Publications

As exhorted by the Bhagavad Gita, physicians do their best karma to manage a patient. The uncertainties and chance can never be altogether eliminated from medical practice despite using best practices because of inherent human and environmental variations. No management is perfect with a 100% probability of success in all cases. The outcome remains with him. The physicians and the patients need to be reminded of this limitation all the time.

A 62-year-old female, a known case of hypothyroidism, diabetes mellitus, and varicose veins, presented with a complaint of swelling of both lower limbs and ulceration on the left leg for 2 months. She also complained of dyspnea on exertion. As per the history, ulcer began as a pea-sized blackish discoloration on the left lower limb just above the ankle joint on medial aspect (Fig. 1) and increased to 6 × 8 cm, with irregular and raised margins (Fig. 2). The base of ulcer had whitish-yellow exudate with no healthy granulation tissue. The surrounding skin revealed hyperpigmentation. On examination, she had bilateral lower limb pitting edema-grade IV (Fig. 3), extending from above ankle to mid-calf region. The skin appeared to be shiny. Investigations revealed microcytic hypochromic anemia and high fructosamine levels. There was no history of trauma. Anti-HIV was negative. A biopsy was taken, thus revealing it to be a stasis ulcer. Our initial assessment for the causes of this ulcer included anemia resulting in poor perfusion, venous insufficiency exacerbated by varicose veins, and hypothyroidism or diabetes mellitus contributing to poor wound healing.

A 34-year-old female, a diagnosed case of chronic liver disease, presented to the emergency department with yellowish discoloration of the skin, abdominal distension, and bilateral lower limb swelling for 1 week. She also complained of painless swelling over her umbilicus for the last 6 months. On examination, she was conscious, oriented, and hemodynamically stable. General physical examination revealed icterus and bilateral pitting pedal edema up to the knees. On abdominal examination, the abdomen was distended and shifting dullness was present. A large swelling of approximately 7 × 5 cm was present over the anterior abdominal wall with a palpable thrill and an audible Cruveilhier-Baumgarten murmur (Figs 1A and B). The swelling was not reducible and had no signs of inflammation. The rest of the systemic examination was normal.

We read with interest an article titled "Estimation of Predictors of Mortality in Patients with Acute Respiratory Failure Secondary to Chronic Obstructive Pulmonary Disease Admitted in Tertiary Care Center" published in the Journal of the Association of Physicians of India.1 We have the following comments to offer.

We would like to highlight the clinical spectrum of human metapneumovirus (hMPV) infection in 11 patients diagnosed in the year 2024 at our center, clarifying that it is neither new nor does it resemble COVID-19. Our observations aim to provide insights and contribute to a clearer understanding of its role in respiratory diseases.

BACKGROUND: Diabetes mellitus is a global epidemic, with an increasing number of undiagnosed individuals, particularly those with type 2 diabetes mellitus (T2DM). However, there is limited data on treatment delays among drug-naïve patients in India. The present study aimed to ascertain the incidence of treatment delay among drug-naïve patients and the sequence of alternate treatments sought since diagnosis.

MATERIALS AND METHODS: This cross-sectional, multicentric, observational study was conducted across 10 primary and secondary care settings in Mumbai from October 2023 to April 2024. Adults of either gender, diagnosed with T2DM, who are drug-naïve, were included. Patient's demographic data, comorbidities, current medications, and medical history were recorded in an electronic case report form and analyzed.

RESULTS: Of the 625 patients enrolled, 591 completed the study. The mean age of the patients was 46.7 years. The proportion of male patients was 54.1%. Overall, 57% of patients had no treatment delays, while 43% experienced delays of ≥3 months. Patients with treatment delays of ≥3 months used alternative/traditional medicines (56.0%), with Ayurveda being preferred by 56.7% of these patients.

CONCLUSION: The study indicated considerable treatment delays among drug-naïve patients in India.

INTRODUCTION: Medical students often experience high levels of stress, anxiety, and depression due to the demanding nature of their studies. Academic pressure can be a significant factor in the development of stress, depression, and anxiety among medical students. The situation may deteriorate if these students have personal, academic, or institutional problems. Hence, this study was planned to identify the prevalence of mental health problems among medical students and their association with personal, academic, and institutional issues.

MATERIALS AND METHODS: We conducted a cross-sectional study among medical students from Sangli District, Maharashtra, India. Data were collected using a predesigned and pretested questionnaire. Chi-square and multivariate regression analysis were used for the statistical analysis. Microsoft Office 365 and SPSS 22 were used for analysis purposes.

RESULTS: A significant proportion of medical students reported experiencing symptoms of mental health challenges: 50.0% depression, 73.6% anxiety, and 22.2% stress. The significant predictors for depression were birth order, physical health, and religiosity; for anxiety-age, upbringing, and stress; gender, year in which they are studying, upbringing, birth order, and physical health. By using binary logistic regression, it was found that personal issues are significant predictors related to depression, anxiety, and stress.

CONCLUSION: Various academic, personal, and institutional issues were contributing to mental health problems among medical students. A robust support system is required to identify and alleviate these problems, which can empower them to cope with challenges and succeed in their academic challenges.

BACKGROUND: Sphenopalatine ganglion (SPG) block combined with occipital nerve block can attenuate the hemodynamic response to the painful stimulus of skull pin application.

