Annals of African Medicine
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   Table of Contents - Current issue
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January-March 2023
Volume 22 | Issue 1
Page Nos. 1-130

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ORIGINAL ARTICLES  

Prospective study of pyrexia with pregnancy p. 1
Bhavana N Mewada, Dimple Gandhi, Farheen Diwan, Paresh Naranbhai Panchal
DOI:10.4103/aam.aam_75_20  
Objectives: Fever in pregnancy is a common clinical problem that increases the risk of morbidity for the mother and fetus. We studied variable medical complications of pregnant women suffering from fever and possible fetal complications. Materials and Methods: A prospective observational study of pyrexia with pregnancy in 50 patients admitted to our hospital irrespective of age, parity, reproductive characteristics, and socioeconomical conditions. Results: First, the majority group of the patients were of urinary tract infections and upper respiratory tract infections. The second majority group of the patients were of malaria, dengue, enteric fever, and pyrexia of unknown origin. Most of the etiologies of pyrexia were preventable. The majority of the patients had a low and moderate grade of pyrexia. Small for gestational age was the most common adverse pregnancy outcome and there were six perinatal deaths. Conclusion: Our study depicts that a wide range of maternal medical complications, as well as fetal and neonatal complications, occur due to pyrexia in pregnancy from various etiology.
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Changes in opthalmic artery doppler velocimetry in women with preeclampsia in Kano, Nigeria p. 5
Mustapha Shu’aibu Hikima, Mansur Yahuza Adamu, Yusuf Lawal, Kabiru Isyaku, Anas Isma’il
DOI:10.4103/aam.aam_26_21  
Background: Hypertensive disorders in pregnancy are among the most serious complications of pregnancy and represent important contributors to maternal and neonatal morbidity and mortality worldwide. Preeclampsia (PE)–eclampsia syndrome is the most important hypertensive gestational condition. Maternal ophthalmic artery Doppler velocimetry enables the identification of pregnant women with increased cerebral blood flow who are at risk of developing severe PE and eclampsia. Hence the need to determine the changes in ophthalmic artery Doppler velocimetric indices in PE in Kano,Nigeria becomes paramount. Materials and Methods: Ninety-six patients with the clinical diagnosis of PE and 96 normotensive pregnant controls between 20 and 40 weeks' gestational age were recruited for this study. Ophthalmic artery Doppler velocimetric indices of the two groups were measured and documented. Results: The mean velocimetric measurements in the control group were as follows: peak systolic velocity (PSV) = 38.04 ± 13.68 cm/s, End-diastolic volume (EDV) =9.14 ± 3.65 cm/s, resistivity index (RI) = 0.75 ± 0.091, pulsatility index (PI) =1.62 ± 0.55, peak mesodiastolic velocity (PMDV) = 21.02 ± 8.83 cm/s, peak ratio (PR) = 0.56 ± 0.14. The mean velocimetric indices in the PE group were PSV = 44.59 ± 11.54 cm/s, EDV = 12.23 ± 2.66 cm/s, RI = 0.71 ± 0.069, PI = 1.67 ± 0.42, PMDV = 32.27 ± 9.12 and PR = 0.72 ± 0.10. Conclusion: There is a significant difference in the ophthalmic artery Doppler velocimetric indices between women with PE and normal pregnant women. Ophthalmic artery Doppler ultrasound is a useful tool in monitoring the hemodynamic changes in cerebral circulation in PE.
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Quality of sleep and disability associated with headache: migraine versus tension-type headache: A comparative study p. 11
Angad Harshbir Singh, Manish Bathla, Parul Gupta, Leezu Bhusri
DOI:10.4103/aam.aam_241_21  
Background: One of the commonest and most frequently said, quoted and understood by even the least educated elements of our society is the neurological symptom of headache. The commonly diagnosed and studied headaches are Migraine and Tension type headache [TTH]. Headache has the power to reduce the very essence of a peaceful life and produce a disability in a person. Aims and Objectives: The aim of our study is to approach the subject with view of correlation of quality of sleep with the disability associated with migraine and compare it to TTH. Materials and Methods: For the same a cross-sectional study design was adopted and a consecutive sampling procedure was adopted. The sample was subjected to basic socio-demography, VAS, PSQI and HDI. Statistical analysis was done on the collected data. Results: Based on scales the results were evaluated using appropriate statistical methods. It was observed that there was a higher female preponderance in both migraine and TTH, there was severe disability associated and both headaches cause poor sleep quality. Conclusion: The current study concludes that headache is a debilitating illness which causes significant disability to a person.
