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   Table of Contents - Current issue
Coverpage
October-December 2021
Volume 10 | Issue 4
Page Nos. 195-264

Online since Monday, October 25, 2021

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EDITORIAL  

Teaching clinical skills to undergraduate medical students in times of physical distancing: Trials and tribulations p. 195
Alladi Mohan, B Sri Hari Rao
DOI:10.4103/jcsr.jcsr_52_21  
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ORIGINAL ARTICLES Top

Detection of acid sphingomyelinase in human saliva and its advantages in the diagnosis of Niemann-Pick disease type B p. 197
Alicia Giner-Ayala, Celia Juana Angaroni, Raquel Dodelson de Kremer, Lidia Dora Martínez
DOI:10.4103/JCSR.JCSR_95_20  
Background: Niemann-Pick disease type B is an autosomal recessive lysosomal storage disorder caused by a deficiency of acid sphingomyelinase (ASM) coded by SMPD1 gene. Diagnostic assays for this enzyme were developed using fibroblasts, leukocytes, plasma and dry blood spots, however, there are no expression studies in saliva in the literature, so far. Saliva is a biofluid used to analyze the health/disease condition of an individual. Methods: We standardized a fluorometric method to determine ASM activity in human saliva of control subjects and in one NPD-B patient. Results: ASM activity was detected in all saliva samples. The range of ASM in saliva of 28 control subjects was 4.5 - 70.4 with an average of 26.93 ± 15.7 nmol/17h/mg of protein. Values in plasma were significantly lower, a 0.056- 3.2 range, with an average of 0.85 ± 0.7 nmol/17h/mg of protein. There was no correlation between saliva and plasma samples (R2= 0.001). ASM was markedly deficient in saliva activity of (0.09 nmol/17h/ mg of protein) as well as in the leukocyte pellet (0.125 nmol/17h/mg protein) and in the plasma (0.68 nmol/17h) of the NPD-B patient. Conclusion: Our observations indicate that saliva could be an alternative biofluid to plasma and to leucocytes to measure ASM activity, representing a non-invasive, easy-collection diagnostic means, which would allow the identification and characterization of these entities.
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Burden of comorbidities and their treatment in patients with active tuberculosis: A prospective study p. 202
Venkat Manolasya, DT Katyarmal, T Muni Suneel Babu, T Sreeja Prasad, T Preethi, B Priyanka, G Robin
DOI:10.4103/jcsr.jcsr_8_21  
Background: Patients diagnosed to have active tuberculosis (TB) may have co-existing comorbid conditions. Treatment for both conditions may lead to possible drug-related problems. Hence, the present study was designed to understand the incidence and pattern of drug-related problems. This knowledge gives a scope to minimise the occurrence and help patients to adhere to treatment. Methods: A prospective observational study was carried out for a period of 6 months. A pre-designed data collection form was used for this study that was used to document clinical data including brief history, laboratory investigations, treatment details and drug-drug interactions (DIs). Results: One hundred and five TB patients were enrolled in the study. Their mean age was 43.7 ± 16.8 years. Sixty patients were found to have comorbidities. One hundred and fifty-eight drug-related problems between comorbidities' treatment regimens and ATT were documented. DIs were the most common drug-related problems. Seventy-nine major DIs and 74 moderate DIs were documented. Nine patients had adverse drug reactions which were ATT-induced hepatotoxicity, thrombocytopenia and anaemia. Conclusions: Co-existence of comorbidities and their treatment resulted in a significant burden on patients who are diagnosed positive for TB. This can lead to treatment delay or failure or default. Strategies and programmes to tackle the burden of comorbid conditions on TB-positive patients are to be developed and implemented aggressively.
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Epidemiological study of cervical cancer in the coastal region of Visakhapatnam p. 208
Shaik Aasma Begam, Sridevi Suvvari, Praveena Voonna, Rooth Vasantha, Sudhakar Godi
DOI:10.4103/JCSR.JCSR_91_20  
Background: Cervical cancer is one of the major public health problems for women in India according to the population-based study. It can be reduced through health education, screening and thereafter treatment of pre-cancers. However, over 80% of women with cervical cancer live in developing countries. In the majority of situations, most women do not have any access to awareness, screening and treatment programmes. Methods: This is a study based on the knowledge of women regarding symptoms, risk factors, prevention and treatment of cervical cancer. A cross-sectional, self-administered questionnaire-based survey was conducted on 200 women from both urban and rural areas of Visakhapatnam, Andhra Pradesh. Results: No significant differences were noted between rural and urban women in their knowledge of cervical cancer was noticed. Of the subjects studied, 41.4% were aware of cervical cancer as a type of cancer affecting women, only 10% of the population know the screening of cervical cancer. Conclusions: The outcome of the results suggest the need for designing a strategy involving government action, conducting awareness, and screening programmes to minimise the occurrence of cervical cancer in this region.
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COVID-19 vaccine hesitancy and its determinants among health-care workers and non-health-care workers: An online survey in India p. 212
