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   Table of Contents - Current issue
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January-June 2021
Volume 23 | Issue 1
Page Nos. 1-112

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EDITORIAL  

Medical leadership during COVID-19 pandemic: A complex, balanced military stewardship p. 1
Naveen Chawla, Sougat Ray, Kaushik Roy, Sunil Goyal
DOI:10.4103/jmms.jmms_87_21  
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INVITED EDITORIAL Top

Navigating through COVID-19 Waves: Pandemic Response using Indicator-based Epidemiological Surveillance Tool (PRIEST) p. 4
Kiran Kumar Maramraj, Sudeep Naidu, Sougat Ray, Ajit Gopinath, Naveen Chawla
DOI:10.4103/jmms.jmms_89_21  
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REVIEW ARTICLES Top

Infectious disease immunotherapies – An update: Revisiting an age-old adage in times of COVID-19 p. 10
Mahima Lall, Suyash Singh, Amar Atal, Anuj Singhal
DOI:10.4103/jmms.jmms_126_20  
This review article tries to bring together the important active and passive immunotherapeutic modalities currently under consideration for COVID-19 disease. The basis of immunotherapy is based on use of naturally occurring agents or drugs to modify the body's immune response to certain antigens, the host immune system competent to successfully target and eliminate the infectious agent, without altering the normal physiology. Pubmed was screened for studies using key words; COVID-19, Convalescent plasma therapy, Immunotherapy, Clinical trials. We identified 537 studies through database searches. After reviewing the title and abstracts, we excluded 452 studies that were not relevant, leaving 85 studies for full-text evaluation. Of these, 53 studies fulfilling predefined inclusion/exclusion criteria were finally included. This study found that the common immunotherapies which were used in COVID-19 pandemic times were plasma therapy, T-reg based therapy, tocilizumab, hydroxychloroquine, dexamethasone, and baricitinib.
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Techno-innovations and molecular methods for diagnosis of COVID-19: Updates from India p. 16
Jitender Gairolla, Pratima Gupta, Prakamya Gupta, Yogendra Pratap Mathuria, Chandarkanta Chauhan, Maninder Deep Kaur, Priyanka Naithani, Manisha Naithani, Pramod Kumar Nagar
DOI:10.4103/jmms.jmms_195_20  
The rapid diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection relies on the availability of a robust method. The demand for SARS-CoV-2 diagnostic kits and other desirable consumables for timely diagnosis have increased drastically after the current pandemic. The cumulative efforts by scientists, funding agencies, regulatory authorities, and corporates have accelerated the process of kit development. Worldwide, rapid molecular techno progression to characterize the biology of any pathogen witnessed during this pandemic faster than ever. Moreover, a paradigm shift from real-time polymerase chain reaction technique to highly sensitive novel CRISPR technology has been observed. India, second most populous country actively leveraged molecular technologies for rapid diagnosis of SARS-CoV-2. This paper focuses on paradigm shift in the methods for diagnosis of SARS-CoV-2 infection with a focus on molecular innovations carried out in India indigenously.
