Tertiary Care Teaching Institute Research Articles

Clinical profile and outcome of children with coronavirus disease 2019 infection during the three waves: An observational study from Eastern India

Background and Objectives: Coronavirus disease 2019 (COVID-19) or severe acute respiratory syndrome coronavirus (SARS-CoV-2) is a global problem, which had occurred in waves thereby causing high mortality globally. The clinical presentations and prognosis varied in different populations and geographical locations. There is a dearth of the study describing the clinical presentation and outcome of children in all the three major waves of the COVID-19 pandemic. Materials and Methods: In this observational study, we described the clinical characteristics and outcomes of children enrolled both prospectively and retrospectively from a tertiary care teaching institute in the eastern part of India. The data included that of all the three major waves of COVID-19 (from April 2020 to March 2022). Results: During the study period, data of 192 children could be retrieved from the hospital records. Boys were more affected than girls. Fever was the most common presenting complaint, followed by cough. Contact with a known case of COVID-19, underlying comorbidity, breathing difficulty, and the number of children affected with multisystem inflammatory syndrome in children (MIS-C) were significantly higher in the first and second waves compared to the third wave. Lymphopenia, abnormal chest X-ray, use of antibiotics, oxygen, intravenous immunoglobulin, and steroids were significantly higher in the first and second waves compared to the third wave. There was no difference in mortality. Conclusions: The third wave in children was milder compared to the first and second waves. Fever was the most common manifestation in all the waves. MIS-C was rarely seen during the third wave. There was no difference in mortality.

Profile and Outcome of DAMA among Paediatric Patients from a Tertiary Care Centre of a Non Profit Private Teaching Institute at Gujarat, India

Introduction: The problem of Discharge Against Medical Advice (DAMA) has been reported globally, including in patients of the paediatric age group. Even the Indian subcontinent faces such problems, whether, it is the private sector or public sector. Terminal illness, low affordability, social reason are a few of the common reasons for this DAMA problem. Aim: To know the outcome and demographic profile of DAMAs among paediatric patients at a tertiary care teaching institute. Materials and Methods: This mix-method, prospective descriptive study was conducted in Department of Paediatrics, Pramukhswami Medical College and Shree Krishna Hospital, Karamsad, Gujarat, India, from March 2020 to February 2021. Contact details of patients, whose parents took DAMA from the hospital, were retrieved from the Electronic Health Record system. Interviews were recorded and the required information was gathered. Median (interquartile range), frequency, percentage and proportion of age, sex, diagnosis, and reasons of DAMAs derived. Results: Out of a total of 1752 registered paediatric patients (1 month to 18 years), 74 patients were given DAMA, of which 42 consented to interview. The mean age was 70.36±67.9 months and 65% were males. Amongst these 42, 31(73.81%) were taken to home and 11 (26.19%) to another hospital; 20 (47.62%) patients died. Among the rest, 6 (14.28%) had morbidity. Total deaths were 20, out of which six died within one hour, another four died within 24 hours, two died within 7 days and rest eight were died any time after 7 days till contacted. Family or social reason was the top cause of DAMA, whereas, poor prognosis with or without affordability issues was next. Among all diagnoses, nearly half of the cases were infectious/ inflammatory, 10% tumour/malignancy, and 6.14% trauma/ head injuries. Conclusion: DAMA rate was not high in this study. But this was not preventable in majority of the cases as poor prognosis as well as family or social reasons were the major causes of DAMA.

Cadaver dissection for oculoplastic procedures: A beginner's guide.

