Current Medical Issues

Gupta D.K., Chaudhuri A., Gaine D.

Abstract Self-directed learning (SDL), which emphasizes the need for students to take ownership of their learning, has become a crucial part of medical education. With the increasing complexity of health care, SDL is seen as a crucial skill for fostering lifelong learning and adapting to new challenges. This systematic review examines the current landscape of SDL in undergraduate medical education, exploring its effectiveness, implementation strategies, and areas for future development. A methodical exploration was carried out within the PubMed database to locate pertinent research articles released between 2012 and 2024. Studies that reported results pertaining to academic achievement, clinical competence, or student perspectives and that concentrated on SDL in undergraduate medical education were included. Two reviewers independently extracted the data, evaluated its quality, and synthesized the results thematically. In all, twenty-three papers were covered in this study. The findings indicate SDL positively impacts students’ academic performance and clinical skills, with many students reporting increased engagement and motivation. Effective implementation strategies included integrating SDL into the curriculum, providing faculty support, and utilizing digital tools to enhance learning. However, the review also identified significant heterogeneity in the definition and assessment of SDL across studies, as well as challenges related to student self-regulation and faculty preparedness. SDL is a useful method in medical education for undergraduates since it helps students become self-reflective, independent practitioners. To fully comprehend its long-term effects, however, longitudinal research, faculty development initiatives, and standardized SDL frameworks are required.

Penugonda A.J., Biswas D., Palani M.T., Priya S., Subaschandrabose R.K., Valiaveetil K.A., Antonisamy B., Kompithra R.Z., Mathew L.G., Moorthy M.

Abstract Background: Dynamics, severity, and immune response of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection vary between children and adults. There are only a few reports on the differential impact of variants in children, and none reported from low-and-middle-income countries. Materials and Methods: Between November 2020 and August 2021, we enrolled children under 16 years testing positive for SARS-CoV-2 by polymerase chain reaction (PCR). We compared virus characteristics (viral load, virus variant - Wild-type or Delta), disease severity (asymptomatic, mild-to-moderate, and severe), and immunity levels to the virus (anti-N and anti-S) after 4–6 weeks. Results: Of 79 children recruited, 29%, 59%, and 11% had asymptomatic, mild-to moderate, or severe presentations, respectively. Wild-type and delta variants presented with similar disease severity. For both variants, anti-S antibody levels were higher than anti-N antibody levels (P < 0.0001). Anti-S was also higher than anti-N among asymptomatic (P = 0.02) and mild-to-moderate disease (P < 0.0001). Children with higher virus loads had higher levels of both anti-S and anti-N antibodies (quartile [QS]1 versus QS3, P < 0.05). Among low (QS3) virus loads, wild-type anti-S levels were higher than delta infected (P = 0.003). In mild-to-moderate disease, the mean Ct value of wild type (32.5) was higher than that of delta infection (25.0) (P = 0.0083). Conclusions: In children, the antibody response is driven by viral load. In mild-to-moderate disease, higher loads of Delta variant of concern resulted in robust antibody response that was absent in severe disease. These results could inform potential responses to future SARS-CoV-2 variants and may guide decisions on targeted vaccination in children.

Hossain A., Goswami P., Mitra K., Taraphdar P., Sannigrahi S., Dandapat S.

Abstract Introduction: The inclusion of the Injectable Contraceptive, Antara Programme into family planning services signals a shift in the nation’s perspective and helps recipients achieve their goals for reproductive health. Depot medroxyprogesterone acetate (DMPA), marketed as Antara injection is considered a highly effective, long-acting reversible contraceptive, but it has limited acceptability. Hence the study was done to explore the reasons for dropouts of injection Antara from the perspective of beneficiaries and service providers in Antara clinics of Burdwan Municipal area of Purba-Bardhaman district, West-Bengal. Methodology: A descriptive type of qualitative research was conducted from February to July 2023 through in-depth interviews (IDIs) of 40 beneficiaries and focus group discussion (FGD) among 10 ANMs-Auxiliary Nurse Midwives. Data collection was done by audio recording of each IDI, FGD, and as well as by taking notes after achieving consent. Finally, inductive thematic analysis was carried out. Results: The reasons for dropouts of Antara injections among beneficiaries were found to be side effects (irregular bleeding, abdominal pain), lack of awareness, and familial barriers. Additionally, the significant challenge of recalling and visiting the clinic again for repeated injections was also recognized as a hindrance to sustained usage. Service providers cited stockouts, procurement issues, and lack of training and counseling as reasons for discontinuation. Both beneficiaries and service providers cited sociocultural factors, and lack of knowledge as a barrier to consistent use of Antara injections. Conclusions: The current study has shed some insight into the factors for the dropouts of Antara as a method of family planning. The study’s findings are anticipated to be applied in formulating regulations that will increase compliance with Antara and make the program more acceptable and consumer-friendly.