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ORIGINAL ARTICLES Top

Cold injuries in the glacial regions of India p. 24
Priya Ranjan, Aditya Pawar, Anant Kumar Naik, Saurabh Bhardwaj, Pawan Sharma
DOI:10.4103/jmms.jmms_51_20  
Background: Personnel deployed at an altitude ranging from 9000 ft to 23,000 ft are exposed to sub-zero temperatures up to −40°C. These conditions lead to the development of various cold injuries which presents in varying grades and severity. Aim: The aim of this study is to study the epidemiological trends and assess risk factors/conditions those are contributing to the development of cold weather injuries (CWI) at extreme cold climate in high altitude areas. Methodology: This is a retrospective, observational study on cold injury cases evacuated from the northern glaciers of India. The data were collected and tabulated in MS-Excel sheets, and analysis was done using percentage, mean, median, linear regression, and P value calculation. SPSS statistical analysis software version 23 was employed for generating the results. P < 0.05 was considered for statistically significant. Results: The annual incidence of cold injuries calculated for troops deployed at high altitude (>9000 feet) with extreme cold climate is 6.4/1000/year. The average duration of exposure for the development of CWI was found to be 4.85 h with a standard deviation = 2.88 h. Statistically significant association was found between the median temperatures and number of cold injury cases evacuated monthly with a strong negative coefficient of correlation (Pearson's) value r = −0.8214, and P = 0.001063. No correlation was found between the severity of frostbites and duration of exposure as the coefficient of correlation r (Pearson's) was weakly positive with a value of 0.19 and statistically not significant with P = 0.127. Conclusion: This study highlights the magnitude of problem, high risk zones, and predisposing activities. Statistical association has been drawn between altitude, temperature and duration of exposure with burden of cold injury. This study provides an insight with respect to associations and risk factors for the development of CWI, in Indian perspective and may be beneficial for better planning and preventive measures to reduce burden of CWI.
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Pharmacological profile of prescriptions containing antidepressants p. 29
Prafull Mohan, Harpreet Singh, Sharmila Sinha, K Prabhakaran
DOI:10.4103/jmms.jmms_85_20  
Background: The prescription of antidepressants is increasing due to the increasing incidence of depression and the use of antidepressants in other indications. There is a need to monitor their prescription practices not only to ensure evidence-based clinical use but also to align classroom teaching with the current clinical trends. Materials and Methods: This observational study was conducted in the department of psychiatry of a tertiary care hospital in western Maharashtra on anonymized prescriptions received within the study period. Results: A total of 214 prescriptions were analyzed with 268 instances of antidepressant prescription. 59.05% of prescriptions were of selective serotonin reuptake inhibitors (SSRIs), 18.11% of atypical antidepressants, 16.92% of tricyclic antidepressants (TCAs), and 5.90% of serotonin-noradrenaline reuptake inhibitors. 46% percent of prescriptions were as per defined daily doses (DDDs), 26% more than DDD and 28% less than DDD. Escitalopram and mirtazapine were the most commonly prescribed drugs. Both did not find mention in the National List of Essential Medicines and World Health Organization–Essential Medicines List (EML). Out of 214 prescriptions, 209 prescriptions were for psychiatric indications and the rest 5 were for nonpsychiatric indications. TCAs were prescribed more for psychiatric indications other than depression, while SSRIs were prescribed equally for depression and other psychiatric indications. Conclusion: Prescription trend in this study is in consonance with other contemporary studies. Extensive use of mirtazapine is a peculiar finding requiring further exploration. As in other studies, SSRIs have been used in doses more than their defined daily dose. Off-label use of antidepressants is widespread, but it should be backed by drug-specific robust evidence. EMLs and clinical usage derive from each other and need to be in mutual sync.
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Study of clinical spectrum, laboratory parameters, and radiological patterns in cerebral venous thrombosis cases occurring at high altitude p. 33
AK Naik, Jai Prakash Prasad, Vani Singh, SK Singh, Barun Kumar Chakrabarty, Jitender Sharma, S Yadav, AK Singh, Vishal Jha
DOI:10.4103/jmms.jmms_68_20  
Context: The risk of cerebral venous thrombosis at particular locations and its association with high altitude is yet to be established completely. The relation between high altitude and venous thromboembolic events has been debated for many years. Cerebral venous thrombosis presenting with nonspecific symptoms like headache can be a tough challenge for primary care physicians deployed at high altitudes. Materials and Methods: Combatants going to wide areas of mountainous territories at varying altitudes presenting with persistent severe headache associated with nausea and vomiting were subjected into the study after evaluation at zonal and tertiary care hospital. Results: Over a period of 18 months from October 2018 to March 2020, 75 cases of headache were screened and evaluated. Eighteen of these patients were diagnosed to have cerebral venous thrombosis. Conclusion: The occurrence of chronic venous thrombosis in combatants who enter and remain at high altitude for the prolonged duration is very common and the gold standard for diagnosis is a clinical evaluation with radio imaging.
