.

Conclusion

Serosurveys among HCWs may help identify transmission patterns and redesign infection control practices in the healthcare setting.

Impact of the COVID-19 pandemic on the frequency, clinical spectrum and outcomes of pediatric guillain-Barré syndrome in India: A multicentric ambispective cohort study

Objective:

To study impact of COVID-19 pandemic on frequency, clinical/electrophysiological profile and treatment outcomes in pediatric Guillain-Barré syndrome (GBS).

Background:

GBS is the most frequent cause of pediatric acute flaccid paralysis. The effect of the COVID-19 pandemic on pediatric GBS is unclear in the literature.

Methods:

We conducted an ambispective, multicentric, cohort study involving 12 of 27 centres in GBS Consortium, during two periods: pre-COVID-19 (March-August 2019) and during COVID-19 (March-August 2020). Children ≤12 years who satisfied National Institute of Neurological Diseases and Stroke criteria for GBS/variants were enrolled. Details pertaining to clinical/laboratory parameters, treatment and outcomes (modified Rankin Scale (mRS) at discharge, GBS Disability score at discharge and 3 months) were analysed.

Results:

We enrolled 33 children in 2019 and 10 in 2020. Children in 2020 were older (median 10.4 [interquartile range 6.75–11.25] years versus 5 (2.5–8.4) years; P = 0.022) and had more sensory symptoms (50% versus 18.2%; P = 0.043). The 2020 group had relatively favourable mRS at discharge (median 1 (1–3.5) versus 3 (2–4); P = 0.042) and GBS disability score at 3 months (median 0 (0–0.75) versus 2 (0–3); P = 0.009) compared to 2019. Multivariate analysis revealed bowel involvement (P = 0.000) and ventilatory support (P = 0.001) as independent predictors of disability. No child in 2020 had preceding/concurrent SARS-CoV2 infection.

Conclusions:

The COVID-19 pandemic led to a marked decline in pediatric GBS presenting to hospitals. Antecedent illnesses, clinical and electrophysiological profile of GBS remained largely unchanged from the pre-pandemic era.

National Early Warning Score 2 (NEWS2) to predict poor outcome in hospitalised COVID-19 patients in India

Background

While several parameters have emerged as predictors of prognosis of COVID-19, a simple clinical score at baseline might help early risk stratification. We determined the ability of National Early Warning Score 2 (NEWS2) to predict poor outcomes among adults with COVID-19.

Methods

A prospective study was conducted on 399 hospitalised adults with confirmed SARS-CoV-2 infection between August and December 2020. Baseline NEWS2 score was determined. Primary outcome was poor outcomes defined as need for mechanical ventilation or death within 28 days. The sensitivity, specificity and Area under the curve were determined for NEWS2 scores of 5 and 6.

Results

Mean age of patients was 55.5 ± 14.8 years and 275 of 399 (68.9%) were male. Overall mortality was 3.8% and 7.5% had poor outcomes. Median (interquartile range) NEWS2 score at admission was 2 (0–6). Sensitivity and specificity of NEWS 2 of 5 or more in predicting poor outcomes was 93.3% (95% CI: 76.5–98.8) and 70.7% (95% CI: 65.7–75.3) respectively [area under curve 0.88 (95% CI: 0.847–0.927)]. Age, baseline pulse rate, baseline oxygen saturation, need for supplemental oxygen and ARDS on chest X ray were independently associated with poor outcomes.

Conclusions

NEWS2 score of 5 or more at admission predicts poor outcomes in patients with COVID-19 with good sensitivity and can easily be applied for risk stratification at baseline. Further studies are needed in the Indian setting to validate this simple score and recommend widespread use.

