Need for Pandemic Preparedness Teaching during the Medical Curriculum.

When we talk about 20-20 it goes without saying that we are talking about Indian Premier League matches. But when we talk about 2020, we get goosebumps even remembering the memories of the coronavirus disease 2019 (COVID-19) pandemic! It was just about that time when the National Medical Commission (NMC) rolled out the Competency-based Medical Education (CBME) curriculum for the first Bachelor of Medicine, Bachelor of Surgery (MBBS) batch admitted in the 2019-2020 academic year. Who knew that the timetable so well planned would go for a toss due to the global pandemic? It was indeed a learning lesson for all. The word pandemic is derived from the Greek words pan = all and demos = people. An epidemic that affects large geographic areas across the entire world at the same time is called a pandemic. Most of the pandemics are caused by viruses, for example, influenza, acquired immune deficiency syndrome, and now COVID-19. Susceptible individuals get affected, they transmit the organism to many individuals in a short time. International travel spreads the disease globally in a short time and a pandemic is declared. Hence, it is the need of the hour to sensitize the medical students by incorporating the pandemic preparedness module in the medical curriculum. How to cite this article: Londhey V. Need for Pandemic Preparedness Teaching during the Medical Curriculum. J Assoc Physicians India 2023;71(10):11-12.

Analysis of COVID Deaths: A single Centre Experience in Mumbai Medical College.

Objectives To calculate the mortality rate of COVID 19 at our centre. To study age and sex distribution of COVID 19 deaths. To study the duration of hospital stay with mortality. To study the comorbidities associated with mortality. METHODS: This is a retrospective analytical study of COVID 19 deaths which have occurred from April 2020 to January 2021. Death records of patients who were Confirmed positive cases of COVID 19 infection by Antigen positivity or RT PCR (polymerase chain reaction) or CBNAAT were analysed based on the total number of admissions, total deaths, age and gender distribution; duration of hospital stay, co-morbidities. RESULTS: There were 763 deaths in our study. Total admissions were 5762. Mortality rate was 13.2%. Out of these 481 were males and 282 females. The mean age of death was in the group of 60-70 years with a median age of 64.8 years. 221 patients had ≥ 3 comorbidities, 162 had ≥ 2 comorbidities. 172 had single comorbidities and 208 no comorbidities. CONCLUSIONS: COVID 19 affects people of all age groups and gender. It neither spares people with comorbidities nor those without any comorbidities. There is no specific therapy for its treatment. Hence Vaccination, and use of masks, social distancing and sanitization are the policies which will help in the long run.

Use of Disease Activity Score (DAS28) and Routine Assessment of Patient Index Data 3 (RAPID3) for Assessment of Rheumatoid Arthritis Disease Activity, in the Indian Setting.

INTRODUCTION: Patient outcomes in rheumatoid arthritis (RA) have significantly improved with the advent of disease modifying anti rheumatic drugs and the newer biological agents. Various scoring systems available for monitoring disease activity in RA have not yet been put into full use in patient management in India. We aim to study the disease activity score 28 (DAS28) and Routine assessment of patient index 3 (RAPID3), their correlation and patient outcomes in RA. MATERIALS AND METHODS: The study was conducted between March 2011-May 2011. A total of 81 patients were included. Patient's history was noted. Clinical examination for tender and swollen joint counts was performed. DAS28 was calculated. MDHAQ was administered to each patient in a language they understood and responses noted. Correlation between DAS28 and RAPID3 was studied using Pearson's correlation coefficient. RESULTS: RAPID3 and DAS28 showed Pearson's correlation coefficient of 0.8699 (p<0.001). Of the 53 patients who met with DAS28 severity criteria of >5.1, 82.7% showed similar results with RAPID3 suggesting severe disease activity. (X2 = 33.512 and p<0.001). A greater proportion of those whose DMARD initiation was 2 years after disease onset, had higher disease activity as compared to those with earlier initiation.

Study of Hepatic Involvement and Thrombocytopenia in Dengue.