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Prevalence of cardiac arrhythmias in patients of obstructive sleep apnea syndrome and changes after 6 months of continuous positive airway pressure therapy p. 39
Ankit Kakar, R Ananthakrishnan, Ajay Handa, SK Joshi, Rahul Tyagi, Soumitra Mohanty
DOI:10.4103/jmms.jmms_16_20  
Obstructive sleep Apnoea (OSA) has generated lot of attention recently. The prevalence of OSA in adult Indian population is approximately 3.5% and the majority of these patients remain undiagnosed. OSA is associated with repeated episodes of hemoglobin desaturation and higher inspiratory effort, combined with repeated arousals during sleep. This causes repeated sympathetic and parasympathetic stimulation. This has been postulated to be associated with both electric and mechanical remodeling of the heart leading to cardiac arrhythmias. In this study, we try to find a correlation between OSA and cardiac arrhythmias and to find the type of arrhythmia as the secondary aim.This study was conducted over three year period at a tertiary care hospital in Mumbai. We screened 186 patients with proven OSA (Apnoea Hypopnea Index> 5). Among these, those with pre-existing structural heart disease or arrhythmia or those not consenting for the study were excluded. 121 subjects were taken up for the study. 01 was lost to follow up, leading to a final sample size of 120. These 120 patients with proven OSAand no pre- existing cardiac pathology were subjected to 24 hour ambulatory Holter monitoring to determine the prevalence of cardiac arrhythmias among this cohort. It was found that 30% of this population had some or the other arrhythmia. (n = 36). Various factors such as age, metabolic and endocrine ailments and others were also accounted for.In the follow up to this study, these 36 patients were advised to use CPAP. Following 06 months of effective CPAP use, these subjects underwent repeat 24 hour Holter examination. Unsurprisingly, significant reduction in prevalence of cardiac arrhythmia was noticed. Now, out of this cohort of 36 subjects, only 02 were found to have cardiac arrhythmia.
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A minimalistic approach to benign anorectal pathologies: Retrospective analysis of 100 patients in armed forces p. 43
Anshul Jain, Deep Shikha Mishra
DOI:10.4103/jmms.jmms_9_20  
Background: Patients with benign anorectal conditions who are treated surgically have long been subjected to fluid diet and and bowel cleansing with either laxatives or enema. Materials and Methods: This study is a retrospective analysis of prospectively maintained data from July 2016 to May 2019 at a secondary level hospital. The study assessed 100 patients who underwent surgical management for fissure-in-ano, fistula-in-ano, and internal hemorrhoids. Results: The intraoperative fecal encounter occurred in five patients (5%). Eighty-nine patients were pain free on postoperative day 3. No patient developed local or systemic sepsis or fecal incontinence. Recurrence was seen in five patients (5%). Conclusion: The study reiterates the fact that surgical management for benign anorectal diseases is straightforward, without the need for extensive perioperative interventions
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Selenium abrogates tenofovir/lamivudine/efavirenz-induced hepatotoxicity in rats p. 47
Elias Adikwu, Michael Ikechukwu Oraebosi, Innocent Biradee
DOI:10.4103/jmms.jmms_82_20  
Background: The therapeutic benefit of tenofovir/lamivudine/efavirenz (TLE) in the treatment of human immunodeficiency virus can be truncated by the occurrence of hepatotoxicity. This study evaluated the protective effect of selenium (Se) against hepatotoxicity induced by TLE in albino rats. Materials and Methods: Adult male albino rats (n = 40) randomized into four groups (n = 10) were used. Group 1 (Control) orally received normal saline (0.2 mL) daily. Group 2 orally received Se (0.1 mg/kg) daily. Group 3 orally received TLE (8.6/8.6/17.1 mg/kg) daily. Group 4 orally received Se (0.1 mg/kg) and TLE (8.6/8.6/17.1 mg/kg) daily. All rats were treated for 90 days. After treatment, the rats were euthanized, and serum samples were centrifuged from blood samples and assessed for liver function markers. Liver samples were harvested and evaluated for morphological changes and biochemical parameters. Results: Impaired liver redox status in TLE-treated rats was characterized by remarkable (P < 0.001) decreases in glutathione peroxidase superoxide dismutase, catalase, and glutathione levels with remarkable (P < 0.001) increases in malondialdehyde levels when compared to control. The alterations in liver function markers were marked by remarkable (P < 0.001) increases in serum aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, alkaline phosphatase, gamma-glutamyl transferase, conjugated bilirubin and total bilirubin levels when compared to control. Hepatocyte necrosis and fatty change were observed in TLE-treated rats. However, TLE-induced hepatotoxic changes were significantly (P < 0.01) reversed in Se supplemented rats when compared to TLE. Conclusion: Se may be clinically effective against hepatotoxicity caused by TLE.
