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   Table of Contents - Current issue
Coverpage
April-June 2022
Volume 11 | Issue 2
Page Nos. 55-122

Online since Thursday, April 14, 2022

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EDITORIAL  

Vaccine-induced thrombotic thrombocytopenic purpura p. 55
Sudha Vidyasagar
DOI:10.4103/jcsr.jcsr_9_22  
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ORIGINAL ARTICLES Top

Spectrum and outcome in patients with unilateral pleural effusion admitted in a tertiary care hospital Highly accessed article p. 58
Neeraj Saini, Saumya Ahluwalia, Srishti Ahluwalia, Pavneet Kaur Selhi, Akashdeep Singh
DOI:10.4103/jcsr.jcsr_57_21  
Background: Unilateral pleural effusion is a challenge for a physician as the differential diagnosis is varied; sparse epidemiological data are available from India on this subject. Methods: We prospectively studied consecutive adult patients (aged >18 years) presenting with unilateral pleural effusion who underwent thoracocentesis with or without radiological guidance for diagnostic workup. Results: Over a period of 1 year, 116 patients admitted with unilateral pleural effusion were included, majority (63.8%) were in the age group of 20–60 years. Most common presenting symptoms were shortness of breath (56%), fever (53.4%), cough (52.5%), chest pain (35.3%), anorexia (34.5%) and weight loss (18.9%). Ninety-nine patients (85.3%) had exudative and 17 patients (14.6%) had transudative pleural effusion. Amongst exudative, tuberculosis (TB) pleural effusion was the most common cause (45.7%) followed by para-pneumonic (12.9%), malignant (10.3%), among others. TB (44.8%) and malignancy (10.3%) were common aetiologies among the lymphocyte-predominant effusions, whereas para-pneumonic effusion (11.2%) and empyema (4.3%) were common aetiologies amongst the neutrophil-predominant effusions. Pleural fluid lymphocyte-to-neutrophil ratio >0.75 increased the sensitivity and specificity to diagnose TB pleural effusion. Conclusions: Patients with TB pleural effusion were comparatively younger as compared to patients with malignant and para-pneumonic pleural effusion. Most pleural effusions resolved with treatment of underlying cause.
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A study of needle-stick injury incidence amongst healthcare workers and its root cause analysis in a tertiary care teaching hospital p. 72
Rangineni Jayaprada, K Vineela, N Ramakrishna, S Yamini, KM Bhargav
DOI:10.4103/jcsr.jcsr_40_21  
Background: Needle-stick injury (NSI) incidence is a major occupational hazard amongst healthcare workers (HCWs). Methods: In this retrospective study conducted amongst HCWs from October 2018 to October 2019, we aimed to know the incidence of NSI and its root cause. At the time of self-reporting of NSI, details were collected regarding mode of injury, viral markers of source and HCWs and vaccination status of HCWs. Exposed HCWs were followed up till 6 months for seroconversion. Results: A total of 47 NSIs were reported during the study period. The incidence rate per annum was 0.13. The NSI incidence was high in intensive care units (ICUs) (47%) and was commonly due to recapping needles (36.2%). Amongst 12 NSIs, sources were positive for viral markers (6 for hepatitis B virus [HBV], 5 for human immunodeficiency virus [HIV] and 1 for hepatitis C virus). Amongst four completely vaccinated HCWs exposed to HBV-positive sources, two had anti-HBV antibody titres <10 mIu/ml. No seroconversion was seen in any of the exposed HCWs during follow-up. Conclusions: The annual incidence of NSI in our hospital was 0.13 and was high in ICUs. This prompted the institution of training sessions for HCWs to reduce the NSIs.
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An observational study to determine the clinical course of asymptomatic and mildly symptomatic COVID-19–positive patients admitted to a tertiary care centre in Puducherry p. 77
Kulkarni Vandana Sharashchandra, Prashant Shivaraj Sajjan, J Ramesh, K Jayasingh, Vithiavathi Satish
DOI:10.4103/jcsr.jcsr_15_22  
Background: Severe acute respiratory syndrome Coronavirus2 (SARSCoV2) disease (COVID-19) has spread nationwide including union territory of Puducherry. Methods: Consecutive asymptomatic or mildly symptomatic COVID-19 patients admitted to the COVID-19 ward were included in the study. Demographic details, following of social norms, contact-exposure history, presence of co-morbidities, vital parameters, clinical symptoms and signs, development of new symptoms, progression and outcome of study patients are reported. Results: Six hundred and forty two patients were included for final analysis. Most of symptomatic patients did not use face mask (87%) and did not follow social distancing (84.1%) or hand hygiene (91.3%). Out of mildly symptomatic patients, 12 become moderately or severely symptomatic and were shifted to intensive care unit. All these patients were male, aged more than 50 years with co-morbidities. Conclusions: Wearing face mask, social distancing and hand hygiene can decrease disease severity. Male patients with co-morbidities and old age are at higher risk of progression to moderate or severe COVID-19 infection.
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Timing to perform bed-side surgical tracheostomy in COVID-19 patients in intensive care unit p. 83
