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   Table of Contents - Current issue
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November 2020
Volume 22 | Issue 3 (Supplement)
Page Nos. 1-140

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EDITORIAL  

Not the last pandemic – Investing in a safe navy for the future pandemic p. 1
Sougat Ray, Sunil Goyal, Kaushik Roy, Naveen Chawla, RJ Singh
DOI:10.4103/jmms.jmms_144_20  
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EDITORIAL REVIEW Top

Testing for severe acute respiratory syndrome coronavirus 2: Unraveling the conundrum p. 6
Atul Kotwal, Arun Kumar Yadav
DOI:10.4103/jmms.jmms_103_20  
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REVIEW ARTICLES Top

Evolutionary origin and structure of SARS-CoV-2 – A brief narrative review p. 10
Pratima Gupta, Jitender Gairolla, Prateek Varshney
DOI:10.4103/jmms.jmms_141_20  
Coronavirus disease 19 (COVID-19) outbreak occurred in Wuhan city, China, in December 2019 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that belongs to the group of beta-coronaviruses (CoVs) and has created an unprecedented situation worldwide. Since the inception of this disease, the mystery about the origin still persists. Over 3200 types of CoVs can infect bats; therefore, finding out the susceptibility of CoVs to specific species of bats is always challenging. Similarities of pangolin-CoV with SARS-CoV-2 and bat CoV suggested pangolin as another intermediate host of SARS-CoV-2. Recombination mechanism is primarily crucial to understand the origin of CoVs as it creates genetic diversity, thus novel variants of viruses emerged. In this review, attention has been paid to understand the origin and structure of SARS-CoV-2. This will help prevent similar pandemics in the future as well as effective in discovering possible therapeutic targets and vaccines.
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COVID-19: End game p. 16
Shruti Vashisht, Sanjay Rai, Sougat Ray, Vivek Phutane
DOI:10.4103/jmms.jmms_113_20  
The COVID-19 pandemic has swept the entire world in a few months' time, much faster than any epidemic before. The scientist, doctors, and politicians worldwide are fervently working round the clock to bring an end to this pandemic which has otherwise stalled the lives of the populations. In the absence of any reliable treatment or vaccine, nonpharmaceutical interventions are presently are the mainstay to prevent and possibly end the COVID-19 pandemic. The development of herd immunity either through natural infection or induced through vaccine can bring down the epidemic. However, it may take a few more months before the normalcy returns.
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Novel coronavirus vaccine: An international holy grail p. 20
Prafull Mohan, Anuj Singhal, Vishal Mangal
DOI:10.4103/jmms.jmms_92_20  
Coronavirus disease 2019 (COVID-19) pandemic is raging in the world with no definitive cure or vaccine at hand. As of July 17, 2020, there have been 13,937,253 cases and 591,957 deaths globally. Hence the rush to find a cure, or a vaccine, or both. We proceed to outline some of the scientific challenges that lie in the path of the successful development of the COVID-19 vaccine. Coronaviruses do not induce long-lasting immunity; enhancing the vaccine candidate's immunogenicity is an essential imperative for the COVID-19 vaccine. On the one hand developing a COVID-19 vaccine should be relatively easy as compared to the vaccine development for HIV and hepatitis C, primarily because of the slower mutation rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). On the other hand, there are different types of challenges, such as identifying optimum immunogenic antigen, safety issues encountered with vaccine development programs for SARS and MERS, identification of suitable adjuvants, and getting the vaccine as soon as possible. Globally, more than 150 projects are working toward the development of the SARS-CoV-2 vaccine; however, only 25 are approved for clinical trials. While existing knowledge of conventional vaccine technologies and next-generation technologies for innovative vaccine platforms has hastened vaccine development, however, the time and finances have both been constrained. Fast-tracking of research, human challenge studies, and inclusion of specific animal models such as ACE2A are some suggested strategies to hasten the process. In addition, there is a need for generous funding, collaborative effort, and comprehensive data sharing to get the world the COVID vaccine sooner.
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Role of ivermectin in COVID-19: Wishful thinking or scientific optimism p. 27
Prafull Mohan, Sharmila Sinha, Rajdeep Uppal
DOI:10.4103/jmms.jmms_146_20  
Ivermectin is routinely used for indications such as strongyloidiasis, onchocerciasis, and scabies. It is also known to possess antimicrobial, anticancer, antimitotic, anti-allergic, and antiviral properties. It has been found to inhibit SARS-COV-2 in an in-vitro study, following which, a lot of interest has been generated regarding its role in the treatment of COVID-19. However, as per extrapolation from in vitro study, the current approved dose of ivermectin may not result in sufficient concentration in the lungs to have an anti-COVID-19 effect. However, a large number of trials using different ivermectin doses are underway to generate conclusive data. If ivermectin fails to show clinical benefit in ongoing trials, additional studies to address its safety at much higher doses, additional mechanisms of its action, and different routes of administration/formulations may be required. As of now, ivermectin shows promise against SARS-CoV-2, but the dose and context of its use remains nebulous.