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Effect of submarine microclimate on respiratory physiology of submariners: An observational study p. 52
Vivek Verma, Abhishek Sharma, N Anand
DOI:10.4103/jmms.jmms_13_19  
Introduction: A few personnel feel more tired staying and working inside submarine, as compared to ashore/outdoor spaces, or even onboard afloat platforms (ships). The microclimate onboard underwater platforms play a vital role in determining the respiratory physiology parameters of personnel onboard. There exists a felt need for deeper evidence in this regard. Aims and Objectives: This study is an effort to analyze if there exists any relationship between concentrations of respiratory gases (such as oxygen and carbon dioxide) and other parameters of submarine microclimate, on the respiratory physiology parameters (such as respiratory rate [RR] and SpO2) of personnel onboard underwater platforms. The difference in concentrations of oxygen and carbon dioxide in exhaled air of personnel both inside and outside submarine was also studied. Any difference between smokers and nonsmokers regarding this parameter was also evaluated. Materials and Methods: The study was carried out on thirty healthy volunteers posted onboard a submarine. Concentrations of oxygen and carbon dioxide in the atmosphere, as also the exhaled air, were measured using a digital gas analyzer. Humidity, temperature, and oxygen saturation were measured using digital meters. The values both inside and outside were recorded and compared. Results: There was a statistically significant difference in the temperature, humidity, and level of CO2 inside and outside the submarine. There was no statistically significant difference in level of oxygen in atmosphere, oxygen and carbon dioxide in exhaled air, RR, and SPO2 level inside and outside the submarine. Conclusion: The corrected effective temperature inside a submarine is to be measured periodically and maintained in the comfort zone. The level of CO2 should be maintained close to environmental levels.
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“A randomized controlled single blind clinical trial to evaluate effectiveness of empirical treatment with albendazole in delaying disease progression among human immunodeficiency virus positive antiretroviral therapy naïve patients at an antiretroviral therapy center of a tertiary care hospital” p. 55
Apoorva Sindhu, TS Ramakrishnan, VK Sashindran, Anurag Khera
DOI:10.4103/jmms.jmms_40_19  
Introduction: Parasitic opportunistic infections are widely accepted to accelerate the progression of human immunodeficiency virus (HIV) infection to acquired immunodeficiency syndrome. A large number of interventions are needed to delay HIV progression and improve the health status of HIV patients. The cheapest, simplistic, and practical intervention in a resource-limited setting like India, where HIV and helminth co-infection is common, is deworming. Methodology: The participants were assesses for their eligibility and recruited into two study arms. Both groups were followed for 1 year. CD4 count was assessed at baseline, 6 months, and 12 months. Study participants assigned to the treatment group were treated at 0, 3, 6, and 9 months with tablet Albendazole (400 mg) for 3 days. Study participants assigned to the control arm were given Placebo (Tablet Calcium 500 mg) for 3 days at 0, 3, 6, and 9 months. Results: In both treatment group and the placebo control group, the mean CD4 count was found to be declining. The mean decline in CD4 count of the intervention group was 72 cells/mm3 at 6 months and 85 cells/mm3 at 1 year. Similarly, the mean decline of CD4 count in the control group was 94 cells/mm3 at 6 months and 120 cells/mm3 at 1 year. We found that the mean difference in CD4 count between the intervention group and control group was −31.66 cells/mm3, −9.98 cells/mm3 and 24.87 cells/mm3 at baseline, 6 months, and 1 year, respectively. Our results are consistent with various other studies conducted in Uganda and Africa, as well as Cochrane systematic review. Conclusion: We conclude that empirical treatment with Albendazole in HIV-positive antiretroviral therapy naïve patients has no significant influence on delaying the progression of HIV disease.