OBJECTIVE: The purpose of this study was to assess the pattern of hepatic involvement and thrombocytopenia in patients with dengue fever and time taken for clinical/biochemical recovery. METHODS: This is a retrospective study done in a tertiary centre. A total of 1111 patients with documented dengue fever, either with NS1 antigen/IgM antibody positive report who were admitted between January 2016 to December 2016.The aminotransferase levels and platelet counts were measured on day 1,4 and7. Patients were assessed clinically on day 1,4,7 or till discharge/death accordingly. CONCLUSION: Out of 1111 patients with dengue infection, 993 had either thrombocytopenia or hepatic involvement or both. Majority of patients with thrombocytopenia and hepatic dysfunction recovered between 4-7 days of admission i.e 53.98% and 29.20%. Statistically significant corelation of platelet count and aminotransferase levels with recovery or death of the patient was seen in our study.

A Cross-sectional Study of Cardiovascular Involvement in Systemic Lupus Erythematosus in an Urban Indian Tertiary Care Centre with Emphasis on 2-D Echocardiography.

BACKGROUND: Cardiovascular manifestations are responsible for considerable morbidity and mortality in patients with SLE. A wide range of manifestations due to active lupus, like pericarditis, valvular affection, myocarditis, and less commonly pulmonary hypertension, are described. This study was undertaken to study cardiovascular manifestations in SLE, with a focus on echocardiography findings, in an urban Indian setting. METHODOLOGY: Fifty consecutive cases of SLE following up in the Rheumatology Clinic of TNMC and BYL Nair Charitable hospital, an Indian tertiary care hospital were studied. They were subjected to an echocardiographic examination if not already done. Detailed history, examination, study of past medical records and investigations were carried out, especially related to cardiovascular system. Treatment details, flares, other systemic involvement were noted. Serial echocardiography if done previously were noted down. The data was analysed using descriptive statistics. RESULTS: An echocardiographic abnormality was noted in 25 (50%) of the 50 subjects. Pulmonary hypertension in 21(42%); valvular abnormalities in 16 (32 %); pericardial effusion in 9 (18%) and diastolic dysfunction in 6(12%) were the echocardiography findings. Six out of the 7 cases with moderately to severe pulmonary hypertension seemed to be responding to immunosuppressive therapy clinically as well as on echocardiography; 1 did not respond. At least 1 traditional risk factor for atherosclerosis was present in 58% of cases. CONCLUSIONS: Screening echocardiography may be recommended, especially at presentation, during SLE flare, or in the presence of cardiac symptoms. Moderate to severe pulmonary hypertension can develop any time in the course of the disease. It may be responsive to immunosuppression. Further detailed studies including multiple echocardiographic parameters and right heart catheterisation need to be undertaken to study the responsiveness of pulmonary hypertension to immunosuppresssive therapy.

Anti CCP Antibodies in Tuberculosis.

INTRODUCTION: Anti-cyclic citrullinated peptide (anti-CCP) antibodies have been considered very specific for rheumatoid arthritis (RA). Some studies have shown that these antibodies can be positive in infectious diseases like TB, HIV, etc. METHODS: Fifty patients of tuberculosis both pulmonary and extra-pulmonary were enrolled in the study from inpatient and outpatient departments from May 2012 to November 2013. Anti-CCP antibody test was done in all the patient by ELISA. RESULTS: Thirty one were pulmonary and 17 were extra-pulmonary and two were disseminated extra-pulmonary TB. Of the 31 cases of pulmonary tuberculosis, 12 cases (38.7%) were positive for anti-CCP antibodies and 19 cases (61.3%) were negative for same. Of the 19 cases of extra-pulmonary tuberculosis, two cases (10.52%) were positive for anti-CCP antibodies and 17 cases (89.48%) were negative. Of the 31 patients of pulmonary TB, nine were sputum positive and 22 were negative. Of those with sputum positive five (55.56%) were positive for anti-CCP antibodies and those with sputum negative 7 cases (31.81%) were positive for anti-CCP antibodies. CONCLUSIONS: Anti-CCP can be falsely positive in cases of tuberculosis. Positivity of anti-CCP antibodies for tuberculosis is more for pulmonary (more for sputum-positive than sputum-negative) than extra-pulmonary TB. Anti-CCP thus is not very specific for rheumatoid arthritis.

Dengue and Chikungunya Virus Co-infections: The Inside Story.