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Telemedicine in the era of COVID-19: The East and the West p. 32
Maninder Pal Singh Pardal, K Rajiva, Godwin O Orkeh
DOI:10.4103/jmms.jmms_86_20  
Introduction: Telemedicine implies the application of clinical medicine by telephone, internet, or any other such networks for the purpose of consulting or performing various examinations or medical procedures. The present pandemic of COVID-19 is the ideal time to evolve telemedicine and increase its utilization for the well-being of humankind. Historical Background: Electrocardiogram transmission over telephone lines is the oldest record of telemedicine in the first half of the 20th century. Teleradiology commenced in India in 1996. The National Telemedicine Taskforce was set up by the Government of India, in 2005. The Arizona State Legislature established the Arizona Telemedicine Program in 1996. Medical devices to capture images were developed in the 1990s. Present Scenario in the East: Besides implementing various national-level projects, India has extended telemedicine services to South Asian and African countries. The Apollo Telemedicine Networking Foundation has grown to 115 centers, including 9 overseas. Recently, the Government of India has launched telemedicine solutions in the form of Social Endeavour for Health and Telemedicine and eSanjeevani. Comprehensive guidelines on telemedicine have also been issued during the COVID-19 pandemic. The Indian Navy is in the process of establishing teleconsultation centers on board several ships, submarines, remote locations, islands, and naval hospitals. Present Scenario in the West: Telestroke is the largest care provider for patients with stroke in the country. The field of dermatology is particularly suited for telemedicine. Telemedicine at sea is an integral part of rescue procedures. One of the fundamental components of medical assistance at sea is the Telemedical Maritime Assistance Service. Socioethical and Legal Considerations: Legal and regulatory measures will be a challenge with the rapidly spreading telemedicine network. Conflicting laws of different nations are some of the other legal issues in telemedicine. There exists an urgent need for specific legislation on telemedicine in India. In the USA, telemedicine covers various legal and regulatory issues at the state and federal levels. Limitations: Limited reimbursement or restrictions on reimbursement from insurance providers, quality of the patient–physician relationship, the quality of the examination, and the quality of care are a few barriers to telemedicine. The social limitation is probably the biggest limitation of telehealth. Conclusion: Despite several barriers, telehealth has shown remarkable growth during the COVID-19 pandemic. India with its large medical and IT manpower and expertise is emerging as a global leader in the field of telemedicine. The COVID-19 pandemic has made telemedicine more relevant than ever.
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COVID-19 in healthcare workers: A review of existing literature p. 36
Vineet Behera, Pramod Kumar Srivastava, Jayakrishnan Jayaramachandran, Sougat Ray, Vivek Hande, Sheila Samanta Mathai
DOI:10.4103/jmms.jmms_133_20  
Background: Healthcare workers (HCWs) are particularly at a risk of acquiring COVID-19 infection. The pattern of disease and outcome in HCWs has not been studied adequately. This review was done to determine the prevalence of COVID-19 in HCWs and to find out the clinical profile and mortality of COVID-19 in HCWs. Materials and Methods: A systematic search of all published or in press studies from January 1, 2020, to July 15, 2020, with confirmed COVID-19 HCWs was done in PubMed, Scopus, and Google Scholar and in other key journals using terms such as “2019-nCoV,” “novel coronavirus 2019,” “COVID-19,” “SARS-CoV-2,” “Wuhan coronavirus,” “health care worker,” “health care professional,” “physician,” and “medical staff.” Results: We analyzed 43 research articles, mostly cross-sectional studies with 20 studies from China, and included 13,725 COVID-19–positive HCWs. Proportion of COVID-19–positive HCWs (n = 8405) among all HCWs (n = 276,392) were 3.04% (95% confidence interval [CI]: 0.62–9.76), while the proportion of positive HCWs (n = 9458) among all COVID-19–positive patients (n = 230,626) were 4.1% (95% CI: 1.44–12.46). The mean age of HCWs was 42.78 ± 6.82 years, 34.47% were males, and 51.04% were nurses. Most COVID-19–positive HCWs were asymptomatic (64.41%), while severe disease occurred in 4.08% with a mortality of 0.80% (47/5823). The incidence of severe disease and mortality among HCWs (n = 9458) and general population (n = 230,626) was extracted from nine studies, and it was seen that severe disease (1.7%) or mortality (0.04%) in HCWs was significantly less as compared to non-HCWs population (8.26% and 1.23%, respectively) (P < 0.001). Conclusion: There is a considerable risk of contracting COVID-19 infection among HCWs which re-emphasizes the strong need of personal protective measures. However, the incidence of severe disease and deaths is significantly low among HCWs, which may somewhat reduce apprehension and be morale boosting for HCWs all across the world.