The purpose of this article is to form a basic guide for beginning the cadaver dissection training programs focused on oculoplastic surgical procedures. Ours was a collaborative study between the departments of Ophthalmology and Anatomy in a tertiary care teaching institute. We formed a step-wise approach to begin the cadaver dissection focused on the oculoplastic surgical procedures. The basics of cadaver procurement, processing, and preparation for dissections were described. The operative requirements of trainees, surgical handling of cadavers, and basic oculoplastic surgical steps were discussed. The types of embalming (cadaver preservation process) and steps have been described in detail. We have emphasized the preoperative discussion about the proposed dissections using standard teachings and skull models for easier understanding. Additional helping tools like soft embalming and injectable substances for better intra-dissection understanding (intra-arterial, intravenous and orbital injections) have been described. Post-dissection cadaver handing and soft-tissue disposal protocols have also been described. Overall, the cadaver dissections provide holistic surgical learning for the residents, specialty trainees, and practitioners. This article may act as a basic step-wise guide for starting the cadaver-based oculoplastics lab dissection in various institutes and workshops.

Prescription Pattern for Antimicrobials and the Potential Predictors for Antibiotics among Patients with COVID-19: A Retrospective Observational Study

Introduction: Long-term repercussions of Coronavirus Disease2019 (COVID-19) on antimicrobial resistance have been raised as a grave concern due to the rampant use of antibiotics in the management of COVID-19. As per meta-analysis, the prevalence of antibiotic prescribing was 74.6% which was significantly higher than the estimated prevalence of bacterial co-infection. World Health Organisation (WHO) recommended that antibiotic therapy should not be used in patients with mild/moderate COVID-19 unless there is any bacterial suspicion. Also, the guidelines laid down by the Ministry of Health and Family Welfare, Government of India, does not recommend systematic empiric antibiotic therapy in patients hospitalised with COVID-19. Despite not being recommended, antimicrobials are still given in clinical practice. Aim: To analyse prescriptions for antimicrobials and to identify potential predictors for antibiotic prescription. Materials and Methods: A retrospective observational study was conducted at a tertiary care teaching institute. Data (demographic profile, co-morbidities, disease category, prescribed antimicrobials, laboratory investigations, and duration of hospital stay) were collected from case files of patients with laboratoryconfirmed Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) infection. These patients were admitted in the institute from January 2021 to May 2021. Logistic regression was used to analyse factors associated with the empirical use of antimicrobial agents. Results: A total of 184 case files were analysed. The mean age of patients was 55.84±15.72 years, with a male preponderance (70.10%). Among antimicrobials, antivirals were prescribed in 159 (86.41%) patients, and antibiotics in 152 patients (82.6%). Antivirals prescribed include Remdesivir [109(68.55%)] and Favipiravir [70(44.02%)]. Ceftriaxone was found to be the highest prescribed antibiotic, with a median duration of administration of six days. An association was found between disease severity and CRP level with antibiotic prescription. On multivariable analysis, the odds of receiving antibiotics were 6.7 times higher in patients with severe disease. Conclusion: More than 80% of COVID-19 patients received antibiotics. Duration of hospital stay was similar among patients whether they received antibiotics or not. Disease severity and raised CRP level were strong predictors for prescribing antibiotics for COVID-19.

Evaluation of Glottic View and Intubation Conditions with Sniffing Position Using Three Different Pillow Heights during Direct Laryngoscopy: A Prospective Analytical Study.

Limited studies are available for assessing the optimal pillow height for sniffing position to obtain the best glottic view during laryngoscopy and intubation in the Indian population. This study was designed to evaluate laryngoscopic view and intubation conditions in sniffing position using three different pillow heights (without a pillow, 4 cm, and 7 cm) during direct laryngoscopy. This prospective analytical study was done in a tertiary care teaching institute. In 60 patients, direct laryngoscopy was performed in the sniffing position first without a pillow (0 cm), followed by a 4-cm pillow, and then a 7-cm pillow to assess the glottic view after administration of anesthesia. The laryngoscopic views were graded using the percentage of glottic opening (POGO) score and Cormack and Lehane (CL) grade. The pillow with the best laryngoscopic view was subsequently used to intubate the patient. Intubation difficulty was assessed by the Intubation Difficulty Score (IDS). The patient was followed up for 24 h postoperatively to evaluate postoperative complications due to intubation. The categorical data were expressed in frequency and percentages and analyzed using the Chi-square test. With a 4-cm pillow, there are a lower CL grade and a higher POGO score compared to views without a pillow and a 7-cm pillow which was statistically significant. There is a significantly lesser IDS score with a 4-cm pillow. The sniffing position with a 4-cm pillow provides a better laryngoscopic view and improved intubation condition than without a pillow and a 7-cm pillow in the study population.