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Pattern of injuries sustained during training: A retrospective record-based study p. 61
Vikas Maheshwari, Neerav Porwal, Rushikesh Gadhavi, Arvind Kushwaha, Arun Kumar Yadav
DOI:10.4103/jmms.jmms_34_20  
Background: Physical injuries constitute a major health problem in the training institutes. The present study was undertaken with the aim to analyze the injury pattern in a training institute. Materials and Methods: This study was carried out on male trainees of a premier training academy. Trainees with all forms of injuries were included in the study. This was a descriptive record-based study carried out at a tertiary-level hospital. The records were extracted from January 2011 to December 2016. These trainees were assessed in terms of their age, term, activity causing the injury, anatomical part injured, and their final disposal. Results: Out of a total of 5400 trainees, 1536 trainees with various forms of injuries were assessed (28.4%; 95% confidence interval [CI]: 27.2–29.7). Their mean age was 18.62 years (standard deviation: 0.9 years). The lower limbs were most commonly injured (n = 1167, 75.91%; 95% CI: 73.7%–78.0%). There were 865 (56.3%) cases of soft-tissue injuries in comparison to 671 (43.69%) cases of bony injuries. Injuries due to physical training outnumbered to those sustained during sporting activities. Majority of the cases were managed conservatively (n = 1445, 94.07%), and only 85 trainees required surgical intervention (5.53%). Loss of man-days ranged from 1 to 309 days (mean: 38.18 days). Conclusion: Injuries are an integral part of training, resulting in morbidity and loss of man-days. The descriptive epidemiology of the injuries may help in formulating preventive and promotive measures for injuries.
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Psychological status of asymptomatic and mildly symptomatic patients hospitalized for COVID-19 p. 65
Prateksha Golas, Uzma Hashim, Amrit Kumar, Seby Kuruthukulangara, Vivek Hande, Sheila S Mathai
DOI:10.4103/jmms.jmms_118_20  
Context: The pandemic of COVID-19, with its high rates of infectivity, unpredictable nature, and measures taken to deal with it such as extended periods of lockdown, has had an adverse impact on the psychological status of individuals affected by it directly or indirectly. To the best of our knowledge, this is the first report from India on the psychological status of COVID-19-positive individuals. Aim: The aim of the study was to assess the impact of COVID-19 pandemic on the psychological status of persons tested positive for COVID-19. Setting and Design: This was a case–control study in a tertiary care hospital setting at Mumbai. Materials and Methods: A total of 104 individuals detected to have positive COVID-19 status and admitted to the hospital from May 1, 2020 to May 30, 2020, were compared with 106 age- and gender-matched controls from the general population for the psychological impact of COVID-19 as measured by Perceived Stress Scale-10, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 Questionnaire, Insomnia Severity Index, and World Health Organization Well-Being Index-5. Statistical Analysis Used: Group comparisons on nominal variables were analyzed by Chi-square test. P < 0.05 was taken as statistically significant. Results: About 58.6% from COVID-19-positive group and 76.4% from control group reported moderate-to-high perceived stress. Moderate-to-severe depressive symptoms were reported in 6.7% versus 15%, moderate-to-severe anxiety symptoms in 1.9% versus 14.1%, clinical insomnia in 3.8% versus 14.1%, and poor quality of well-being in 22.1% versus 35.8%, in cases versus controls, respectively. Control group reported significantly higher levels of perceived stress (P = 0.020), depressive symptoms (P = 0.021), anxiety symptoms (P = 0.013), insomnia severity (P = 0.045), and poorer well-being index (P = 0.018) compared to COVID-19-positive group. Conclusions: Despite limitations, study findings, if replicated, highlight the urgent need for incorporating psychological screening and interventions into protocols for dealing with ongoing COVID-19 pandemic not only for infected individuals but also for the community as a whole.