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ORIGINAL ARTICLES Top

Return to work strategy with antibody-based tests in COVID19: An observational study from a metropolitan area, India p. 46
Sougat Ray, Naveen Chawla, Ayon Gupta, Kiran Kumar Maramaraj, Sanjeev Kumar, Kavita B Anand
DOI:10.4103/jmms.jmms_90_20  
Background: The utility of antibody tests in policy making is limited to seroprevalence surveys. World Health Organisation has stated that recovered people have antibodies to SARS-CoV-2. Convalescent serum contains antibodies that can neutralize the virus in cell cultures and IgG is both a marker for viral exposure and an indicator of recovery. We undertook this study to report immune response as a return to work strategy in a containment zone of 757 adults from a working mens' hostel. Methodology: The individuals were divided into three cohorts. Cohort-A comprised of RTPCR confirmed cases, Cohort-B comprised of those who were admitted as suspects but were negative in Rt-PCR test and Cohort-C were those, who remained asymptomatic. We studied the clinical features and undertook a qualitative antibody test of all adult males from the hostel after transmission of the disease was assumed to be over in the containment zone. Result: Dry cough, sore throat and fever were the most common presenting symptoms. (Fig 1). On serology testing, 47/87 (54.04%) tested IgG positive from Cohort A and 25/74 (32.05%) individuals were IgG positive from Cohort B with a significant statistical difference (p<0.05). There were 176 (29.72%) individuals who were IgG positive from Cohort C (Table 1), who remained asymptomatic. We found the seroconversion rate to IgG to be 67.85% (19/28) in symptomatic confirmed cases [OR 2.50 (0.97-6.43)]. None of the subjects tested positive for IgM. Conclusion: We found around half of the confirmed cases to seroconvert to IgG and antibodies were not detected in the rest. The utility of the test in return to work decision is therefore, debatable. The study found almost 30% of the unconfirmed individuals to have seroconverted, indicating presence of asymptomatic transmission. Preventive measures of social distancing, wearing of masks alongwith well ventilated offices with adequate air exchange mechanisms would be the future strategy for work place functioning.
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Planning a modular intensive care unit for patients of the COVID-19 pandemic p. 51
Shankar Narayan, Rangraj Setlur, Nikahat Jahan, Kaushik Chatterjee, Madhuri Kanitkar
DOI:10.4103/jmms.jmms_91_20  
Introduction: The COVID-19 pandemic has provided opportunity to the Armed Forces Medical Services (AFMS) healthcare institutions to plan and execute their surge capacity facilities and identify areas for improvements in planning in the future. Material and Methods: Available medical literature on the experiences of other countries in activating surge capacities in healthcare for the pandemic were examined in detail as were existing guidelines for establishing Intensive Care Units (ICU). Personal communications with peers to understand difficulties faced in activating surge capacities were also factored in. Results: Based on the findings from these sources, a plan to establish ten-bedded ICU units specifically for COVID-19 is evolved. The best practices and latest guidelines and experiences have been collated and modified suitably to suit the AFMS in this aspect. Conclusion: Planning ICUs in ten-bedded modular units will enable the AFMS to cater to surge capacities in the future for all situations where sudden increase in number of patients is anticipated.
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COVID-warriors: Psychological impact of the severe acute respiratory syndrome coronavirus 2 pandemic on health-care professionals p. 57
Prashant Jambunathan, Manisha Jindal, Priyadarshee Patra, T Madhusudan
DOI:10.4103/jmms.jmms_44_20  
Background: The COVID-19 pandemic, caused by the Severe Acute Respiratory Syndrome Corona Virus 2 (SARS CoV-2) has the potential to affect the mental health of health-care professionals in several adverse ways, owing to a multifactorial, unprecedented volley of evolving factors. It may contribute to the elevated levels of depression, anxiety, and worry among the personnel on the frontline, who are often affected by medical and psychosocial factors, including pre-existing illness, scarcity of resources, uncertainty of outcome, prolonged working hours, lack of consensus, prevalent societal misbeliefs, prevailing stigma, and a constant threat to safety. Aim: The aim of this study was to screen health-care professionals for symptoms of depression, anxiety, and worry during SARS CoV-2 pandemic. Methods: In this cross-sectional study, a questionnaire was designed based on Patient Health Questionnaire-9, generalized anxiety disorder-7. It was disseminated through web-based and mobile-based social networks, thereby keeping in line with the social distancing and lockdown protocols. Results: Two hundred and fifty-seven participants were included in the study. Anxiety and depression were present in 23% (n = 59) and 16.8% (n = 43) of participants, respectively, most cases being mild in intensity. Nearly 56.4% (n = 145) of the participants reported that they were worried about COVID 19 pandemic, major cause of worry being risk of family and friends to be infected by COVID 19. About 40.9% (n = 105) participants reported sleep disturbances. Nearly 33.5% (n = 86) of participants reported increase in their smoking/alcohol consumption during lockdown. Conclusions: A significant proportion of health-care professionals experienced worry, sleep disturbances, anxiety, and depressive symptoms. Having clear guidelines, policies and procedures, training on infection control measures, occasional drills and being able to maintain communication with family members while in quarantine can go a long way in reducing worry and psychological impact of pandemic on health-care professionals.