Perception of Medical Faculty and Students about Online Teaching during the COVID-19 Pandemic in a Tertiary Care Teaching Institute

Perception of Medical Faculty and Students about Online Teaching during the COVID-19 Pandemic in a Tertiary Care Teaching Institute

COVID-19 infection among health care workers: A hospital based study from Indian state of Meghalaya.

ABSTRACTBackground:COVID-19 can infect any individual, but the group most susceptible is the Health Care Workers (HCWs) who are directly involved in COVID-19 patient care. Despite adhering to the recommended personal prospective equipment, a disproportionately large number of cases of COVID-19 were reported among the HCWs.Aims and Objectives:To study the burden of COVID-19 infection among the HCWs and to study the probable factors associated with increased risk of COVID-19 infection among HCWs.Materials and Methods:A hospital-based prospective cross-sectional study was conducted at a tertiary care teaching institute in the state of Meghalaya, India for the period between 1st May 2020 and 30th June 2021 and included only laboratory-confirmed COVID-19 cases. Data collected included: A) Demographic data – age, gender, category of HCW, B) History of exposure, place of posting, C) Clinical presentation and disease category.Results and Observations:A total of 144 cases were included in the study. The mean age of affected HCWs was 33.83 ± 1.408 years and male to female ratio was 0.47:1. The commonest age group affected was 18 to 30 years of age (45.14%). The majority of the HCWs were Nursing Officers (staff) (52.78%) followed by Resident Doctors (18.06%). Out of all cases, 135 (93.75%) were either asymptomatic or had mildly symptoms. In 96 (66.67%) HCWs, there was high-risk contact with a known case of COVID-19. High-risk contact outside the COVID-19 designated area of the hospital was noted in 53 (36.81%) cases; however, only 22 (15.27%) patients had a history of working in the COVID-19 designated area at the workplace.Conclusion:The most common group that got infected was the nursing staff followed by the resident doctors, with more than ninety percent of the cases having either mild symptoms or were asymptomatic. The risk of contracting COVID-19 infection was higher in non-COVID-19 as compared to COVID-19 designated areas of the hospital.

Clinical Profile of Hypoglycaemia in Neonates at Risk in a Tertiary Care Teaching Institute in Southern India: A Longitudinal Study

Introduction: Hypoglycaemia is common in babies at risk. Without early detection, timely diagnosis and treatment, hypoglycaemia can cause disastrous consequences on neurological and developmental outcomes. Therefore, continuous monitoring of blood glucose levels in babies at risk should be done to reduce its impact. Aim: To describe the clinical profile and sequential blood sugar levels in the first four postnatal days in at-risk neonates and to identify the risk group of neonates with recurrent hypoglycaemia. Materials and Methods: This was a longitudinal study done in the Neonatal Intensive Care Unit (NICU) and Special Newborn Care Unit (SNCU) of a tertiary care teaching institute; Sri Avittam Thirunal Hospital (SATH), Government Medical College, Thiruvananthapuram, Kerala, India, from October 2017 to October 2018. Neonates admitted with risk factors for hypoglycaemia according to ‘National Neonatology Forum’ clinical guidelines with low capillary blood sugar (<40 mg/dL) within the first two to four hours of life were included in the study. These neonates were followed-up clinically till fourth postnatal day with glucose monitoring. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 22. Categorical variables were expressed as proportions and compared using the Chi-square test. A p-value <0.05 was considered statistically significant. Results: A total of 368 ‘at risk’neonates had hypoglycaemia at admission (2 to 4 hours) and of these 200 (54.3%) developed recurrent hypoglycaemia. Out of the neonates with recurrent hypoglycaemia, 150 (75%) were preterm and 50 (25%) were term. The preterm Small for Gestational Age (SGA) had a higher chance of developing recurrent hypoglycaemia than preterm Appropriate for Gestational Age (AGA) and Large for Gestational Age (LGA) (p-value=0.0256). Although, 102 (40.2%) preterm had asymptomatic hypoglycaemia, 90 (78.9%) term neonates showed symptoms of hypoglycaemia. The major clinical manifestation was jitteriness in those with a single episode 31 (18.45%) and lethargy/poor activity in those with more than one episode 66 (33%). The blood glucose levels less than 25 mg/dL at admission was significantly associated with the occurrence of a repeat episode of hypoglycaemia (p-value=0.028). Conclusion: Blood glucose monitoring in neonates with risk factors is mandatory as 54.3% of neonates developed recurrent hypoglycaemia. Of these, preterm SGA had a high chance of developing recurrent hypoglycaemia. The variable presentations in neonatal hypoglycaemia indicates the need for detailed and thorough clinical examination with glucose monitoring in these at-risk neonates. Initial blood glucose level less than 25 mg/dL was significantly associated with recurrent hypoglycaemia.