Amit Sudarshan Bhondve, Sushrut Madhukar Ingawale, Nehar Dilip Rajapurkar
DOI:10.4103/jcsr.jcsr_38_21  
Background: India has already witnessed two COVID-19 waves, and in midst of it, India was not far behind in rolling out COVID-19 vaccination. However, considering the novelty of the disease and very short duration invested in developing the vaccine, hesitancy to take the vaccine was expected. Methods: This cross-sectional study was conducted by using validated, multi-lingual, self-administered online questionnaires designed separately for the health-care workers (HCWs) and non-HCWs. Adult subjects willing to participate in our study by filling the online questionnaire were included. First 1000 responses were selected for the analysis. Results: On Likert scale, 45% HCWs and 51.2% non-HCWs were hesitant about vaccination. Binary logistic regression predicted the factors of hesitancy as follows. for HCWs (female-gender [odds ratio (OR) = 0.518, 95% confidence intervals (95% CI) 0.368–0.728, P < 0.001], middle-age [26–35 years (OR = 1.78, 95% CI 1.644–8.062), P = 0.001], 35–55 years [OR = 2.51, 95% CI 1.279–4.925, P = 0.007], doubtful vaccine efficacy [OR = 2.262, 95% CI 1.283–3.989, P = 0.005]); for non-HCWs [{no past medical illness (OR = 1.672, 95% CI 1.019–2.906, P = 0.048)], doubtful vaccine efficacy [(OR = 2.442, 95% CI 1.022–5.834, P = 0.048)]. Conclusions: Our observations suggest that the vaccine hesitancy can be a major hindrance to achieve desired vaccination coverage in India. This hesitancy is safety, quality control, novelty of the disease and vaccine, efficacy and false belief of herd immunity among the community.
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Keratometry in paediatric eyes with cataract in Indian population p. 221
Abhay R Vasavada, Aditya Sudhalkar, Mamidipudi R Praveen, Sajani K Shah, Viraj A Vasavada
DOI:10.4103/jcsr.jcsr_23_21  
Background: To compare the keratometric data of unilateral cataractous paediatric eyes with their corresponding non-cataractous fellow eyes. Methods: In this clinic-based observational study eyes of 354 consecutive children who presented with unilateral or bilateral cataract were analysed. Other data collected included age at the time of surgery, gender, keratometry, axial length (AL) and laterality of cataract. Keratometric values were obtained under general anaesthesia using a handheld Nidek Auto Keratometer. AL was measured with an ultrasound A-scan using either the immersion or the contact technique (Ocuscan, Alcon). Results: The average K value in the cataractous eyes was 44.97 ± 2.53 D (range: 37.38–55.13 D). The K values in different age groups were significantly different (P < 0.001). Irrespective of age, there was a significant difference between the K values of unilateral (n = 34 eyes: K = 44.16 ± 2.02) and bilateral cataracts (n = 320 eyes: K = 45.07 ± 2.56) (P < 0.05). In the age groups of 6–18 and 18–60 months, there was significant difference in K values of males and females (P < 0.02, P < 0.008). There was no significant difference in K values of unilateral cataractous eyes and their fellow eyes (P = 0.096). Age and AL demonstrated a significant linear relationship with K values: K =46.29− (0.6 1 log of age in months) (R2 = 0.09, P < 0.001) and K = 53.78− (0.451 AL) (R2 = 0.17, P < 0.001). Conclusions: The keratometric values of young children were steeper than those of older children. There was no significant difference in K values of the unilateral cataractous eyes as compared to the fellow eyes.
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Clinical profile of fever in patients admitted through the outpatient department in a North Indian tertiary care teaching hospital p. 227
Gurpreet Kaur Salh, Veenu Gupta, Harpreet Kaur, Srishti Ahluwalia, Saumya Ahluwalia
DOI:10.4103/jcsr.jcsr_18_21  
Background: Febrile illnesses are a common cause of morbidity and mortality and present diagnostic challenge, especially in the absence of reliable data in India. Fever has varying aetiologies such as infections, connective tissue disorders and malignancies. The infections may be indistinguishable clinically, and appropriate management will depend on the aetiologic profile. This study was planned to know the aetiology and seasonal variations of fever in adult patients. Methods: A prospective observational study over a period of 15 months was conducted on adult patients aged ≥18 years with febrile illness. Details of history and results of physical examination were recorded. Routine baseline and special investigations were done as clinically indicated. All patients were followed until discharge from the hospital. Results: Out of 122 patients, 79 were male. The maximum number of patients was in the age group of 31–40 years. The most common symptoms were myalgia, cough and vomiting. The aetiology of febrile illness was acute undifferentiated febrile illness (33.6%), undiagnosed undifferentiated fever (23%) and other diagnosis (43.4%). Common aetiologies of acute undifferentiated febrile illness were dengue fever (10.6%) and enteric fever (9.8%). Amongst other causes, tuberculosis and urinary tract infections were common. Seasonal variation was seen in enteric fever, dengue fever, pneumonia and tuberculosis. Conclusions: Common aetiologies were dengue, enteric fever and tuberculosis. It is important to understand the profile of febrile illness; so that evidence-based management can be initiated, especially in a resource-limited country like India.
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REVIEW ARTICLES Top