Anand D., Prasad T.K., Sudharsanan A., Priyadharsini K.S.

Chakraborty D., Biswas D., Puri S., Malik A., Eqbal S., Aleena I., Ghosh R., Dey S., Sen P., Paul S.

Abstract Background: Stroke is already an epidemic, and the awareness about stroke, prevalence of risk factors, presentations, response to treatment, and outcome are variable in different parts of a country. We aimed to study the details of acute stroke patients who presented to a tertiary care private hospital in eastern India. We wanted to know how the patient’s family members, as well as private doctors in the community, responded to the acute stroke. Methodology: In this prospective and retrospective study for 2 years, from September 2021 to August 2023, we included patients over 18 years of age who presented with acute stroke symptoms within 24 h and were admitted to our hospital. In relation to an acute stroke, we noted patient demographics, clinical, radiological, and hematological details, treatment, and outcome (in hospital and after 3 months). Results: We included 366 patients and found that 74% were hypertensives and 50% were diabetics. We thrombolyzed 24 patients and performed mechanical thrombectomy on eight of them. In a significant number of cases, patients arrived late (only 45 out of 366 were candidates for acute stroke intervention), and attendants were not immediately ready with their consent for 15 of these 45 patients. Conclusion: We urgently need more public awareness programs to educate everyone about the “acute stroke pathway” and help them confidently accept the benefits and drawbacks of acute stroke intervention. We need to institute more stroke prevention clinics at the earliest to address the modifiable risk factors of stroke.

Geethanjali R.A., Prabhakaran B., Sridevi S.K., Priyadharshini L., Dinesh V., Archana V.

Abstract Lymphomas encompass a group of malignancies involving the lymphoreticular system, while extranodal non-Hodgkin’s lymphomas affect any organ or tissue excluding lymph nodes and the spleen. Extranodal lymphomas (ENLs) have different characteristics and often have distinct pathogenic mechanisms and clinical behavior, which has a significant impact in their diagnosis and treatment. This unique case series highlights the difficulty in diagnosing ENL cases from different sites because they clinicoradiologically mimic inflammatory pathology. Although clinical diagnosis, imaging studies, and histopathological diagnosis help arrive at a final diagnosis, this diagnostic dilemma should be kept in mind and additional workup for biopsy should be considered. Here, we present five cases which had ENLs in the gastrointestinal tract, tonsils, thyroid gland, and testis for which histopathology needs ancillary studies like immunohistochemistry to confirm the tissue diagnosis. It is important to note that any delay in diagnosis will have an impact in the appropriate treatment of the patients in such instances.

Arul A.O., Karthik K.R., Christopher D.J.

Abstract Background: Pulmonary mucormycosis is a rare life-threatening fungal infection that primarily affects immunocompromised individuals, leading to severe morbidity and high mortality. The delta wave of the COVID-19 pandemic in India witnessed an alarming surge in mucormycosis cases, posing a significant health threat nationwide. This study aims to evaluate the risk factors, clinical features, radiological presentation, microbiology, diagnosis, complications, and outcomes of patients with pulmonary mucormycosis before and during the COVID-19 pandemic. Methodology: This study retrospectively analyzed case records of patients diagnosed with pulmonary mucormycosis who presented to the departments of pulmonary medicine, respiratory medicine, and infectious diseases at a large 3000-bed tertiary teaching hospital in Southern India between 2012 and 2022. Results: Among the 37 patients with pulmonary mucormycosis, 24 (65%) were male, and 13 (35%) were female, with a mean age of presentation of 50.5 years. There were 25 cases of non-COVID-19-associated pulmonary mucormycosis (CAPM) and 12 cases of CAPM. The most common risk factor was diabetes in 34 patients (91%), with the mean glycosylated hemoglobin A1C (HbA1C) at presentation being 10.28. History of steroid use was present in 9 (24%) patients, predominantly among those with CAPM. Cough was the most frequent presenting symptom seen in 27 (73%), followed by fever 24 (64%), dyspnea 11 (30%), and hemoptysis 6 (16%). The most common computed tomography (CT) scan findings were consolidations and cavitations. Majority of the samples 25/37 (67%) were acquired using bronchoscopy. Rhizopus arrhizus was the most commonly isolated species. All patients received systemic antifungal therapy with amphotericin and posaconazole. However, only four patients (11%) underwent combined surgical treatment along with appropriate antifungal agents. The overall mortality in this study was 15/37 (41%). Conclusions: Pulmonary mucormycosis requires a high index of suspicion, and a delay in the diagnosis leads to complications and poor outcomes. Uncontrolled diabetes mellitus and chronic kidney disease were the conventional predisposing factors for pulmonary mucormycosis. However, CAPM was associated with both diabetes and steroid usage. Early identification of the disease is the key, and an early referral for bronchoscopy in a susceptible host can shorten the time to diagnosis and probably improve outcomes. Treatment requires a multipronged approach with control of risk factors, appropriate antifungal therapy, and aggressive early surgery where feasible.