Santosh Kumar Swain, Ishwar Chandra Behera, Pragnya Paramita Jena
DOI:10.4103/jcsr.jcsr_41_21  
Background: Tracheostomy is an important surgical procedure in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) pandemic, particularly those patients undergoing prolonged tracheal intubation. The timing and indications for tracheostomy in COVID-19 patients with ventilators are still controversial. Methods: We prospectively studied the best timing for performing surgical tracheostomy in COVID-19 patients (n = 22) from April 2020 to May 2021 in the COVID-19 ICU attached to our COVID-19 hospital. The tracheotomised patients were followed up and the number and timing of the death were documented. Results: There were 14 males (male:female = 1.75:1). The mean duration of endotracheal intubation to tracheostomy was 14.4 days (range 10-22 days). The mean time for tracheostomy was 18.45 min (range 12–25 min). Five patients (22.7%) died after tracheostomy. The median time between tracheostomy and death was 4 days. Conclusions: Surgical tracheostomy has to be performed in a proper time with safe manner for benefit of the patients with COVID-19 and the health care professionals managing the patient.
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A double-blind prospective randomised controlled clinical study comparing 0.5% hyperbaric bupivacaine with nalbuphine and 0.5% hyperbaric bupivacaine for spinal anaesthesia in lower limb orthopaedic surgeries p. 88
Pathapati Divya, Rajan Anand, Debadas Bagchi
DOI:10.4103/jcsr.jcsr_50_21  
Background: Intrathecal nalbuphine is one such opioid, highly lipid soluble with an agonist action at the kappa and antagonist activity at the muopioid receptors, known cardiovascular stability, minimal dose and volume of this drug that can be added to a local anaesthetic agent. Methods: This prospective randomised double-blind study was conducted to evaluate the effects of adding nalbuphine to 0.5% hyperbaric bupivacaine in spinal anaesthesia to know the efficacy, duration of analgesia, incidence of side effects and complications. Sixty American Society of Anesthesiologists (ASA) grade I and II patients were randomly allocated to Group A and Group B of 30 each who received 0.4 mL (0.4 mg) of nalbuphine and 0.4 mL of normal saline added to 3 mL (15 mg) of 0.5% hyperbaric bupivacaine, respectively. Intraoperative haemodynamic parameters, onset, duration of sensory and motor block, visual analogue scale (VAS) score, duration of effective analgesia and possible side effects were monitored and compared. Results: There was no statistically significant difference in the haemodynamic parameters, onset of blockade, duration of motor blockade and side effects. However, in two-segment regression, time of sensory blockade, duration of effective analgesia and VAS scores in Group A were found statistically significantly higher (P < 0.001) compared to Group B. Conclusions: Intrathecal nalbuphine used as adjuvant to bupivacaine prolongs duration of effective analgesia, without any significant side effects with stable haemodynamic parameters.
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A comparative study of dexmedetomidine–propofol and fentanyl-propofol on perioperative haemodynamics, propofol requirement and post-operative recovery profile in patients undergoing elective abdominal surgeries - A prospective randomised double-blind study p. 94
Kuraparthi Jasmitha, Natham Hemanth, Aloka Samantaray
DOI:10.4103/jcsr.jcsr_2_21  
Background: Dexmedetomidine is gaining popularity for its sympatholytic, sedative and haemodynamic stabilising properties, without significant respiratory depression. Methods: A prospective randomised double-blind study was conducted on 60 patients belonging to American Society of Anesthesiologists (ASA) Grade I and II undergoing elective abdominal surgeries who were randomised to receive either dexmedetomidine (Group D-P) or fentanyl (Group F-P) 10 Min prior to induction. Induction was done with midazolam along with propofol in 20 mg aliquots until bispectral index (BIS) value drops below 60. Infusion of one of the study drugs was continued along with propofol infusion which was titrated to maintain BIS around 40–60. Vecuronium to provide muscle relaxation and bolus doses of fentanyl were given whenever additional analgesia was needed. Intra-operative propofol, vecuronium and additional fentanyl requirement, time from discontinuation of anaesthetic drugs to extubation, time from the end of surgery to achieve a Ramsay sedation score of 2 and to the first post-operative analgesic request were recorded. Post-operatively, patients were monitored till 24 h for any adverse events. Results: A significant decrement in heart rate was observed in the D-P group in comparison to the fentanyl group. The D-P group was found to have required less propofol for induction, limited additional fentanyl requirement, less time required for extubation and a delay in request for first post-operative analgesia which was statistically significant. Conclusions: Propofol–dexmedetomidine provides better haemodynamic stability with lesser intraoperative propofol and fentanyl requirement, early cognitive recovery and longer postoperative analgesia when compared to propofol–fentanyl.
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REVIEW ARTICLE Top