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KAP survey among doctors and nurses regarding methods of disinfection in ongoing COVID-19 pandemic p. 62
Seema Sharma, Laxmikant Choudhary, Pravin V Kumar, Arun Kumar Yadav, Nitin S Taneja
DOI:10.4103/jmms.jmms_60_20  
Background: COVID-19 is a viral infectious disease caused by the most recently discovered coronavirus named as SARS-CoV-2. The disease spread from person to person through droplets discharged from the nose or mouth of a person with COVID-19 while coughing or exhaling or through fomites. Hence, disinfection methods play an important role in preventing the COVID-19, which the health-care workers must know for better prevention, control, and the management of COVID-19. Aim: The aim of this study is to assess the knowledge, attitude, and practice (KAP) among health-care workers regarding disinfection measures in an ongoing COVID-19 pandemic. Materials and Methods: The study was a cross-sectional study with a study population as health-care professional (doctors and nurses) directly or indirectly involved in COVID-19. The study conducted partly in Chennai and partly rest over the country between March 2020 and April 2020. A pretested structured questionnaire was used to collect data. Results: A total of 210 participants (87.1% doctors and 21.9% nurses) included the study. Overall, 34 (16.2%) respondents had “adequate” knowledge, “correct” attitude and “proper” practices. Statistically significant association found between occupation and level of attitude (P = 0.003); occupation and level of practice (P = 0.011); qualification and level of knowledge (P = 0.017), attitude (P = 0.002), and practice (P = 0.015); involvement in patient care and level of attitude (P = 0.039) and practice (P = 0.003); involvement in training and level of attitude (P = 0.041) and practice (P = 0.003); ever trained on disinfection and level of attitude (P = 0.036) and practice (P = 0.011). Conclusions: KAPs of health-care workers with respect to methods of disinfection in the present ongoing COVID-19 pandemic are not adequate. These gaps should be addressed through educational initiatives, training, infection control campaigns, and strict implementation of guidelines issued by the WHO, Ministry of Health and Family Welfare India, Indian Council of Medical Research, and other reliable sources.
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Knowledge, attitude, and practice toward COVID-19 among pregnant women in a tertiary care hospital during the COVID-19 outbreak p. 66
Deep Kamal, Vaidehi D Thakur, Santosh K Swain, CR Vikneshram
DOI:10.4103/jmms.jmms_81_20  
Background: During COVID-19 pandemic, Indian health authorities implemented massive measures to control the rapid spread of infection. Nonetheless, even during pandemic, pregnant women need constant obstetrics consultations during the antepartum period and adequate care during intrapartum and postpartum period for uneventful outcome. Undeniably, adherence to these control measures is largely affected by knowledge, attitude, and practices (KAP) towards COVID-19. Aims and Objectives: To assess knowledge, attitude, and practice towards COVID-19 amongst pregnant women and to find the association of demographic variables (age, place of residence, and education) with KAP. Materials and Methods: The cross-sectional, descriptive study was conducted for pregnant women attending the outpatient department of Obstetrics in a tertiary care Defense hospital. We investigated 506 pregnant women serially from Obstetrics OPD of the hospital for KAP towards COVID-19 with a questionnaire of 14 questions. The study population was assessed for the KAP score and association of demographic variables with KAP. Descriptive statistics were used to describe the findings. Median and standard deviation (SD) were calculated for KAP and Pearson's Chi-square test was used to analyze the association of demographic variables with KAP. Results: In our study scores for adequate knowledge, positive attitude, and good practices were 75.3 %, 73.9%, and 92.7 % respectively. The analysis of the association of various demographic variables with KAP about COVID-19 revealed significant association. Conclusion: The majority of pregnant women was knowledgeable about COVID-19 and had positive attitude and good practices. However, health authorities may need to take proactive steps for this vulnerable subpopulation.