MATERIALS AND METHODS: About 60 patients, aged 18-65 years, were randomly assigned to two groups. All patients were classified as American Society of Anesthesiologists (ASA) grades I and II, had a Glasgow Coma Scale (GCS) score of 15/15, and were scheduled for elective craniotomy. Group S was given a scalp block with 0.25% bupivacaine, while group SPG was given a bilateral transnasal SPG block with 0.5% bupivacaine, along with greater and lesser occipital nerve blocks using 0.25% bupivacaine. The primary objective was to assess the change in mean arterial pressure (MAP) following skull pin application. The dose of propofol used as rescue was also noted.

RESULTS: All 60 patients completed the study. The MAP differed significantly in group SPG from prior to pin insertion to 2 (p-value = 0.034) and 3 minutes (p-value = 0.026) following pin insertion. The maximum percent change from the prior to pin insertion timepoint was observed at 2 minutes (p < 0.001). The heart rate (HR) also differed significantly in group SPG from the prior to pin insertion to 2 (p-value = 0.001) and 3 (p-value = 0.006) minutes following pin insertion. The maximum percent change from the prior to pin insertion was observed at 2 minutes following pin insertion (p < 0.001). There was no significant difference in the percent change in HR between the two groups from prior to pin insertion to any of the timepoints.

CONCLUSION: Bilateral SPG block with posterior scalp block can attenuate the hemodynamic response following skull pin insertion in patients undergoing craniotomy under general anesthesia.

BACKGROUND: Liver fibrosis worsens prognosis in metabolic dysfunction-associated fatty liver disease (MAFLD). FibroScan® is the most widely used noninvasive tool for evaluating fibrosis, but performing this assessment requires specialized equipment and expertise. This study aimed to assess the potential of four additional noninvasive techniques for diagnosing liver fibrosis that rely on routine laboratory measurements, that is, fibrosis (FIB)-4 score, FIB-5 score, aspartate aminotransferase (AST)/alanine transaminase (ALT) ratio, and the aspartate aminotransferase to platelet ratio index (APRI).

METHODS: This study was performed following a cross-sectional observational design at a tertiary care hospital in India. The study included adult patients who were observed to have elevated serum AST and ALT levels and fatty deposition on ultrasonography, as these indicate a risk for liver fibrosis, that is, MAFLD or metabolic dysfunction-associated steatohepatitis. The specificity and sensitivity of FIB-4, FIB-5, APRI, and AST/ALT ratio were compared with those of FibroScan® (FibroScan® 502, Echosens, Paris, France).

RESULTS: Among the alternative noninvasive methods, FIB-4 had the highest specificity (78%) and sensitivity (85%) that were closest to the specificity (88%) and sensitivity (92%) of FibroScan®. FIB-5 and APRI demonstrated moderate sensitivity (80% and 76%, respectively) and specificity (75 and 70%, respectively). The AST/ALT ratio had relatively poor diagnostic capability, with a specificity of 60% and sensitivity of 65%. The area under the curve (AUC) for the methods being compared was 0.82 (FIB-4), 0.79 (FIB-5), 0.74 (APRI), and 0.65 (AST/ALT ratio).

CONCLUSION: FibroScan® is the preferred option for evaluating liver fibrosis in patients with MAFLD. However, when unavailable, FIB-4 may be the next most reliable alternative for identifying or excluding advanced fibrosis. Other methods (FIB-5, APRI, and AST/ALT) are less accurate.

BACKGROUND: Liver cirrhosis indicates inflammation, necrosis, as well as fibrosis, resulting in progressively decreasing liver function. As the disease advances from a compensated to a decompensated stage, patients experience severe clinical complications, that result in elevated mortality, as well as morbidity, rates. Accurate predicting short-term mortality is essential for making clinical decisions, particularly when it comes to liver transplantation (LT). Several scores, encompassing model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP), as well as their variants, along with specific biomarkers such as red cell distribution width (RDW) alongside RDW to platelet ratio (RPR), have been proposed for assessing these patients' prognosis. However, comparative effectiveness of these scoring systems in predicting outcomes remains underexplored.

METHODS: This study involved a cohort of participants diagnosed with cirrhosis, who were evaluated to identify the most reliable predictors of 30-day mortality. The study compared the efficacy of multiple scoring systems, including CTP, MELD, model for end-stage liver disease-sodium (MELD-Na), model for end-stage liver disease-high-density lipoprotein cholesterol (MELD-HDLc), RDW, and RPR, by analyzing their correlation with patient outcomes. Data were collected on demographic profiles, clinical findings, and laboratory markers to calculate these scores and assess their predictive accuracy.

RESULTS: The study found that among the various scores, the MELD as well as MELD-Na scores demonstrated the highest accuracy predicting 30-day mortality in liver cirrhosis patients. Alcohol emerged as the predominant etiology of cirrhosis, and there was a significant male predominance in the cohort. The results were consistent with existing literature, confirming the reliability of MELD alongside MELD-Na as stronger prognostic tools compared to the CTP score and other markers.

CONCLUSION: MELD along with MELD-Na scores constitute reliable indicators of mortality over the short term in individuals with cirrhosis and should be preferred in practice for assessing the need for LT and other critical interventions. These findings underscore the importance of using evidence-based scoring systems to improve patient management and outcomes in liver cirrhosis, a condition with a high global mortality burden.