Dengue Versus Multisystem Inflammatory Syndrome – When the Grey Zone Gets Thinner

Despite the decline in COVID-19 cases, the potential threat of multisystem inflammatory syndrome (MIS) - a hyperinflammatory response following acute SARS-CoV-2 infection - looms large. Although initially described in children, it is being increasingly reported in adults. In dengue endemic regions, MIS is likely to cause diagnostic dilemma with dengue due to overlapping clinical and laboratory features. We describe a young male with fever, gastrointestinal symptoms, a transient rash, thrombocytopenia, and positive dengue NS1 antigen test. Early onset of thrombocytopenia, significant gastrointestinal symptoms and protracted fever were atypical, raising suspicion of MIS-A in view of a recovery from a recent SARS-CoV-2 infection. However, absence of neurologic and cardiac manifestations, stable hemodynamics, absence of mucosal involvement and negative inflammatory markers helped in managing the patient conservatively as dengue. This case highlights diagnostic challenges faced by clinicians treating suspected dengue in the face of increasing recognition of MIS and need for systematic research to establish diagnostic criteria for MIS-A.

Simulated Randomized Controlled Trial to Learn Critical Appraisal (SiRCA): A Randomized Controlled Study of Effectiveness Among Undergraduate Medical Students

Introduction: The ideal method to teach evidence-based medicine (EBM) to medical students is unclear. We determined the effectiveness of a simulated randomized controlled trial (RCT) in improving critical appraisal and EBM skills among medical students compared to traditional training.

Methods: One hundred and eighteen medical students were randomized into two groups. Sixty-one students (immersion arm) were trained in critical appraisal using a simulated RCT aimed at determining efficacy of a “brainy pill” on ability to crack puzzles. Fifty-seven students (traditional group) were trained using a journal club with a checklist. Primary outcome of change in knowledge and skills of critical appraisal and EBM was determined by comparing scores on pre- and post-intervention Fresno tests.

Results: Mean age of students was 21.76 (SD - 0.78) years. Seventy (59.3%) were females and 48 (40.7%) males. Mean pre-test scores of traditional and immersion groups were 8.0 (SD - 4.88) and 9.31 (SD - 5.49) respectively and post-test scores were 50.2 (SD - 16.2) and 68.12 (SD - 14.72) respectively (post-intervention mean difference - 17.92; 95% CI 12.26 - 23.57; p<0.0000001). Odds of achieving 65% or more in post-intervention Fresno test score was significantly higher in immersion group (29.8% vs 8.2%; OR 4.76; 95% CI 1.62-13.97; p = 0.001). Perceived competence regarding EBM skills improved significantly in immersion group.

Conclusions: Simulated RCT is effective in imparting critical appraisal and EBM practice skills to medical students. Trainers should consider integrating and reinforcing this approach in EBM curriculum to make learning contextual and immersive. 

Does management reasoning constitute the backbone of the clinical learning environment?: Conceptual analysis of the existing notions

Management reasoning is a paradigm whereby learning occurs in a context bound fashion on analysing the biophysical factors existing in the clinical learning environment. In the contemporary medical education forums, much importance is being laid on clinical reasoning and this warrants the appropriate usage of the biomedical knowledge in arriving at the diagnosis. We perceive that clinical reasoning, in pure sense, often doesn't solve the purpose of rendering the best management plan to the patient. This holds stronger when the case is non-linear and highly complex in nature. Management reasoning fills the gap between hypotheses generation, i.e. accomplishing diagnosis and devising management plan. Indeed, it is a complex activity relying on several factors including the physician's perceptual abilities and situated cognition derived from formal and informal learning experiences. In contrast to clinical reasoning, which can be taught using structured scenarios, management reasoning necessitates analysing multitude of factors revolving around a patient and prioritizing those in order to titrate the best possible management plan. This commentary spotlights different dimensions of management reasoning, emphasizes the need of teaching it in the current scenarios, enlists the ways it can be taught, and opens the platform for discussing further on this underemphasized topic.

Diagnosis, impact and management of hyperhidrosis including endoscopic thoracic sympathectomy

INTRODUCTION

Hyperhidrosis is a disorder of excessive and uncontrollable sweating beyond the body's physiological needs. It can be categorised into primary or secondary hyperhidrosis based on its aetiology. Detailed history review including onset of symptoms, laterality of disease and family history are crucial which may suggest primary hyperhidrosis. Secondary causes such as neurological diseases, endocrine disorders, haematological malignancies, neuroendocrine tumours and drugs should be adequately examined and investigated prior to deciding on further management. The diagnosis of primary hyperhidrosis should only be made only after excluding secondary causes. Hyperhidrosis is a troublesome disorder that often results in social, professional, and psychological distress in sufferers. It remains, however, a treatment dilemma among some healthcare providers in this region.