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Knowledge, attitude, practices and behaviour study regarding COVID-19 amongst health care workers of armed forces in North-Western part of India p. 72
Vikram S Grewal, Kuntal Bandyopdhyay, Punita A Sharma, Rekha Rani, Atul Kotwal
DOI:10.4103/jmms.jmms_95_20  
Background: A concerted effort has been made by the Government of India and the Armed Forces to train all health-care workers (HCWs) in various aspects of the prevention and management of COVID-19. This study was conducted to evaluate the efforts by assessing their knowledge, attitudes, practice, and behavior regarding COVID-19. Materials and Methods: A quick online survey, using a web portal and social media platform with a pretested questionnaire, was conducted. Responses were collected for 3 days and analyzed. Results: A total of 988 HCWs participated, including 61 (6.17%) specialist officers, 98 (9.91%) medical officers, 17 (1.72%) dental officers, 135 (13.66%) nursing officers, 518 (52.4%) paramedical staff, and 159 (16.09%) supporting staff. There was a high prevalence (>90%) of knowledge related to symptoms and transmission of the disease with no statistically significant difference in knowledge based on the category of HCW except for bleaching powder requirement (0.001) and chemoprophylaxis (0.001). The majority of the participants (>95%) agreed that lockdown, infection control programs, and repeated training of HCWs are good measures to control COVID-19 spread. Observing full precaution while handling personal protective equipment was the only practice which demonstrated a significant association with increasing qualification of the participant (P < 0.001). Conclusions: Levels of knowledge, positive attitude, and good practices are high among HCWs in the Armed Forces, however, feeling of anxiousness and worry prevail being frontline workers with maximum proximity toward patients. Aggressive, continuous, relevant target population-oriented information, education, and communication is the need of the hour, with structured and programmed interventions for positive mental health during course of the pandemic.
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Impact on anxiety of COVID-19 and lockdown p. 78
Vinay Singh Chauhan, Kaushik Chatterjee, Kirti Singh Chauhan, Jyoti Prakash, Kalpana Srivastava
DOI:10.4103/jmms.jmms_96_20  
Background: India was placed under “lockdown” since March 25, 2020, to curb the spread of COVID-19 pandemic. Faced with this unprecedented situation, many individuals reported mounting apprehensions and some sought medical relief of anxiety. This study was carried to assess the impact of anxiety on COVID-19 pandemic and lockdown on the general public (18–65 years of age) and to assess its correlates. Materials and Methods: An online survey was conducted during lockdown. Using a survey form, a link was circulated using social media and E-mail. The survey included bilingual informed consent, sociodemographic data, characteristics specific to lockdown, and a self-rating anxiety scale. The survey link was circulated from April 1, 2020, to April 30, 2020. Results: A total of 987 responses were collected and analyzed. The study revealed minimal-to-moderate anxiety in 28.5%, marked-to-severe anxiety in 3.3%, and extreme anxiety in 0.1% of the participants. Anxiety scores were significantly correlated with younger age, students, currently employed, male gender, and lower income. Conclusions: The current survey indicates that 31.9% are experiencing significant anxiety due to lockdown and COVID-19 pandemic. Younger age, students, currently employed, male gender, and lower income are associated with higher anxiety. These findings suggest that there is a need of expanding the mental health services in society during and immediately after the pandemic situation.
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COVID-19 Preventive measures among health-care workers: Desperate times, desperate measures p. 83
Sourya Mohakuda, Basant Pathak, Anchit Raj Singh, T VSVGK Tilak, P Harikrishnan
DOI:10.4103/jmms.jmms_99_20  
Background: In these desperate times when the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has caught the entire world off guard, we have very few evidence-based preventive measures currently available. Various preventive practices, which include both pharmacological interventions (PIs) and non-PIs (NPI), adopted by the health-care workers (HCWs) might play a crucial role in protecting them against COVID-19. This study aims to identify these preventive measures adopted by HCWs in a dedicated 1000-bedded temporary COVID-19 hospital in northern India, with HCWs coming from various parts of the country. Objectives: The objective was to study the various forms of preventive measures undertaken by HCWs and to calculate their prevalence. Methodology: This cross-sectional web-based survey was conducted in a population of HCWs in a 1000-bedded COVID-19 hospital in northern India. Results: Most HCWs included in the study were using multiple preventive measures not necessarily backed by evidence. In this study, 81.8% of the participants were using hydroxychloroquine (HCQ) prophylaxis. Nurses had the highest adherence to HCQ prophylaxis, however they were also the most concerned regarding side effects. Increase in the frequency of hand hygiene and bathing practices was seen in majority of the participants. HCWs were also found to practice various preventive measures such as Vitamin C supplements (37.8%), yoga (37.1%), and warm saline gargles (36.3%). Other less common methods noted were steam inhalation, amlaki, kaadha, tulsi drops, chyawanprash, and nasya. The Internet served as the main source of information. Conclusion: The role of various preventive practices in the setting of a novel infection needs to be studied further. With no dearth in information advocating various proven or unproven strategies available on the Internet, their use by both HCWs and general population is inevitable. This is irrespective of their job or educational profiles. Whether or not such practices are useful in our fight against COVID-19 is a question that can only be answered through further studies.