INTRODUCTION: There have been various studies from India describing the acute presentation and the long-term sequalae of Chikungunya (CHIKV) infection. However, there are very few studies discussing the Chikungunya-Dengue (DENV) co-infection from Western India. The present project was undertaken to study the clinical features of Dengue and Chikungunya co-infection and compare with Chikungunya mono-infection; correlate the clinical findings with seroprevalence and molecular identification of Dengue and Chikungunya using IgM ELISA and RTPCR. MATERIAL AND METHODS: Three hundred suspected cases of Dengue and/or Chikungunya patients from out patients department and indoor wards, more than 12 years of age suffering from acute febrile illness, joint pains and rash for less than 10 days were included from June 2010 to April 2015. Proven cases of malaria, enteric fever, leptospirosis were excluded from the study. Leptospira IgM, Dengue IgM and PCR, Chikungunya IgM and PCR was done on all 300 samples. RESULTS: Sero-surveillance of the patients revealed that 59% (177) patients were positive for Dengue IgM alone, while 2% (6) tested positive for Chikungunya IgM alone. 6.7% (20) patients tested positive for Dengue and Chikungunya both. Ninty seven (32.3%) patients were negative for Dengue and Chikungunya. Of the 300 samples, 7% (21) were positive for DENV, 35% (105) were positive for CHIKV, 10% (30) were both DENV and CHIKV positive and 48% (144) were negative for both through RT-PCR. DISCUSSION: In our study, the patients of CHIKV mono-infection and DENV + CHIK co-infection had high VAS score, morning stiffness, arthralgias, restriction of joint movements as compared to patients with DENV mono infection. Patients of dengue mono infection had bone pains and myalgias in addition to joint pains; however there was restriction of joint movements in only 13.2% as compared with 100% of mono CHIKV or dual infection. These clinical features can be helpful in distinguishing DENV mono infection as compared to co-infection. The study highlights the diagnostic importance of RT-PCR in CHIKV and DENV co-infection, as 10% cases were identified using RT-PCR as compared to 6.7% cases by IgM antibodies.

SLE Neuropathy-Anything New?

SLE (systemic lupus erythematosus) is a multisystem autoimmune disorder of unknown aetiology which can present with myriad clinical presentation. The neurological manifestations of SLE consist of central nervous system (CNS) and peripheral nervous system manifestations (PNS). The CNS manifestations are aseptic meningitis, cerebrovascular accidents (stroke), demyelinating disorders, headache, involuntary movements like chorea, myelopathy, acute confusional states, cognitive dysfunction, mood disorder, seizures, psychosis and cranial nerve palsies.1 The PNS manifestations are Guillain Barre syndrome (GBS), autonomic disorder, mononeuropathy, polyneuropathy and plexopathy.1 Neuropathy in SLE can be clinically classified as mononeuritis multiplex and symmetrical and asymmetrical polyneuropathy. Symmetrical polyneuropathy being the most commonly seen clinical entity amongst the neuropathies in SLE. The neuropathy can be slowly progressive or acute in onset. Electrophysiologically, neuropathy is classified as axonal neuropathy, small fibre neuropathy, demyelinating neuropathy, mixed axonal-demyelinating sensorimotor polyneuropathy and plexopathy. Axonal neuropathy is further divided into sensory, sensorimotor and mononeuritis multiplex. Demyelinating neuropathy can be of two types: acute inflammatory demyelinating polyneuropathy (AIDP) and sensory demyelinating polyneuropathy. Anecdotal case reports also suggest that CIDP can occur as part of SLE neuropathy.2.

Awareness about Ethics Committee amongst the Medical Teachers in a Medical College.

INTRODUCTION: The Ethics Committees (EC) are established to safeguard the safety and rights of the subjects participating in a research study. No formal training about Ethics Committee is given to the medical students in undergraduate and post graduate education as a part of curriculum. AIMS AND OBJECTIVES: To study the awareness about the composition and functioning of EC amongst the medical teachers. METHODOLOGY: A prevalidated questionnaire was given to the medical teachers who consented to participate in the study, fill up the questionnaire immediately and return it. The questions consisted of knowledge about the composition of the EC and its functioning in general. RESULTS: Ninety two (51%) belonged to non-clinical branches; 88(49%) were clinicians. Forty (22%) had undergone ICH-GCP training (27 belong to clinical and 13 non-clinical branches). Forty four point four percent were well informed about the composition of EC in general. The most common wrong answer was "Dean" is the Chairperson of EC. CONCLUSIONS: As the years of experience as Faculty in Nair increased, the knowledge about the composition of EC's in general increased but the information about functioning of IEC did not improve significantly. The awareness about EC was significantly higher amongst the PG teachers.