METHODS

The medical records and clinical outcomes of 35 patients who underwent endoscopic thoracic sympathectomy for primary hyperhidrosis from 2008 to 2018 in Department of Cardiothoracic Surgery were reviewed.

RESULTS

The mean age of the patients was 27±10.1years, with male and female distribution of 18 and 17, respectively. Fifty-one percent of patients complained of palmar hyperhidrosis, while 35% of them had concurrent palmaraxillary and 14% had palmar-plantar-axillary hyperhidrosis. Our data showed that 77% (n=27) of patients were not investigated for secondary causes of hyperhidrosis, and they were not counselled on the non-surgical therapies. All patients underwent single-staged bilateral endoscopic thoracic sympathectomy. There was resolution of symptoms in all 35 (100%) patients with palmar hyperhidrosis, 13(76%) patients with axillary hyperhidrosis and only 2 (50%) patients with plantar hyperhidrosis. Postoperatively 34.3% (n=12) of patients reported compensatory hyperhidrosis. There were no other complications such as pneumothorax, chylothorax, haemothorax and Horner's Syndrome.

CONCLUSION

Clinical evaluation of hyperhidrosis in local context has not been well described, which may inadvertently result in the delay of appropriate management, causing significant social and emotional embarrassment and impair the quality of life of the subjects. Detailed clinical assessment and appropriate timely treatment, be it surgical or non-surgical therapies, are crucial in managing this uncommon yet distressing disease.

Melioidosis: distinctive clinico-epidemiological characteristics in southern India

As it is increasingly being reported from India, we carried out a prospective study of patients with culture-proven melioidosis from south India, examining clinical, laboratory features, epidemiological data, risk factors, treatments, outcomes at three and six months, and factors associated with mortality.Between 2014 and 2018, 31 cases were identified. Diabetes (83.9%) and alcohol abuse (58.1%) were common risk factors. Musculoskeletal, skin and soft tissue manifestations together constituted 48.4% of presentations, while 29% had pneumonia. During the intensive phase, 74.2% received one of three recommended antibiotic regimes, but 51.6% did not receive continuation treatment. Pneumonia and lack of continuation treatment were independently associated with a high mortality of 25.8%. Hot spots for melioidosis exist in India, and there is considerable diversity of presentation, including skin, soft tissue, musculoskeletal and neurological involvement. High rates of bacteraemia are shown.

Intangibility of the invisible hand - Analysing the micro-dynamics of novice mentoring program based upon one institutional experience

Although mentoring has been regarded as an essential component in the developmental phase of medical students, it is the nature of hierarchical relationship and the quality of emotional exchange which determine its sustainability. With great enthusiasm, we had launched our mentoring program for the new entrants of our medical school. After an initial faculty development workshop on mentoring, we framed our guidelines for implementing the program. To measure the relationship satisfaction on both sides and self-efficacy, we used relationship satisfaction scales. As the winds offered us the beginner's fortune, our program went on well for the first six months. Slowly, the colour of the mentorship program began to fade. Students began to find excuses for not meeting their mentors and the sessions truncated into a "hay- how do you do - bye" meetings. Through this commentary, we would like to introspect the factors which would have dampened the interest. Would it be the asynchronous agency support or lack of motivation / self-efficacy or roadblocks in Communication Bridge or lack of adequate matching or lack of need? The outcomes of our introspection would be of help for others who run the mentorship programs or who wish to install in their own institutes.

Snake envenomation: is the 20 min whole blood clotting test (WBCT20) the optimum test for management?

BACKGROUND

The 20 min whole blood clotting test (WBCT20) is a simple bedside test recommended by World Health Organization (WHO) to assess hemotoxic envenomation and guide administration of polyvalent anti-snake venom (ASV). However, reliability and validity of this test has not been well documented in literature.