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Initial experiences in the use of portable chest radiography as a tool to guide clinical management of COVID-19 positive patients in resource limited settings p. 71
Ojaswi Bharat Khandediya, Dindigal Ramakrishnan Narasimhan, Priti Kapoor, Sagar Sinha
DOI:10.4103/jmms.jmms_130_20  
Introduction: Radiological diagnosis of COVID-19 has shifted from the use of routine chest X-rays (CXRs) early on during the pandemic to high-resolution computed tomography (HRCT) of the chest to accurately describe the pattern of COVID involvement of the lungs. The morphological patterns seen at HRCT are increasingly being tapped into by a clinician in the management of this uncharted territory, for example, HRCT lung findings are categorized into three distinct phenotypes by an intensivist for guiding advanced ventilatory management of COVID patients. However, in resource-limited settings, HRCT places a heavy burden on the radiology departments and poses an enormous challenge to infection control in the CT suite. Our study aims to describe CXR patterns of COVID-19 acquired by portable radiography units and correlate them to symptom onset and progression in an attempt to enroll it as a reliable tool to assist clinical management including intensive unit care and ventilatory support. Methodology: Our study was a retrospective observational study of portable CXR findings in all patients diagnosed as COVID-19 positive by reverse transcription-polymerase chain reaction at a tertiary medical center from April to May 2020. Results: A total of fifty patients were included in the study, and the presence or absence of CXR findings in the presence or absence of clinical symptoms was analyzed. Our study showed that 24 (48%) patients had baseline features of lung involvement on CXR. Patients who presented with fever or breathlessness were found to be highly likely to show changes on the CXR. The most commonly noted changes were ground-glass opacities in 31 (63%) of patients with a bilateral, peripheral pattern of involvement seen in the lower zones of the lungs. Conclusion: While the higher sensitivity of the HRCT is of great clinical value, the portable CXR offers a feasible alternative to screen, follow clinical progress, and assist management of COVID-19 patients and should be considered as a means to reduce radiological service demands and reduce the risk of cross-infection.
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The COVID-19 pandemic and beyond: A systems thinking analysis using iceberg model to transform an organization into a pandemic-resilient institution p. 75
Kiran Kumar Maramraj, Kaushik Roy, Ilankumaran Mookkiah, Ajit Gopinath
DOI:10.4103/jmms.jmms_183_20  
The pandemic continues to be a long-drawn battle with the emergence of new variants of concern of SARS CoV-2 virus and continued challenges of COVID-19 vaccination such as coverage, longevity of protection and real-world vaccine effectiveness against transmission prevention. It is therefore, imperative for every organisation that, it looks beyond the visible impact of pandemic, transform into a COVID-resilient institution and prepare for future threats. We applied systems-thinking approach and used iceberg conceptual model as a tool to evaluate the determinants of pandemic impact on an organisation and to develop a long-term public health strategy. This strategy is a robust four-pronged plan comprising of stringent preventive-cum-mitigation mechanisms in place, efficient health-care facilities, improved habitability and long-term adaptation to new working-norms. The model can be replicated in any organisation which has self-sustainable in-house facilities for accommodation and health care. This strategy comprises of feasible and scientific interventions which can be used to flatten the impact of future outbreaks, epidemics and pandemics of emerging/ re-emerging communicable diseases on functioning of an organisation. The four-pronged strategic interventions plan would serve as a readily available blueprint and better equip the organisations to fight future public health emergencies in an effective manner.