Congenital methaemoglobinaemia: a rare cause of cyanosis in an adult patient.

Cyanosis is a physical finding that can occur at any age but presents a great challenge as the causes are multiple and varied. When patients present with cyanosis and dyspnoea that are unrelated to cardiopulmonary causes, methaemoglobinaemia should be considered as a possible diagnosis although rare. Methaemoglobinaemia can be asymptomatic even when methaemoglobin (metHb) levels are as high as 40% of the total haemoglobin values. Although acquired methaemoglobinaemia caused by environmental oxidizing agents is common; congenital deficiency of the innate reducing enzymes is so rare that very few cases have been documented. We report this case of type I congenital methaemoglobinaemia.

Leprous polyneuritis cranialis mimicking orbital apex syndrome.

Leprosy is one of the most prevalent infections in India, with our country accounting for almost 60 percent of the world's patients. Hence unusual presentations of leprosy should be sought for and treated at the earliest. We report this rare case of polyneuritis cranialis secondary to leprosy. Affection ofa single cranial nerve has been described previously but there is only one report of leprosy presenting like orbital apex syndrome.

Complete heart block in a case of rheumatoid arthritis.

We report a case of complete heart block in a patient with rheumatoid arthritis because of its rarity and unusual features like younger age, short duration and negative rheumatoid factor.

The study of complications of vivax malaria in comparison with falciparum malaria in Mumbai.

INTRODUCTION: Severe malaria due to P. vivax infection is increasingly observed now a days. Organ failure in vivax malaria is caused by mechanisms of inflammation as well as sequestration. In this study we have compared the complications in vivax malaria with those in falciparum or mixed malaria. AIMS AND OBJECTIVES: 1) To study various complications in adult inpatients of vivax malaria. 2) To compare the incidence of complications in vivax, falciparum and mixed malaria. MATERIALS AND METHODS: This was a retrospective observational study done at a tertiary care hospital in Mumbai over 3 months period. All adult indoor patients positive for malarial infection based on peripheral smear or malarial antigen (LDH) spot test were included in the study. Their demographic profile, complications, course in ward till discharge or death was noted. Data was analysed using appropriate statistical tests. RESULTS: 680 cases of malaria were included in the study. 338 were infected with P. vivax, 206 with P. falciparum, 136 with mixed infection. Severe disease was present in 162 (23.82%) cases of malaria of which 50 (31%) had vivax infection, 64 (39%) had falciparum infection and 48 (30%) had mixed infection. The complications seen in vivax malaria were: thrombocytopenia (68%), leukopenia (19%), ARDS (3%), high bilirubin (5%), acute renal failure (3.5%), anemia (3%), mucosal bleeding (8%), cerebral malaria (3.5%), hypotension (5%), metabolic acidosis (4%) and death (1.77%). CONCLUSIONS: 31% cases of severe malaria had vivax monoinfection. Thrombocytopenia, leukopenia, acute respiratory distress syndrome, hypotension, mucosal bleeding were seen as frequently as in falciparum and mixed malaria. Acute renal failure, cerebral malaria, high bilirubin, anaemia, metabolic acidosis and death were also found in vivax malaria but less frequently than in falciparum and mixed malaria.

Reflex sympathetic dystrophy following pacemaker insertion.

A 55 year old male presented with pain and swelling over dorsum of right hand and small joints, and loss of sweating over right hand since two months. He was a known case of mitral valve prolapse (MVP) with mitral regurgitation and complete heart block for which pacemaker was implanted 1 year back. Bilateral wrist X-ray was suggestive of pronounced demineralization (osteopenia) in the right hand. He was thus diagnosed to have reflex sympathetic dystrophy syndrome (RSDS) considered to be induced by pacemaker insertion. After treatment with amitryptiline and indomethacin his symptoms dramatically improved.