Lipopolysaccharide: An indispensable source for potential targets and therapeutic design against Gram-negative bacteria p. 233
Chiranjeevi Pasala, Sudheer Kumar Katari, Ravina Madhulitha Nalamolu, Sharon Priya Alexander, Umakanth Naik Vankadoth, Siva Ranjani Pakala, Amineni Umamaheswari
DOI:10.4103/JCSR.JCSR_72_20  
Gram-negative bacteria show more drug-resistant than Gram-positive bacteria due to unique structural attribute and cause significant morbidity and mortality across the globe. Such characteristic structure is an organelle lipopolysaccharide (LPS) on the outer membrane (OM) of cell wall essential for growth and survival of bacteria. LPS is a major cell wall component formed by dedicated transenvelope multiprotein complexes that shield the underlying peptidoglycan layer and play a key role in host–pathogen interactions with the innate immune system. Moreover, which constitutes the surface-exposed molecules with lipid portion in the outer leaflet of the OM that able to show antibiotic resistance and also responsible for the variety of biological effects associated with bacterial sepsis. LPS synthesis and structure are a conserved subject in infections during bacterial adaptive changes. Such changes ensue immune evasion, prolonged inflammation and augmented antibiotic resistance by working as molecular decoys which titrate the antimicrobials away from its intracellular antibiotic target. Herein, this review summarises the key features of LPS structure, function and biosynthesis. Moreover, it highlights the broad-spectrum conserved targets in the Raetz pathway without an alternative way for LPS biosynthesis vital for the development of novel therapeutic interventions against Gram-negative pathogens.
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Coronavirus disease 2019-associated mucormycosis – A syndemic p. 240
Megha Priyadarshi, Tirlangi Praveen, Ankit Mittal, Gagandeep Singh, Immaculata Xess, Naveet Wig
DOI:10.4103/jcsr.jcsr_51_21  
Coronavirus disease 2019 (COVID-19) and COVID-associated mucormycosis (CAM) came as a syndemic that not only severely increased morbidity and mortality but also posed a serious challenge for the healthcare system of a developing country like India. Although mucormycosis is a rare disease with a worldwide incidence of 0.43 cases per million population/year, these two COVID-19 waves caused a total of more than 14,000 cases in India itself. Mucormycosis is an angio-invasive fungal infection with rapid progression. The three major modalities of treatment involve early surgical debridement, initiation of antifungal therapy and controlling the predisposing risk factor. A complex interplay of factors, including pre-existing disease such as diabetes mellitus, use of immunosuppressants and immunomodulators, risk of hospital-acquired infection and immune dysregulation post-COVID-19, may all predispose to the development of CAM. Future research regarding the efficiency of newer antifungal with lower side effect profiles and evidence-based establishment of risk factors for adopting preventing strategies is the need of the hour. The disease is known to have high mortality despite the best treatment. We review in this article the aetiopathogenesis, various diagnostic modalities and treatment considerations for this disease.
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CASE REPORTS Top