Randomized control study of nebulized colistin as an adjunctive therapy in ventilator-associated pneumonia in pediatric postoperative cardiac surgical population.

Ventilator-associated pneumonia (VAP) with multidrug-resistant (MDR) gram negative organisms is a common problem in intensive care unit (ICU). Aerosolized antibiotics enhance the efficacy of systemic antibiotics when added as adjuvants. The primary objective of the study was to compare the clinical and bacteriological outcome of patients with VAP who were administered intravenous (IV) antibiotics alone with those patients who were treated with adjunctive nebulized colistin (NC) along with IV antibiotics. The secondary objective was to study the occurrence of any adverse events during colistin nebulization. The study was a prospective, randomized, double-blinded controlled study conducted at a tertiary-care teaching institution. Ninety-eight children from surgical ICU aged less than 12 years who were diagnosed with VAP due to gram negative bacteria following cardiac surgery were chosen and divided randomly into two groups. The experimental group (NC group) was treated with systemic antibiotics along with NC, whereas the control group (NS group) was administered systemic antibiotics with nebulized normal saline (NS). Clinical and bacteriological outcomes were noted. Statistical analysis was done using SPSS Version 20.0 software. The patient characteristics were compared using independent Student's t test and Chi-square test. There was a statistically significant reduction in the duration of mechanical ventilation, postoperative ICU and hospital stay (P < 0.05) in the NC group compared with the NS group. Aerosolized colistin may be considered as an adjunct to systemic IV antibiotics in pediatric patients with VAP due to gram negative bacteria susceptible to colistin.

Health-related quality of life in children with juvenile idiopathic arthritis: A developing country perspective

Objective: To assess the Health-Related Quality of Life (HRQoL) in domains of physical, emotional, social, and school functioning in children suffering from juvenile idiopathic arthritis (JIA).Materials and Methods: This hospital-based prospective observational study was undertaken in children from 2 to 12 years of age attending the Rheumatology clinic of a tertiary care teaching institute of Eastern India with a diagnosis of JIA for at least 6 months. Pediatric QoL inventory 4.0 generic core scale was used after obtaining the necessary permission.Results: Out of a total of 92 patients of JIA, 85 (male/female: 39/46) were taken up for the study polyarticular JIA was the commonest variety (54/85, 63.5%) followed by systemic JIA (sJIA) (25/85, 29.4%) and oligoarticular JIA (6/85, 7.0%). Male gender (P = 0.059, 0.000), better BMI (P = 0.004, 0.001), better disease control (P = 0.00, 0.00), sJIA subcategory (P = 0.002, 0.000), and longer duration of disease (P = 0.015, 0.000) correlated with better QoL in both child and parent scores whereas better socioeconomic status fared better only in parent scores (P = 0.017) and educational status of parents in child scores (child P = 0.000), Child and parent score were comparable across all domains and also overall scores.Conclusion: This study brings out certain important aspects of QoL in children suffering from JIA which may have some significant impact on disease control per se. Larger community-based multicentric studies would help us in delineating further this aspect of the disease and formulating guidelines for improving QoL in such children.