Tikhile A., Tyagi S., Mulay S., Ursekar R.

Abstract Background: Leave against medical advice (LAMA) is a constant source of frustration for all emergency physicians irrespective of the setup. These patients have higher healthcare costs and readmission rates and even carry a higher morbidity and mortality. The literature on the subject from India is limited. We conducted this study to find the proportion of patients LAMA from the emergency medicine department (EMD). Materials and Methods: The study was conducted at an EMD of a tertiary care hospital attached to a medical college in western Maharashtra with an aim to estimate the incidence of LAMA cases and describe various characteristics of these patients. Results: A total of 28,802 patients visited EMD during the study period and 6582 patients (22.8%) left against medical advice. Majority of LAMA patients were male (58.3%) and belonged to the age group of 18–40 (52.9%) years. Maximum patients who left against medical advice belonged to the basic specialties such as internal medicine, general surgery, and orthopedics. Among LAMA patients, majority were discharged between 5 PM and 9 AM (n = 4490; 68.2%). Symptomatic improvement (46.8%) and financial constraints (17.3%) were the reason why majority of patients left against medical advice. Conclusion: LAMA remains a significant problem globally. There are very limited data from India on the demography of LAMA patients and reasons for patients choosing to LAMA. Our study provides a few insights into the issue, but large-scale prospective studies are required to plan policies which can help in reducing the LAMA burden.

Samajdar S.S., Chatterjee R., Mukherjee S., Dey A., Saboo B., Pal J., Joshi S., Chatterjee N.

Abstract Artificial intelligence (AI) is a milestone technological advancement that enables computers and machines to simulate human intelligence and problem-solving capabilities. This article serves to give a broad overview of the application of AI in medicine including the current applications and future. AI shows promise in changing the field of medical practice although its practical implications are still in their infancy and need further exploration. However, AI is not without limitations and this article also tries to address them along with suggesting solutions by which AI can advance healthcare for betterment with mass benefit.

Saraswathi S., Mukhopadhyay A., Sumana M., Debata I., Panda P.S.

Abstract Background: Diabetes typically projects the Iceberg phenomenon, with most cases being hidden. The Indian diabetes risk score (IDRS) by the Madras diabetic research foundation is a validated and useful screening tool that identifies high-risk people in primary care settings. The study aimed to assess the risk of type 2 diabetes mellitus among adults in an urban slum in Bengaluru, Karnataka with the Indian diabetic risk score (IDRS). Methodology: A cross-sectional study was carried out in the community involving adults, aged 18 years and above, in the urban field practice area for 3 months. A pretested questionnaire with the IDRS tool was used for data collection. Results: Of 300 participants, 53% were males and 47% were females. The diabetes risk, as per the IDRS scores, was high in 58.2%, moderate in 27.2%, and low in 14.6% of the population. The diabetes risk was associated significantly with gender, age, occupational status, physical activity, abdominal circumference, and family history (P < 0.00001). Conclusion: Screening by the IDRS tool showed that the risk of developing diabetes was moderate to high in the study population.

Al-Aamri B., AL Breiki A., Hazra D., Al-Aamri T., Al-Shehi M.

Abstract Background: Febrile neutropenia, a critical concern in chemotherapy-treated oncology patients, demands swift and guideline-based management. This study evaluated guideline adherence and clinical outcomes in the management of febrile neutropenia in oncology patients in the emergency department (ED). Methods: This retrospective study was conducted over 4 years. The primary focus was the evaluation of adherence to guidelines for patient disposition and clinical outcomes. Data were retrieved from the hospital’s electronic records, systematically organized, and analyzed. Results: A total of 121 febrile neutropenic cases were included in the study. Of these, 52.9% were classified as low risk, with 44.6% having hematological malignancies and 55.4% having solid malignancies. Most patients (89.3%) presented with active cancer, and the mean neutrophil count was 0.18. High-risk patients exhibited significantly higher rates of positive blood cultures (31.6% vs. 1.6%) and positive urine cultures (20.8% vs. 7.7%). Chest X-rays were positive in 5.5% of low-risk patients and 23.2% of high-risk patients. Fungal infection rates were 1.6% in low-risk patients and 29.8% in high-risk patients. Complications were more frequent in high-risk patients, including sepsis-induced hypotension in 6.3% of low-risk patients and 43.9% of high-risk patients. Deaths occurred in 21.1% of high-risk patients, and intensive care unit (ICU) admissions were 24.6% in the high-risk group, with no ICU admissions in the low-risk group. Binary logistic regression revealed that male patients had a 60% lower risk of guideline discordance than female patients (odds ratio [OR]: 0.400, 95% confidence interval [CI]: 0.180-0.891, P = 0.025), whereas diabetic patients had a 75% lower risk than nondiabetic patients (OR: 0.254, 95% CI: 0.069–0.934, P = 0.039). Conclusion: As expected, high-risk patients demonstrated greater illness severity than low-risk patients, with higher rates of admission, sepsis-induced hypotension, and mortality.