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A comparison of direct laryngoscopy versus videolaryngoscopy using aerosol box for intubation in emergency surgeries during Covid-19 pandemic: A pilot study p. 88
Deepak Dwivedi, Parmeet Bhatia, Manish Aggarwal, Subrato Sen, Bhavna Hooda, Puja Dudeja
DOI:10.4103/jmms.jmms_100_20  
Background and Aims: This study was planned to compare intubating conditions with aerosol box, while attempting intubation with either direct laryngoscope (DL) using Macintosh blade or McGrath MAC™, videolaryngoscope (VL). Methodology: Sixty adult patients coming for the emergency surgeries during COVID-19 pandemic were divided equally by consecutive sampling into either Group 1 (DL) or Group 2 (VL). General anesthesia was administered with aerosol box covering the head and trunk of the patient. The laryngoscopy was attempted based on the group allocation with either VL or DL through aerosol box. Following observations were noted, total intubation time, number of attempts, Cormack–Lehane (CL) view, intubation difficulty scale (IDS), use of airway adjuncts, and external laryngeal maneuver. Results: Mean (standard deviation) time taken to intubate was 25.36 (6.22) sec in DL group and 21.9 (5.56) sec in VL group. Median IDS scoring was 1 in DL group and 0 in VL group indicating toward ease of intubation with the videolaryngoscope. Improved glottic view (CL Grade 1) was attained commonly with VL group and higher CL grades (2b) were common with DL group (23.3%). No intubation aids were required in VL group although 30% in DL required bougie for the intubation. External laryngeal maneuver was applied in 40% subjects undergoing DL with no maneuvers needed in VL group. First pass success of intubation was comparable in both the groups. Conclusion: Intubating conditions are favorable with VL when aerosol box is included which requires acquisition of the skills depending on its availability. However, the intubation should be attempted with the technique the clinician has the expertise during this pandemic.
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Antibody response among nucleic acid amplification test confirmed COVID-19-positive patients: A cross-sectional study p. 93
Gurpreet Singh Bhalla, Rajat Shukla, Kuntal Bandyopadhyay, Rachana Warrier
DOI:10.4103/jmms.jmms_107_20  
Introduction: Coronavirus disease 2019 (COVID-19) pandemic has caused immense loss of lives, enormous devastation, and has affected lives globally. Timely diagnosis is necessary to contain its spread. While it is important to test symptomatic individuals and high-risk contacts through reliable and confirmatory test (nucleic acid amplification test [NAAT]) to find out the positive cases of COVID-19, it is also vital to check their immunity status through the serological tests to find out the varied immunological response in the affected population. Materials and Methods: All NAAT confirmed COVID-19 patients were included in the study. With a repeat respiratory sample for NAAT, simultaneous serum sample was taken for the detection of IgM and IgG antibodies. Data were compiled and analyzed statistically. Results: During the first repeat NAAT, 71.43% had mounted an antibody response, whereas 28.57% had no response. Irrespective of the antibody status, 68.57% tested positive for SARS-CoV-2 virus in NAAT. Although the number dwindled on second repeat NAAT, it raised important questions regarding humoral response and its clinical and diagnostic applicability. Conclusion: Not all, COVID-19 patients mount a humoral response due to yet unexplained factors. Furthermore, exclusive dependence on serology assays will miss the diagnosis in these patients. More research is needed for description and applicability of humoral response in COVID-19 patients.
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Hydroxychloroquine as pre-exposure prophylaxis against COVID-19 in health-care workers: A single-center experience Highly accessed article p. 98
Sheila Samanta Mathai, Vineet Behera, Vivek Hande
DOI:10.4103/jmms.jmms_115_20  
Background: Health-care workers (HCWs) are at high risk of acquiring COVID-19. Hydroxychloroquine (HCQ) possesses in vitro antiviral activity and inhibits viral replication of coronavirus in cell cultures. The national task force for COVID-19 in India recommended the use of HCQ prophylaxis against severe acute respiratory syndrome coronavirus 2 infection in HCWs. Methodology: We conducted a retrospective cohort study in a mixed tertiary care facility to find the incidence and clinical profile of COVID-19 in HCWs between April 2020 and June 2020, who were advised preexposure prophylaxis with HCQ, at the start of the pandemic. Details of HCQ usage were collected using an online questionnaire form. The clinical profile, treatment, and outcome of COVID-19-positive HCWs were also studied. Results: We included 604 HCWs, of which 491 (81.2%) had taken adequate HCQ prophylaxis while 113 (18.7%) did not take adequate HCQ, 443 (73.3%) had high-risk COVID-19 exposure, and 32 HCWs (5.1% of the total) were COVID-19 positive. There were 10 COVID-19 cases (2.1%) among HCWs taking HCQ while 22 (19.4%) cases occurred in HCQ not compliant HCWs, with a relative risk of 0.1046 (95% confidence interval: 0.0510–0.2147, P< 0.0001), indicating a reduced risk of COVID-19 among HCWs taking HCQ prophylaxis. Among the noncompliant cases, 14 (43.7%) never took HCQ, 4 (12.5%) took HCQ but had poor compliance, and 4 (12.5%) stopped HCQ prematurely. Most (91.7%) COVID-19-positive HCWs were asymptomatic or had mild symptoms, moderate symptoms were seen in 3 (9.3%), and there were no severe cases or deaths. Conclusions: The use of HCQ as preexposure prophylaxis in HCWs was associated with reduced risk of COVID-19, suggesting its role as an effective chemoprophylactic agent.