Study of effect of gluten-free diet on vitamin D levels and bone mineral density in celiac disease patients.

Objective:Celiac disease (CD) is a multifactorial immune-mediated enteropathy caused by a response to ingested gluten. The current available treatment for CD is lifelong gluten-free diet (GFD). This study was done to see the effect of GFD on Vitamin D levels and bone mass density in celiac patients.Methods:A prospective interventional study on newly diagnosed celiac patients was conducted in the Pediatrics department of a tertiary care teaching institute in 2 stages viz. on presentation and after 6 months of GFD. Anthropometric measurements, biochemical investigations, Vitamin D levels, and DEXA scan was done at recruitment and after 6 months of GFD and was analyzed.Results:In newly diagnosed 60 pediatric celiac patients, positive effect of GFD on anthropometry, hemoglobin, Vitamin D levels, DEXA scan parameters was observed. Significant difference was found in Vitamin D levels which increased from baseline 14.85 ± 5.39 to 18.22 ± 5.67 ng/ml after 6 months of GFD (P < 0.05). Significant difference was found in BMD (mean Z-score) which increased from -0.941 ± 0.738 to -0.640 ± 0.60 after 6 months of GFD (P < 0.001).Conclusion:Our study concluded that there is significant increase in vitamin D levels as well as Z-score, bone mass density (BMD) and bone Mass Content (BMC) after 6 months of GFD.

Retrospective Autopsy-based Profiling of Fatal Snake Bite Cases Brought to Tertiary Care Teaching Institute of Haryana

Snakebite is a major public health problem throughout the world especially in tropical and sub-tropical countries. Snake venom is probably the oldest known poison to mankind and has been described in oldest medical writings and myths. Since the dawn of civilization, snakes have inspired a mystic feeling of good and evil in human mind. An authentic measure of the global burden of snakebite envenoming remains obscure despite several attempts to estimate it and, apart from a few countries, reliable figures on incidence, morbidity, and mortality remains elusive. This retrospective autopsy-based observational study was carried out in the Department of Forensic Medicine of a tertiary care teaching institute of Haryana during 8-year time span from 2010 to 2017. A total of 55 fatal cases of snake bites which included 38 males and 17 females were used to study the trend of disease. As observed in the study, maximum cases were from 21-30 years age group of rural background having male preponderance and snake bite related deaths peaked during monsoon season. The other observations noticed were, hands and feet were widely getting affected due to snake bite while swelling and cellulitis were the commonest findings seen at the local site of bite. Maximum cases had single set of fang marks seen at the site of bite while there were some cases with no visible marks. A discussion on the findings of our study could be used to formulate a rough idea of burden of this neglected disease in Haryana state and there is an urgent need to educate the population regarding the risks and create awareness regarding seeking timely treatment for the same.

A study on predictors of nomophobia among undergraduate medical students of a Tertiary Care Teaching Institute in Kolkata, West Bengal

A study on predictors of nomophobia among undergraduate medical students of a Tertiary Care Teaching Institute in Kolkata, West Bengal

Umbilical granulomas and umbilical polyps: Comparative evaluation with silver nitrate cauterization and surgical excision