Sivakumar P., Rajkumar P., Sridevi S.K., Priyadharshini L., Elancheran M.

Abstract Amyloidosis encompasses a diverse group of conditions characterized by the extracellular accumulation of misfolded, insoluble proteinaceous material with a cross-beta-pleated sheet structure, leading to organ damage. Due to its varied origins and manifestations, different diagnostic tools are required for accurate diagnosis. A definitive diagnosis is achieved through biopsy, revealing amyloid deposits in the affected tissue. When stained with hematoxylin and eosin, amyloid material appears as amorphous eosinophilic acellular deposits. These morphological features are shared with other substances such as collagen, fibrin, plasma, hyaline globules, hyalinization, and necrosis, posing a diagnostic challenge for pathologists. However, morphology, surrounding tissue morphology, and special stains can differentiate between amyloid and amyloid-like material. This case series of six cases highlights the appropriate staining techniques for differentiating amyloid from amyloid-like material in histopathology.

Almamari I.K., Hazra D., Al-Alawi A.K.

Abstract Background: Medical clearance for patients presenting with psychiatric-like illnesses has been a topic of debate for years. This study aimed to determine the predictors of diagnosing psychiatric illness in the emergency department (ED). Methods: The study included patients aged ≥13 years presenting to the adult ED with psychiatric-like illness over 1 year (January 01, 2019–December 31, 2019). Medical charts were reviewed, and multiple variables were coded and analyzed. Results: Our study included 361 patients, constituting 0.89% of the total ED visits. The majority (335 patients, 92.8%) were diagnosed with primary psychiatric illnesses, while 26 patients (7.2%) had underlying medical conditions contributing to their symptoms. Bivariate and multivariate logistic regression analysis identified the predictors for initial psychiatric diagnoses, including abnormal behavior (odd’s ratio [OR]: 8.29; 95% confidence interval [CI]: 2.04–33.65; P < 0.01) and substance abuse (adjusted OR: 17.27; 95% CI: 3.88–76.88; P < 0.01). Notable findings involved family history or previous psychiatric illness (OR: 2.32; 95% CI: 0.59–6.09; P < 0.01), absence of medical comorbidities (adjusted OR: 2.47; 95% CI: 1.05–5.86; P < 0.01), and no new medication initiation before illness (OR: 6.43; 95% CI: 1.52–27.18; P < 0.01), normal sensorium (adjusted OR: 2.84; 95% CI: 0.81–10.00; P < 0.01) and intact orientation (adjusted OR: 6.73; 95% CI: 1.24–36.42; P < 0.01) demonstrated statistically significant predictors of an initial psychiatric diagnosis in the ED. Conclusion: Significant predictors of initial psychiatric illness included abnormal behavior, substance abuse, family psychiatric history, absence of major medical conditions, no recent medication changes before illness onset, normal sensorium and orientation, and normal laboratory markers at presentation.

Eddula V., Matety A.R., Deepthi C.S., Chaudhuri S., Pappula V.

Abstract Background: This cross-sectional observational study aimed to analyze the clinical and mycological characteristics of dermatophytosis in patients visiting the outpatient clinic of the department of dermatology at a tertiary care hospital in Telangana. Methodology: The study was conducted from November 2017 to July 2019, involving patients clinically diagnosed with dermatophytosis. Data collection included detailed demographic and clinical information and laboratory investigations such as direct microscopy, fungal culture, and hematological examinations. Specimens were collected from skin lesions, nails, and hair, processed using appropriate methods, and subjected to culture and microscopic examination. Descriptive statistics was performed to present the findings. Results: A total of 100 participants were recruited, with a median age of 24 years. The majority were male (n = 75, 75%) and students (n = 47, 47%). Most participants (n = 71, 71%) presented with extensive tinea followed by tinea corporis and tinea capitis. Trichophyton mentagrophytes was the most isolated variant (n = 42, 97.7%) among positive cultures. Conclusion: Young male populations are the most common victims in this region. The significant number of tinea cases and the high prevalence of T. mentagrophytes underscore the necessity for precise diagnosis and effective management strategies in treating dermatophytosis.