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Knowledge, attitude, and practice toward COVID-19 among health-care professionals, ancillary support staff, family members, and patients in a tertiary care COVID-19 hospital p. 105
Harmeet Singh Arora, Satish Chandra Mishra, Arun Kumar Yadav, PL Vidya, Arijit Kumar Ghosh, R Ananthakrishnan, Ajay Joshi
DOI:10.4103/jmms.jmms_116_20  
Background: Corona virus disease-2019 (COVID-19) is a recently emerged and rapidly growing public health emergency. Adequate knowledge, positive attitude, and good practice among different sections of the society, including health-care workers, are quintessential in prevention and control of this deadly disease. Hence, the present study was undertaken with the objective of determining the knowledge, attitude, and practice among health-care workers (HCWs) including ancillary support staff, their family members, and patients toward COVID-19. Materials and Methods: A cross-sectional 40-item survey was conducted among HCWs, family members, and patients in a dedicated tertiary care COVID-19 hospital during May 2020–June 2020.The responses were tabulated and regression analyses were performed to determine the significance of each parameter among different groups. Results: Of 596 participants, among health-care professionals, ancillary support staff, family members, and patients, most were graduates (72.9%, 74.6%, and 50.6%, respectively), while 50% of the patients were educated up to high school. Social media and Internet was the main source of information for health-care professionals, while it was news media for others. Younger age was significantly associated with knowledge and attitude among HCWs (P = 0.001, P= 0.006) and ancillary support staff (P = 0.01, P < 0.001), while younger age and education were positively associated with knowledge among family members (P = 0.007, P < 0.001). Among patients, only education related to better knowledge (P < 0.001) and younger age with better practice (P = 0.001). Conclusion: Overall, HCWs and ancillary support staff have better knowledge and attitude toward COVID-19. Education was associated with better practice among patients. Health education programs to improve the awareness and encourage appropriate practices toward this global hazard, especially among the general public, are required to conquer this virus and limit the spread of infection.
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Psychological status of pregnant women during COVID-19 pandemic: A cross-sectional study from Mumbai p. 113
Shradha Khatri, Aparna K Murthy, Uzma Hashim, Seby Kuruthukulangara, Ashalass Kumari, Prasad R Lele
DOI:10.4103/jmms.jmms_120_20  
Context: The ongoing COVID-19 pandemic poses important challenges to mental health. Pregnant women are a vulnerable group to experience adverse psychological impact of the pandemic, with consequences on maternal and foetal outcomes; currently there are scant data for the same in India. To the best of our knowledge, this report is the first from India on psychological status of pregnant women during COVID-19 pandemic. Aim: The aim is to study the impact of ongoing COVID-19 pandemic on psychological status of pregnant women. Setting and Design: Cross-sectional observational study in a tertiary care hospital setting in Mumbai. Materials and Methods: Out of total 98 pregnant women reporting to antenatal clinic of the hospital during the study period from June to July 2020, 66 gave informed consent to participate in the study. Perceived Stress Scale (PSS-10), Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) were administered using an online form. Statistical Analysis: Group comparisons were analyzed using appropriate nonparametric tests. Results: About 66.7% of women were primigravida, 39% in second trimester and 75.8% in age group 21–30 years. 28.8% missed scheduled antenatal visit, higher when compared to hospital data prior to pandemic. 39.4% worried about their unborn baby getting infected from Corona virus and 25.8% worried about themselves getting infected. About 72.2% reported moderate levels of perceived stress as measured by PSS-10, 51.6% reported mild-to-moderate level of depressive symptoms by PHQ-9 and 39.4% reported mild-to-moderate anxiety symptoms by GAD-7. PHQ-9 and GAD-7 scores of women aged 21–30 years were higher than those aged 31–40 years (P = 0.017 and 0.005 respectively). Conclusion: High rates of perceived stress, depressive, and anxiety symptoms in pregnant women found in this study suggest a need to incorporate psychological screening and interventions in routine antenatal care during ongoing pandemic.