METHODS

Sixty consecutive patients with history of snake bite were prospectively evaluated at a teaching hospital in India over 2 years. Envenomation was established by clinical and laboratory criteria. WBCT20 was done at 0, 4 and 12 h using standardized protocol. Prothrombin time (PT) with international normalized ratio (INR) was estimated at similar intervals to detect venom-induced consumption coagulopathy. Sensitivity, specificity and likelihood ratios (LR) were determined for WBCT20 using envenomation criteria as gold standard. WBCT20 was compared with PT/INR at cutoff values of ≥1.4 and ≥1.2. Two observers performed test-retest correlation to determine inter-observer variability of WBCT20.

RESULTS

 .

Seventeen of 60 patients had evidence of hemotoxic envenomation. Four patients had combined neurotoxicity and hemotoxicity. Sensitivity and specificity of WBCT20 were 94 and 76%; positive and negative LR were 3.9 and 0.08, respectively. No inter-observer variability was noted.

CONCLUSIONS

WBCT20 is a highly sensitive test with excellent reliability for detecting envenomation. However, the false positive rate in this study was 24%. Asymptomatic snake bite patients with a positive WBCT20 but no corresponding clinical signs of envenomation should be tested using PT/INR before receiving ASV to prevent unnecessary waste of anti-venom.

The patient is king: But does the king accept wise counsel?

Trust is the most important component of the doctor-patient relationship. This relationship has evolved substantially from a sacred paternalistic bond to a very prejudiced, consumeristic link. Changes in legal systems have brought medicine into the purview of consumer litigation and therefore the patient is the king akin to the consumer. In this short paper, the implications of the rights of the patient from a consumer point of view and the issues related to its use/misuse in daily interactions is discussed. How patients could potentially participate in decision making is stressed. At the same time, the fallout of their unnecessary intrusions into the doctor's clinical expertise and advisory capabilities needs to be recognised and tactfully countered to build and maintain trust in the doctor-patient relationship.

Comparing Curricular Reform in Medical Schools and the Ship of Theseus: Insights Regarding Philosophical and Ideological Characteristics

Most of the curricular reforms are either imprecise, lacking appropriate contextualization or keen in "lifting" the solution from one context and fixing it in some other context. The greatest obstacle for curricular reform is something intrinsic [philosophical and ideological] and related to the general disposition of educators to resist the change and love status quo. We would like to put forth that viewing reforms under these lenses is the ultimate requirement and when winds of reform begin to blow in curriculum, definitely it would become unstoppable and one reform would give birth to the necessity for other reform. This commentary intends to discuss the under emphasized intricacies related to curricular reform by comparing it with analogy of "The Ship of Theseus."

Diagnostic utility of bone marrow examination in evaluation of fever: a descriptive study on 98 immunocompetent adults from a tertiary care institute in south India

Five-year clinico-laboratory data from 99 (one HIV seropositive) adults (mean age = 41.3 ± 20.4 years) who underwent bone marrow examination for fever persisting for ≥ 1 week were analysed and correlated with microbiological characteristics. Infections, reactive marrow changes and haematolymphoid malignancies were most commonly associated with fever. A high concordance rate of 71% was noted between aspiration and trephine biopsies. Bone marrow granulomas (BMG) were seen exclusively on sections and were most commonly of tubercular and typhoidal in origin (two Salmonella Typhi, one Salmonella Paratyphi A). The common aetiologies associated with fever and cytopenia(s) were BMG, acute leukaemia and haemophagocytic lymphohistiocytosis (HLH; n = 3). The yield from bone marrow culture was inferior compared to other body fluids. In conclusion, bone marrow histology is superior to smears in the evaluation of prolonged fever. Marrow culture may not be useful in immunocompetent individuals other than if Salmonellosis is suspected.