Background: Umbilical granuloma (UG) and umbilical polyps (UPs) are the most common umbilical abnormalities in neonates, causing inflammation and drainage. Aims: The aim of this study was to compare the effectiveness of the technique of silver nitrate cauterization and surgical excision on both UG and UP in pediatric patients. Settings and Design: A prospective study on UG and UP was carried out in a high-volume tertiary care teaching institute from January 2015 to December 2020. Materials and Methods: The patients were randomly distributed by chit method into two groups: Group A treated with surgical excision and Group B treated with silver nitrate cauterization. Statistical Analysis: The unpaired Student's t-test was used to find the existence of any statistical significance between the parameters of the two groups. Results: There were 105 patients with 59 males and 46 females. There were 70 patients in Group A and 35 in Group B. Most of the patients in both Group A and Group B were between >1 and 3 months of age group. Blood mixed umbilical discharge was the most common complaint. There was complete resolution of symptoms in 100% of patients in Group A. In Group B, success with first attempt with cauterization was achieved in 20 (57.14%) patients and 12 (34.29%) patients after the second attempt. In Group B, successful management was achieved in 2 (5.71%) patients after the third attempt combined with double ligation. In 1 (2.86%) patient, there was an incomplete response to cauterization. Minimal perilesional burn (in the umbilicus) was observed in four cases, two each in the UG and UP groups. Conclusions: The technique of silver nitrate cauterization for both UG and UP is a simple, less expensive, and safe procedure in experienced hands. Most patients show complete responses at the first attempt. In others, complete resolution is accomplished at the second or third attempt. Surgical excision should be performed in cases with an incomplete response and larger lesions.

A prospective interventional study to assess the impact of a 'structured compact training' on knowledge and skills of safe blood transfusion practices among nurses working in a tertiary care institute.

There is scarce information on the baseline knowledge and practices of nursing officers in relation to administration of blood components. We set out to evaluate the influence of training on their knowledge and skills through Kirkpatrick's levels of Training Evaluation. This interventional cross sectional study of 7months duration conducted in a tertiary care teaching institute involved 200 nursing officers. Hundred were assigned to study/intervention group and 100 were assigned to control/ comparison group by systematic random sampling. Knowledge was tested in different domains-blood components, pre-transfusion checks, transfusion process, post-transfusion process and blood administration practice. The baseline knowledge scores of intervention and control group were similar-15.16 ± 4.11 and 15.02 ± 4.75 (p=0.831). Post-intervention (phase I) after 1 month, the scores improved significantly for domain A, B, C, D and E to 4.3 ± 2.21 (p=0.0001), 3.46 ± 2.15 (p=0.0001), 7.02 ± 3.55 (p=0.0001), 2.51 ± 1.46 (p=0.0012), and 5.86 ± 3.61 (p=0.0018) respectively. In phase II, after 3 months of training, and the scores were significantly better from baseline for all domains except E. For domain A, B, C, D and E, scores were 3.82 ± 2.46 (p=0.0001), 3.53 ± 1.98 (p=0.0001), 7.38 ± 3.87 (p=0.0001), 2.48 ± 1.55 (p=0.0035), and 5.86 ± 3.61 (p=0.95) respectively. Our study showed that baseline scores were low in the nursing officers. No significant difference was found in baseline scores in subject and control population. However, post-intervention, a significant improvement in scores was observed in the study group across all domains.

Anti-Smoking Campaign – An Innovative Initiative against Smoking by Tertiary Care Teaching Institute of North India

Background: Smoking as a practice has been in existence since 5000 B.C. Smoking in public places was banned in India from 2nd October 2008. According to reports by WHO Tobacco kills more than 7 million people each year. Studies show that few people understand the specific health risks of tobacco use. The present study was done to analyze the impact of the Anti-smoking Campaign in the Institutes’ Campus and also to make people aware of the harmful effects of smoking and motivate them to quit this habit.Methodology: The campaign constituted of various interventions as screening &amp; collection, monitoring through CCTV Surveillance, imposing penalty as per the Act, Destruction of collected material, Behavioral change communication through Anti-smoking March, Public Lectures, Display of Pamphlets/Signages at various places in the institute &amp; No smoking Pledge and involvement of top management.Results: Total about 2613 Kgs of Tobacco and Tobacco products has been collected and destroyed from March 2014 till April 2020. On an average 40 Kilograms of Tobacco material is collected and destroyed per month. Till April 2020, 108 offenders who were caught smoking in the institute were penalized. ‘No smoking Pledge’ was taken by all the participants. Conclusion: The success achieved by the anti-smoking campaign in the Institute suggests that there is a dire need and challenge before us to launch such type of campaigns in all the institutes worldwide to curb this menace from our society.