Porokeratotic eccrine ostial and dermal duct nevus: A rare case report p. 246
S Sudheer Kumar, K Ram Kumar, V Chenchaih, Grandhi Usha, P Venkata Ramana
DOI:10.4103/JCSR.JCSR_83_20  
Porokeratotic eccrine ostial and dermal duct nevus (PEODDN) is an uncommon benign disorder that clinically mimicks comedo nevus but usually favors the palms and soles, where pilosebaceous follicles are absent. It also can present with widespread involvement along Blaschko's lines. It is a disorder of keratinisation involving the intraepidermal eccrine duct (acrosyringium) with classical histopathological examination findings (eccrine hamartoma and cornoid lamellation). The patient is a 32-year-old woman with a 12-year history of pruritic skin lesions on her right palm and index finger. Histopathological examination revealed multiple small epidermal invaginations with overlying parakeratotic cornoid lamellation and loss of granular layer. Few dyskeratotic cells are seen at the base of epidermal invagination. After clinic-pathologic correlation, the diagnosis of PEODDN was made. Late-onset and rare clinical presentation as pruritic lesion are the characteristic features that make this patient an extraordinary presentation of PEODDN.
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A rare case of adverse drug reaction and drug interaction in a human immunodeficiency virus patient p. 249
Kaza Kavya, MV S. Subbalaxmi, Mutnuru Phani Chakravarty, Soanker Radhika, Mallika Goyal
DOI:10.4103/JCSR.JCSR_6_20  
We are reporting a case of rifabutin-induced uveitis in a woman with human immunodeficiency virus (HIV)-tuberculosis (TB) coinfection involving the right hip. Identifying the culprit drug and tailoring the appropriate regimen was a challenge to the clinicians. We described the clinical features, ophthalmological findings, laboratory findings and radiological findings in skeletal TB and follow-up in a woman with HIV-TB coinfection. Improvement of vision on stopping rifabutin with rifampicin confirmed our diagnosis. This case highlights about adverse drug reactions and drug interactions in case of HIV and TB coinfection. Patients receiving therapy with combinations of any of these agents should be warned about signs and symptoms of uveitis and monitored closely for the development of rifabutin toxicity.
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Microtia deformity correction with three-dimensional and two-dimensional templates: A pathway for effective ear reconstruction p. 252
Pradeoth Mukundan Korambayil, Kurian Alappatt, Prashanth Varkey Ambookan
DOI:10.4103/JCSR.JCSR_73_20  
Expression of anatomical landmarks of the ear results in the success of ear reconstruction in microtia. Ear reconstruction in India is routinely done with a two-dimensional (2D) template by tracing the contralateral ear with an X-ray sheet. There is a need of a proper template to understand the finer details of the ear reconstruction. In this report, a three-dimensional (3D) template in association with a 2D template is utilised to augment the reconstruction ability of the plastic surgeon. After computed tomography scan, an accurate 3D scan of the normal ear is obtained. Using the 3D ear model file, a negative mould of the ear 3D model is developed and fed into a 3D printer. The model is sterilised and used for reconstruction. Hyperbaric oxygen therapy is used as an adjunct for the procedure. Simultaneous utilisation of 3D and 2D templates for ear reconstruction appears to increase the ability of plastic surgeons to recreate the ear.
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SPECIAL FEATURE: COMMENTARY Top

Evolution, development, and simulation-based testing of 'Check CRISIS' – A unique cognitive tool in perioperative crisis management p. 256
VR Hemanth Kumar, Kusha Nag, P Rani, M Ravishankar, Dinker Pai
DOI:10.4103/JCSR.JCSR_99_20  
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CORRESPONDENCE Top

Fostering integration between undergraduate medical education and primary healthcare p. 263
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/jcsr.jcsr_27_21  
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