Introducing a course on Evidence Based Medicine for undergraduate medical students – experience from an Indian medical school

This article was migrated. The article was not marked as recommended. Introduction: Although evidence based medicine (EBM) is part of undergraduate training in several countries, Indian medical schools are yet to make a meaningful start. We report our experience with EBM training for undergraduate. Methods: Third year students undergoing clinical clerkship at a teaching hospital underwent an 8 week course on EBM with modules on concepts, formulating questions, searching for evidence and critical appraisal. Feedback was taken and assessment done on knowledge and searching skills. Results: 90% of students had poor awareness of EBM. 92% considered evidence the most important component of EBM; 5% considered clinical expertise and patient values as part of EBM. At baseline majority cited Google the most reliable search tool. Only 27% felt EBM relevant to their curriculum. 66% rated the course good, very good or excellent. Hands-on training enhanced learning lack of background knowledge of diseases hindered it. Conclusion: Awareness of EBM is low among undergraduates and most find it irrelevant to their curriculum. Our experience suggests that it is feasible to integrate EBM training into undergraduate curriculum. More studies reporting knowledge and skills before and after EBM courses would strengthen the cause for making it part of undergraduate medical curriculum in India.

Hemophagocytic lymphohistiocytosis: An unusual complication in disseminated Mycobacterium tuberculosis

Background:

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially fatal, hyperinflammatory syndrome that may rarely complicate the clinical course of disseminated Mycobacterium tuberculosis (MTB). The clinical course of tuberculosis-associated HLH (TB-HLH) has been reported to be unpredictable.

Materials and Methods:

Here we describe the clinicopathological features, laboratory parameters, management, and outcome data of a patient who satisfied the 2004 diagnostic criteria for HLH secondary to disseminated MTB; we also do a systematic review of the international literature on TB-HLH. The literature review (January 1975–March 2014) found that HLH complicated the clinical course of 63 tuberculosis patients (41 males, 22 females, mean age = 45 ± 23.5 years) with a high mortality rate of 49% (31/63 died). The mean serum ferritin level (n = 44/63) was 5963 ng/mL (range 500–38,539 ng/mL); and a higher proportion (54.2%) of patients had pancytopenia at presentation. On univariate analysis (n = 53/63), age >30 years [hazard ratio (HR): 2.79, 95% confidence interval (CI):1.03–7.56, P = 0.03], presence of comorbidities (HR 4.59, CI: 1.08–19.52, P = 0.04), marked hemophagocytosis in bone marrow (HR: 2.65, CI: 1.16–6.05, P = 0.02), and nonusage/delayed usage of antitubercular therapy (ATT) (HR: 3.44, CI: 1.51–7.87, P = 0.003) were associated with decreased survival, though none of these parameters attained statistical significance (P > 0.05) in multivariate analysis. Usage of corticosteroids and/or immunomodulator drugs (HR 1.00, CI: 0.66–3.22, P = 0.35) did not alter the outcome in these patients.

Conclusion:

HLH should be considered as a differential diagnosis in patients with tuberculosis who present with cytopenias, organomegaly, and coagulopathy. Strong clinical suspicion and early usage of ATT might be useful in reducing the morbidity and mortality. The utility of immunosuppressive/immunomodulator therapy lacks general concensus among treating physicians, and warrants further studies.

Impact of focused training on communication skills of final-year medical students in a medical school in India

BACKGROUND

Although communication skills are important for a good physician-patient relationship, Indian medical curricula give very little emphasis on training medical students in this aspect.

AIMS

To determine the change in communication skills of final-year medical students following focused training.

METHODS

This was an educational interventional study done at Pondicherry Institute of Medical Sciences, a tertiary care teaching hospital in South India, to assess communication skills among final-year MBBS students. Fifty-two students (24 males and 28 females) participated in the study. A pre-test was conducted in the form of an objectively structured clinical examination (OSCE), followed by focused training for four hours. The same OSCE was administered as post-test. A comparison between the pre-test and post-test scores was done using Wilcoxon Signed Ranks Test.

RESULTS

Ninety-six per cent of participants (50 out of 52) showed improvement in their performance after the focused training. The mean marks of the pre-test and post-test were 10.77± 3 and 18.04±2, respectively, out of a maximum mark of 20 (p<0.05). One out of 52 participants did not show any improvement, and one participant scored less in the post-test compared to the pre-test. There was no significant difference in the performance between male and female students.