Infection and utilization rates of bone allografts in a hospital-based musculoskeletal tissue bank in north India

BackgroundThe bone bank unit of interest in this article was established in January 2018, in a tertiary care teaching institute of north India. Aim of this article is to describe the sources of allografts obtained, discard rates of allografts and infection rates in the recipients after use. Material and methodsAll the relevant details of donors and recipients were maintained, and donors were screened for standard inclusion and exclusion criteria before obtaining the grafts. Aerobic culture was performed before storage and just prior to use. Samples with incomplete documentation, incomplete donor screening or positive cultures were discarded. Data on surgical site infection in recipients was collected from hospital records retrospectively. Initially ELISA based serological tests were used for screening. Donor has to undergo these tests again after 6 months to account for the window period of proliferation of viruses. Nucleic acid amplification tests (NAAT) for these viral agents were introduced in the hospital in May 2018. ResultsAllografts from a total of 196 donors were obtained in the bone bank over 2 years. Major source of bone was femoral heads harvested during total hip arthroplasty or hemi-arthroplasty. 44(22.4%) grafts had to be discarded. 95 allografts were used in 88 patients during this time. Most common indication for use was surgery for bone tumors (40%), followed by complex primary or revision arthroplasty (30.5%). Three (3.4%) recipients developed deep infection postoperatively. ConclusionFrozen allograft bone from hospital based bone banks is a reliable source of allografts. When meticulous precautions for sterility are followed, risk of infection is low. Monitoring of such bone banks should fall within a framework of the local legislature. Incomplete documentation is the major reason for wastage of the samples obtained. NAAT may be useful in screening of donors, as it reduces the wastage and the holding time of the allografts.

A Randomized Controlled Trial of High Rate rTMS Versus rTMS and Amitriptyline in Chronic Migraine

The patients with chronic migraine (CM) respond poorly to pharmacological agents including tricyclic antidepressants, beta-blockers, anticonvulsants, calcium channel blockers, flunarizine, and melatonin. The combination of 2 or more pharmacological agents has not shown better efficacy but increased side effects. High rate repetitive transcranial magnetic stimulation (rTMS) has been reported effective in episodic migraine and converts CM to episodic migraine. A combination of high rate rTMS with a pharmacological agent may be more effective compared to rTMS alone. We evaluate the efficacy and safety of 10 Hz rTMS compared to rTMS and amitriptyline in CM. Randomized controlled trial. Tertiary care teaching institute in India. Patients with CM as per International Classification of Headache Disorder third edition (ICHD-3) beta criteria were included whose age was between 18 years and 55 years. CM was defined if there were 15 headache days per month and at least 8 of these attacks having migraine characteristics for a period of more than 3 months. Patients with major psychiatric, other neurological or systemic disease, and those on migraine prophylaxis were excluded. The demographic details, frequency of headache attacks and headache days per month, migraine triggers, and associated symptoms were noted. The severity of headache was noted using a 0-10 Visual Analog Scale and the number of abortive drugs per month was noted. CM patients were randomly assigned to rTMS (group I) or rTMS and amitriptyline (group II). 10 Hz rTMS was applied using a figure of eight magnetic stimulation coil. The coil was placed over the left frontal cortex corresponding to the hot spot of the right abductor digiti minimi, which is approximately 7 cm lateral from the midline and 2 cm anterior to interaural line. The motor threshold was measured, and 70% of it was used for rTMS. Ten trains of 10 Hz rTMS, each train comprising of 60 pulses with an inter-train interval of 45 seconds were delivered in one session. Three such sessions were delivered on an alternate day and were repeated every month for 3 months. Amitriptyline was prescribed in a dose of 10mg, increased to 25mg after 2 weeks; thereafter increase in dose to 50 mg was optional. The primary outcome was > 50% reduction in headache days, and secondary outcomes were the reduction in severity of headache, abortive drug, and side effects. Forty-one patients were included in group I and 42 in group II, and their baseline characteristics were comparable. A higher proportion of group II patients had more than 50% reduction in headache days at 3 months (76.2 vs 31.7%; P < 0.001) compared to group I. More than 50% reduction in headache severity was also greater in group II compared to group I at 3 months (47.6% vs 19.5%; P = 0.01). Side effects were comparable, and none had to be withdrawn. A higher proportion of patients was shifted from group I to group II. Combination of rTMS and amitriptyline is safe and more effective in CM compared to rTMS alone.