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PERSPECTIVE Top

Management protocols for functioning of operation theatre complex during COVID-19 pandemic – Perspective of a zonal hospital p. 82
Vidhu Bhatnagar, MS Honwad, Smita Dutta, Kamender Sharma
DOI:10.4103/jmms.jmms_114_20  
Chinese Centre for Disease Control and Prevention announced a novel coronavirus as causative pathogen of COVID-19 on 08th January 2020, after the epidemic broke in Wuhan, China. The coronavirus infection has been incontrollable since then and was given the status of pandemic by the World Health organization in March 2020. World has come to a standstill with the advent of COVID-19 pandemic and multiple changes have made way in the normal functioning of life as well as health-care system. Despite lockdown and restrictions on movement and travel, the virus has managed to seep into multiple countries and presently India is witnessing more than 50,000 new cases daily. Health-care system all over world is exhausted and struggling to handle this contagious virus. This article is an attempt to summarize essential knowledge of COVID-19, review current understanding of COVID-19, and provide recommended management protocols for functioning of operation theater complex which have been formulated and are being followed in our Armed Forces Zonal Hospital in Southern India since Mar 2020.
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CASE REPORTS Top

Reactivation of a 35-year-old scar! Highly accessed article p. 88
Eeshaan Ranjan, Sandeep Arora, Navya Donaparthi, Safia Ahmed, Arpitha Pemmaraju
DOI:10.4103/jmms.jmms_41_19  
Sarcoidosis is a systemic inflammatory disorder of unknown etiology characterized by the presence of noncaseating granulomas. Scar sarcoidosis refers to the infiltration of old scars with noncaseating epithelioid cell granulomas. This reactivation of old scars, manifesting as cutaneous sarcoidosis, is highly specific for sarcoidosis and very unusual. This report describes an old scar with an unusually long history of quiescence and its reactivation after 35 years along with manifestations of pulmonary sarcoidosis.
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Wall-to-wall heart – The largest left atrium ever reported p. 92
Saikat Bhattacharjee, Shikha Awasthi, Prashant Jambunathan, Preema Sinha, Prateek
DOI:10.4103/jmms.jmms_68_19  
A 59-year-old male patient presented with a history of dyspnea on exertion for the past 10 years, which was gradually progressive in nature. The patient had orthopnea and paroxysmal nocturnal dyspnea for the past few months. On evaluation, he was found to have cardiomegaly and a giant left atrium. Contrast-enhanced computed tomography of the heart showed the left atrium to be enlarged to a dimension of 20.7 cm which, as of the time of writing, is the largest ever reported.
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Transient pancreatitis post laparoscopic cholecystectomy: A rare case report p. 95
M Arun Kumar, Bhavna Pahwa, Dharmendra Singh, Anupam Sharma
DOI:10.4103/jmms.jmms_14_20  
Acute postoperative pancreatitis is an uncommon complication following laparoscopic cholecystectomy. The common complications in the early postoperative period are usually attributable to a bile duct injury or a bleeding vessel. Pancreatitis in such a setting usually resolves by conservative management unless there is an active obstruction at the lower common bile duct. Very few cases have been documented in the literature in this contention. In this case report, a case of acute pancreatitis following laparoscopic cholecystectomy is described in terms of the clinical presentation, laboratory parameters, management strategy, and a short review of the literature.