CONCLUSION

Focused training can enhance the communication skills of medical students. Hence, it may be included in the curriculum of undergraduate medical teaching programmes in India.

Selective myelosuppression following yellow phosphorus ingestion

Toxicity from accidental and intentional ingestion of yellow phosphorus, ubiquitously present in fireworks and rodenticides, has recently become more frequent. Gastrointestinal, renal, neurologic, and cardiovascular manifestations are common, with mortality of 23 per cent to 73 per cent. Reports of haematological abnormalities are rare. We report only the second case of severe neutropenia secondary to selective myelosuppression in a 14-year-old girl following intentional ingestion of yellow phosphorus. Leucocyte counts recovered spontaneously without further complications. Our case indicates that, besides hepatic and renal function monitoring, physicians should meticulously monitor blood counts in such cases for early detection of marrow suppression. Further studies are required to elucidate the complex mechanisms and significance of this unusual toxicity of yellow phosphorus.

Polyarthritis and massive small bowel bleed: An unusual combination in scrub typhus

Scrub typhus is an acute febrile illness caused by the intracellular parasite Orientia tsutsugamushi. Although most cases present with mild symptoms and signs and recover spontaneously, some cases can be severe with multi-organ dysfunction and a protracted course, which may be fatal if left untreated. Apart from fever and constitutional symptoms, atypical presentations allow this disease to mimic several common conditions. We report a case of scrub typhus in an 18-year-old male who presented with severe polyarthritis involving all large joints and a massive lower gastrointestinal bleed from ulcers in the terminal ileum, secondary to vasculitis in the small bowel. This combination of pathologies has not previously been reported in cases of scrub typhus. The patient improved following surgical intervention and specific anti-rickettsial therapy with azithromycin.

Prevalence and patterns of hearing loss among chronic kidney disease patients undergoing haemodialysis

BACKGROUND

The prevalence, degree, and patterns of hearing loss associated with chronic kidney disease (CKD) reported by various studies differ significantly. The effects of haemodialysis and duration of disease on hearing loss remain unclear.

AIMS

The aim of this study was to determine the prevalence and degree of hearing loss in CKD patients on haemodialysis.

METHODS

This study included 120 CKD patients on haemodialysis. Information regarding age, gender, duration of disease, subjective hearing loss, exposure to ototoxic drugs, comorbidities like diabetes, hypertension, and hypothyroidism, renal functions, electrolytes and number of haemodialysis sessions received were obtained. An equal number of age and sex matched controls were used to determine prevalence of hearing loss in CKD patients after subjecting both groups to pure tone audiometry. We compared CKD patients with and without hearing loss for association of hearing loss with disease duration, number of haemodialysis, and blood parameters.

RESULTS

Hearing loss was present in 41.7 per cent of CKD patients, significantly higher than controls (p=0.001), and was mild in the majority of patients. Impairment was noted across high and low frequencies of audiometric testing. Median duration of disease was the same (18 months) among CKD patients with and without hearing loss (p=0.62). CKD patients with hearing loss received 72 haemodialysis compared to 122 sessions by those without hearing loss (p=0.04).

CONCLUSION

Mild sensorineural hearing loss is common in CKD. Hearing loss has no specific pattern as it prevails at high and low frequencies. Hearing loss may be inversely associated with the number of haemodialysis sessions but not with duration of disease.

Bilateral thalamic bleed and cerebral venous sinus thrombosis in Japanese encephalitis

Japanese encephalitis (JE) is a potentially serious form of viral encephalitis with varied clinicoradiological manifestations. We report the case of a 19-year-old girl admitted with headache, vomiting and altered sensorium in the absence of fever, whose cerebrospinal fluid analysis showed lymphocytic pleocytosis with significant protein content and positive serum IgM JE antibodies. MRI with venography revealed bilateral thalamic haemorrhage and cerebral venous sinus thrombosis. Although thalamic hypodensities are a well-described feature, thalamic haemorrhage and cerebral venous thrombosis are distinctly rare in JE. This report highlights the role of imaging in cases of encephalitis in general and JE in particular, in the early detection of uncommon manifestations that may complicate these diseases.