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Findings in chest radiographs of patients admitted with novel coronavirus infection at a tertiary care institution in India: A retrospective study p. 118
Amit Bajpai, Sagar Arora, Gaurav Shukla, PI Hashim, Somnath Pan, Niharika Gupta, Rajeev Sivasankar, Sheila S Mathai
DOI:10.4103/jmms.jmms_136_20  
Aim: In the ever-changing understanding of the ongoing COVID 19 pandemic, this study aims to present the spectrum of findings in chest radiographs conducted in serologically proven symptomatic patients of COVID 19 in a tertiary care hospital in Mumbai, India. Methods: The study was a retrospective analysis of 449 chest radiographs(CXRs) obtained from serologically proven symptomatic 312 COVID patients in a tertiary care institute at Mumbai, India. CXRs were conducted as per a hospital approved protocol. The x-rays were analysed by three radiologists for presence of consolidation, ground glass opacities, interstitial opacities and distribution of findings. Results: Out of the total CXRs reviewed, 50.7% were abnormal with 91.7% of them showing the commonest pattern of finding as consolidation. The majority of findings were seen (71.1%) in patients above 50 yrs of age. 84 cases (26.9%) had a serial radiograph follow up mandated by their clinical status. Of these, 75% were abnormal. There were 46 fatal cases, out of which 22 patients (47.82%) underwent CXRs and 10 (21.73%) were followed up. All of these radiographs (100%) showed abnormal findings. Conclusions: Chest radiographs conducted in this retrospective analysis of patients with symptomatic COVID-19 infections showed that a little more than half of the patients with the infection had abnormal findings. The commonest pattern of involvement was a patchy peripheral consolidation with no predilection for any particular side. However, there was a significant basal predominance (85.5%). The progression of findings was seen in 75% of the CXRs with good correlation between clinical & radiological severity. The study shows that CXRs have an important diagnostic and prognostic role in the management of patients with the COVID-19 infection.
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CASE SERIES Top

Eight hospitalized patients with COVID-19 p. 124
Purvesh Agrawal, Nidhi Khandelwal
DOI:10.4103/jmms.jmms_37_20  
In December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in China and has spread globally, creating a pandemic. Information about the clinical characteristics of infected patients is limited. We hereby report the initial experience (clinical features and management) of COVID-19 cases in India. Among the first eight patients diagnosed with SARS-CoV-2 infection in Uttara Kannada district, clinical presentation was frequently a mild respiratory tract infection. Only one of eight patients required supplemental oxygen. Although we cannot draw any conclusions on the basis of these very few cases, available data indicate considerable variability among different countries in the proportion of severe cases of COVID-19 among those testing positive.
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Atypical presentations in COVID-19-lung abscess, pulmonary thromboembolism and ST-elevation myocardial infarction: Diagnosis and management in a temporary COVID-19 hospital p. 128
P Harikrishnan, Sourya Mohakuda, Basant Pathak, Anchit Raj Singh, TVSVGK Tilak, R Srinath, Shalendra Singh, Shamik Paul
DOI:10.4103/jmms.jmms_110_20  
COVID-19 pandemic has adversely affected every tenet of societies all across the world. The gruesome disease, which is primarily a respiratory illness, as is being unmasked with each passing day, has been reported to have a variety of presentations. Here, we report three such cases with atypical manifestation in COVID-19 who were managed in a resource-limited makeshift COVID-19 temporary hospital in Northern India. The dictum to avoid unnecessary exposure by restricting investigations or procedures that would not directly aid in management has been reiterated in this series of cases.
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CORRESPONDENCE Top

COVID-19 and HBOT: A conceptual standpoint p. 133
Gaurab Ghosh
DOI:10.4103/jmms.jmms_112_20  
The Role of Hyperbaric Oxygen Therapy as an adjunct to treating patients with severe –COVID-19 infection is critical in recovery outcome of the patients as discussed in the articles reviewed in this paper and it will form a basis to develop treatment protocol for HBOT for COVID-19 patients by hyperbaric medical authorities. The critical standpoints in respect of pathophysiology and pharmacodynamics are emphasized in this paper.
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Initiation of COVID-19 testing by cartridge-based nucleic acid amplification test (Cepheid Xpress SARS-CoV-2): Our experience at a zonal hospital p. 135
Rajat Shukla, Gurpreet Singh Bhalla
DOI:10.4103/jmms.jmms_79_20  
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Simulation: Will it be a new patient in the COVID era? p. 137
Kaminder Bir Kaur, Deepak Dwivedi, Vishal Mangal
DOI:10.4103/jmms.jmms_93_20  
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Practice of pediatric nephrology during the COVID-19 pandemic: Readapting the wheel in unprecedented times p. 139
Suprita Kalra
DOI:10.4103/jmms.jmms_127_20  
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