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Leprosy presenting with papulosquamous skin lesions in a case of human immunodeficiency virus infection p. 98
Preema Sinha, Anwita Sinha, Prateek Kinra, Ruby Venugopal
DOI:10.4103/jmms.jmms_81_19  
Leprosy has a wide range of clinical manifestations, which sometimes imposes a clinical challenge and may lead to misdiagnosis. Interactions between leprosy and human immunodeficiency virus (HIV) have been little studied and poorly understood to date. However, coinfection still poses dilemmas in leprosy as to the occurrence of the immune reconstitution inflammatory syndrome manifesting as clinical leprosy and reversal reactions, higher chances of relapse after the successful completion of the multidrug therapy (MDT) and drug interactions between MDT and antiretroviral therapy. Furthermore, coinfection can lead to atypical clinical manifestations of leprosy. Herein, we describe a rare presentation of leprosy in a patient of HIV infection who reported with papulosquamous lesions over both upper and lower limbs histopathologically consistent with Hansen's disease.
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Necrotizing lymphadenitis with generalized adenopathy: A diagnostic dilemma – Kikuchi–Fujimoto disease p. 101
Gaurav P S Gahlot, Ravindra Dubey, Tathagata Chatterjee, Manu Chopra
DOI:10.4103/jmms.jmms_2_20  
Kikuchi–Fujimoto disease (KFD) is a rare, self-limiting, benign disorder of lymphoreticular system that commonly occurs in young Asian women predominantly under <30 years of age. Clinically, it presents as cervical lymphadenopathy, fever, and weight loss; therefore, it is a disease of exclusion in countries such as India, which are endemic for tuberculosis. Here, we are describing a case of a young female who again presented with low-grade fever and arthralgia; 1 month after the completion of 6-month antitubercular treatment. In view of generalized lymphadenopathy, raised erythrocyte sedimentation rate; clinical, radiological, and fluorodeoxyglucose positron emission tomography-computed tomography scan findings; and the differentials diagnoses of disseminated tuberculosis, lymphoma, or sarcoidosis were considered. Histopathology of the right axillary lymph node showed paracortical expansion by histiocytes, necrosis, numerous apoptotic debris, and paucity of plasma cells with the absence of neutrophils, thus confirming the diagnosis of KFD. The correct diagnosis thus helped to relieve the anxiety of the patient and prevented unnecessary medication.
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Vaginal cuff dehiscence with small-bowel evisceration following total laparoscopic hysterectomy – An unusual case Highly accessed article p. 104
Vaidehi D Thakur, Manoj M Paprikar, SM Singh
DOI:10.4103/jmms.jmms_3_20  
Small bowel evisceration from dehiscent vaginal cuff is unusual subsequent to laparoscopic hysterectomy. This complication is seldom cited in studies and reviews. We present an uncommon case of evisceration of small bowel from vaginal cuff dehiscence (VCD). The event occurred approximately 2 hours subsequent to the first act of coitus performed 3 months after the laparoscopic hysterectomy. Patient was brought to the emergency department for primary treatment. Urgent surgical intervention was planned. Small intestine was reposed after saline wash. Repairing of the vault was done with continuous suture by polyglactin-910 braided synthetic absorbable suture no.1. Patient was sent to home after 5 days of surgery. The strength of vaginal vault in laparoscopic hysterectomy depends on technique of vaginal cuff closure and types of suture materials used during surgery. Postoperative counseling of patients for recommencing physical activity and sexual intercourse is also of utmost significance.
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SHORT COMMUNICATION Top

Is antibody-dependent enhancement a cause for COVID Vaccine hesitancy p. 107
Shabeena Tawar, Parnika Chandola, Sougat Ray
DOI:10.4103/jmms.jmms_93_21  
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COMMENTARY Top

Infectious disease immunotherapies: An update, revisiting an age-old adage in times of COVID-19 p. 109
AT Atal, Mahima Lall, Anuj Singhal
DOI:10.4103/jmms.jmms_79_21  
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LETTER TO EDITOR Top

Throat packs: Protocols never to be violated p. 111
Sonia Bhan, Debashish Paul, Shalendra Singh, Nipun Gupta
DOI:10.4103/jmms.jmms_5_20  
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