Role of Neuroimaging in COVID 19 Infection—A Retrospective Study

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a member of the family of coronaviruses, induces COVID-19 disease which is predominantly a respiratory illness. Several authors have reported neurological manifestations such as acute venous and arterial strokes and rarely acute disseminated encephalomyelitis, hemorrhagic posterior reversible encephalopathy syndrome, and acute inflammatory demyelinating polyneuropathy by studying magnetic resonance imaging of brain parenchymal signal abnormalities in patients with COVID-19. Owing to sparsity of literature on extrapulmonary manifestation of COVID, it is imperative to study the mechanism of neuronal invasion and manifestations of COVID-19. This study aimed to assess and correlate neurological manifestations in patients with COVID using imaging findings on computed tomography and magnetic resonance images. A retrospective observational study was conducted among 80 patients who tested positive for COVID-19 disease via a reverse transcription–polymerase chain reaction (RT-PCR) test in a tertiary care teaching institute in Pimpri, India. Most patients presented with acute arterial and venous strokes. Arterial stroke was the most prevalent finding; nearly 42.50% showed imaging findings consistent with arterial stroke; 25% patients had findings of venous stroke. Meningitis and spontaneous hemorrhage were found in 10% of cases. Rare complications such as acute disseminated encephalomyelitis comprised 7.50%, and encephalitis was found in 5%. This study highlights the need for increased neuroimaging in suspected patients to alert the treating physicians about the neurological complications. As the conventional RT-PCR and serum tests are unremarkable in the early onset of COVID-19, it is important to have a multidisciplinary approach and more neurology consultations in COVID-19 suspected patients with an emphasis on prompt neuroimaging to prevent potential life-threatening complications. To alert the attending physician about neurological involvement in patients with COVID-19, it is vital that nursing staff is aware about the neurological manifestations of COVID-19 so that they can recognize change in patients' neurological status without any undue time delay.

English

BACKGROUND Public health emergencies including a disaster are inevitable. Moreover, the vulnerability and health impacts are more profound in urban densely populated dwellings. Household preparedness for public health emergencies need to be focused to minimize the morbidity and mortality associated with such situations. METHODS An urban community, situated in field practice area of a tertiary care teaching institute of Ahmedabad, Gujarat was approached for a cross-sectional study through door to door structured interviews. A pre-designed questionnaire was administered to assess the knowledge as well as preparedness for public health emergencies among the respondents. The adult representative family member from each of the selected households formed the sampling unit. Statistical tests of association and logistic regression analysis were used to find our relationship between household preparedness and some of the independent factors. RESULTS From a total of 405 households, majority of the respondents were male (65.7 %), married (92.1 %), having secondary level education (43.7 %) and belonged to socio-economic class IV (37.8 %). Only 44 % of the respondents had experienced any form of public health emergency in the past and only 14.6 % had an experience of relief work. “Flash floods following heavy rains” and “earthquake” were the commonest disaster experienced by the respondents. None of the surveyed households had first aid kit or a fire-extinguisher. Majority of the respondents (N = 280, 69.1 %) were aware of emergency contact numbers in case of public health emergencies. The overall household level preparedness was only 12.59 %. Perceived susceptibility to public health emergencies and household preparedness had significant statistical associations with education, occupation, type of house and socio-economic class. CONCLUSIONS Education, occupation, and social class play roles in both perception as well as household preparedness for public health emergencies. A very low level of preparedness and their possible factors should be addressed through adequate channels so that the damage due to such emergencies could be minimized. KEYWORDS Disaster, Household Preparedness, Public Health Emergency, Urban Community