A systemic review of association between UDP glucuronosyltransferase family 1 member A1 (UGT1A1) polymorphisms in Gilbert's syndrome in Sickle Cell Disease p. 99
Sanya Sachdeva, Ragini Bodade, Anand Bodade
DOI:10.4103/jcsr.jcsr_56_21  
Gilbert's syndrome (GS) is a benign hereditary disorder of bilirubin metabolism due to a mutation in the UDP glucuronosyltransferase family 1 member A1 (UGT1A1) gene which results in hyperbilirubinaemia and related complications mainly cholelithiasis. It can be co-inherited along with sickle cell anaemia, thalassaemias and other haemoglobinopathies including glucose-6-phosphate dehydrogenase deficiency, hereditary spherocytosis and cystic fibrosis. More than 100 mutations have been reported in UGT1A1 gene and the most common as insertion of extra (TA) nucleotides in the promoter region of TATA box. The more the number of TA repeats, the higher is the bilirubin levels. These mutations result in a 10%–35% reduction in the UGT1A1 enzyme activity resulting in mild to moderate unconjugated hyperbilirubinaemia and related complications. For diagnosis the mode of inheritance is more important than testing in the patients. However; the inheritance pattern of GS differs in ethnicities. For early diagnosis to prevent worsening of the symptoms and for timely management one should be aware of the inheritance pattern in patient. In this systemic analysis we studied the association between complications in GS with the genotypes and complications. It was found that TA7/7 is more significant in GS with sickle cell disease (SCD) group when compared to healthy controls with 2.2% chances of having this genotype in GS with SCD than healthy controls. The significance of having TA7/7 genotype is similar in GS with SCD and α-thalasaemia group. However, there is a high recommendation to carry out multicentre studies and conduct meta-analyses for establishing universal recommendations.
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CASE REPORTS Top

Unanticipated catastrophe during pre-operative routine check of anaesthesia workstation - Water in rotameter p. 109
Sunil Kumar Valasareddy, Siva Kumar Segaran, RV Ranjan
DOI:10.4103/jcsr.jcsr_58_21  
Medical gas production, supply and distribution is a closely regulated process with its intrinsic safety designs and procedure along with this anaesthesia work station designed with utmost safety for delivering anaesthetic gases to patients during the peri-operative period. The ingress of condensed water into anaesthesia machine from central medical gas pipeline can lead to catastrophic incidents.
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An unusual cause of liver and renal abscess in an immunocompetent individual p. 112
Samanvith Patlori, Shetty Mallikarjuna, Phani Chakravarty, Kavya Kaza
DOI:10.4103/jcsr.jcsr_29_21  
The occurrence of combined liver and renal abscess by Candida albicans in an immunocompetent patient is a rare entity. Here, we report a 40-year-old female who presented to the hospital with complaints of fever, right flank pain, vomiting and loose stools. Contrast-enhanced computed tomography (CT) of the abdomen revealed liver and renal abscess with contracted left kidney with multiple urinary calculi and bilateral mild to moderate hydroureteronephrosis. Culture of the aspirate from abscess grew C. albicans. Blood cultures and urine cultures were sterile. She was treated with tablet voriconazole and percutaneous drainage of renal and hepatic abscess was done. Fever spikes and pain abdomen subsided after 1 week of therapy. Repeat CT abdomen after 3 weeks showed resolving liver and renal abscess.
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A rare presentation of type 1 diabetes mellitus: Diabetic ketoacidosis with severe dyslipidaemia and eruptive xanthomas p. 115
Ochai Attai Ateko, Yakubu Lawal, Rifkatu Mshelia-Reng, Uchenna Okechukwu Ugwuneji, Ifeanyi Ucha Julius, Felicia Ehusani Anumah
DOI:10.4103/jcsr.jcsr_44_21  
Diabetic ketoacidosis (DKA) is the most common life-threatening complication of diabetes, especially in type 1 diabetes mellitus (T1DM). Severe dyslipidaemia causing extensive xanthomas is very rarely reported in DKA. We report the case of a 30-year-old male with T1DM who presented with features of ketoacidosis and had extensive eruptive xanthomas. Blood samples drawn on admission showed excessively lipemic serum and marked dyslipidaemia after analysis. The patient was treated with insulin, rehydration and statins with good clinical outcome. The present case highlights the importance of serial monitoring of lipids and early lipid-lowering therapy in DKA presenting with severe dyslipidaemia, especially when occurring with cutaneous symptoms.
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SPECIAL FEATURE: BRIEF COMMUNICATION Top

Transfusion-related acute lung injury: A rare case after single packed red blood cell unit transfusion p. 119
PM Bala Bhasker
DOI:10.4103/jcsr.jcsr_16_21  
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CORRESPONDENCE Top

Subacute sclerosing panencephalitis and movement disorders p. 121
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
DOI:10.4103/jcsr.jcsr_30_22  
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