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Prevalence and knowledge of kidney disease risk factors among Nigerians resident in Lagos State Metropolitan District, South West Nigeria p. 18
Monica Ewomazino Akokuwebe, Erhabor Sunday Idemudia
DOI:10.4103/aam.aam_223_21  
Objective: The objective is to determine the prevalence of kidney disease (KD) risk factors and their knowledge among Nigerians aged 15–64 living in the Mainland and Island metropolitan districts of Lagos State, South West Nigeria. Materials and Methods: A total of 1171 respondents between 15 and 64 years of age were recruited for the measurements of prevalence and knowledge of KD risk factors using a structured questionnaire. Descriptive, bivariate, and logistic regression statistical analyses were employed. Results: The respondents' mean age was 33.83 ± 11.54, with a male-to-female ratio of 0.54:0.46. Respondents without KD have lower knowledge of KD risk factors (38.26; 37.27‒39.25) than those with KD (45.00; 38.84‒50.16) with an overall knowledge score of 38.39 (37.41‒39.36). The prevalent risk factors include indiscriminate use of analgesics and frequent use of traditional remedies (P < 0.05). Knowledge predictors of KD risk factors among respondents were older age (≥30 years) (with KD–Adjusted Odds Ratio (AOR) 1.06: 95% confidence interval [CI]: 0.82‒1.98; without KD–AOR 2.10: 95% CI: 1.52‒2.25) and chronic ailments (with KD–AOR 1.51: 95% CI: 0.28‒2.93; without KD–AOR 3.03: 95% CI: 0.04‒7.49). Conclusion: The study revealed a lower knowledge of KD risk factors exists in respondents without KD, but the prevalence of risk factors was higher among both cohorts of respondents. Therefore, concerted efforts should be made to sensitize strategic public health programs to expand accurate and adequate awareness and understanding of KD risk factors and their implications for well-being, and to possibly avoid the risk of the disease later in life.
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Red cell requisition and utilization pattern in a tertiary care hospital of South India Highly accessed article p. 33
Parmatma Prasad Tripathi
DOI:10.4103/aam.aam_141_21  
Introduction: The equilibrium between supply and demand for red blood cells is increasing unpredictably in many countries. An understanding of trends in blood usage profile and current usage can help predict future trends in demand and to put efforts to reduce use in particular areas. This study helps in analyzing the pattern of red blood cell utilization in a tertiary care hospital. Materials and Methods: This retrospective study was conducted in a blood bank, tertiary care hospital over a period of 6 months. All the requests coming to blood bank with information regarding patient's demographic details, diagnosis and indication for transfusion, type of request, blood transfused or returned were collected and reviewed. Crossmatch transfusion (CT) ratio, transfusion index (TI), and transfusion probability were also calculated. Results: A total of 10,364 patients (20,399 requests) utilized total 32,608 units of blood and its components, out of those 14,195 units of packed red cells units were utilized. March month had maximum number of requests and utilization. Most of the requests for blood were from the inpatients (wards) and were requested and utilized in the age group of 21–30 years with male predominance. Patients in the division of medicine utilized most blood. Although the division of surgery requested most of the blood, on an average, they utilized only one-third of the requested product. Overall, anemia was the most common indication for red cell utilization. In surgical group, spine surgery had a maximum CT ratio. Neurosurgery and hand surgery had the lowest TI in all specialties. Hand surgery and spine surgery had a lowest transfusion probability. Overall, utilization rate in our study was 59.8%. Conclusion: A regular review of blood unit's usage is very important to estimate the blood utilization pattern in any hospital. Profile of blood utilization will act as indicator for quality management of blood bank.
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CO RADS grade of HRCT Thorax and RT PCR testing for the diagnosis of coronavirus disease 2019 (COVID 19): A descriptive hospital based study of asymptomatic planned surgery cases p. 40
Kaushik Ghosh, Susmita Ghosh, Amitava Acharyya, Kalyan Sarkar, Ambarish Bhattacharya, Muhammad Sohail Hassan, Uday Shankar Ghosh
DOI:10.4103/aam.aam_205_21  
Background: The coronavirus disease 2019 (COVID-19) reporting and data system (CO-RADS) grade of high-resolution computed tomography (HRCT)–thorax scan investigation is an innovative tool for the diagnosis of COVID-19 patients. By this tool, majority of moderate-to-severe COVID-19 patients are screened to detect lung pathologies. Hardly any study has explored its use vis-a-vis reverse transcriptase-polymerase chain reaction (RT-PCR) in asymptomatic patients. Objectives: (1) The objective of the study is to assess the frequency COVID-19 patients among asymptomatic subjects who were admitted in the hospital for planned surgery, (2) estimate the sensitivity and specificity of CO-RADS grade of HRCT-thorax investigation for the diagnosis of COVID-19 patients where RT-PCR test was considered as “Gold Standard” test. Methodology: A descriptive retrospective study was conducted by studying the records in the case files of 150 patients who were admitted in the Department of General Surgery, Man Mohini Health Clinic, Murshidabad, West Bengal for minor surgical procedures between September 1 and December 31, 2020. Data were collected from hospital records. The CO-RADS grade of HRCT-thorax investigation and RT-PCR test were performed for the diagnosis of severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) virus. The MS-excel application was applied for data analysis. Results: The mean age of the participants was 42.58 ± 14.29 years. A total of 17 (11%) and 39 (26%) of the patients were diagnosed with COVID-19 by HRCT-thorax and RT-PCR test, respectively. The sensitivity and specificity of CO-RADS grade of HRCT-thorax investigation for diagnosis of COVID-19 patients were 43.58% and 100%, respectively. The positive and negative predictive values of CO-RADS grade of HRCT-thorax investigation were 100% and 83.45%, respectively. Conclusions: The frequency of asymptomatic patients with COVID-19 that was missed by HRCT thorax was high, compared to the gold standard RT-PCR, reflecting its low sensitivity and low negative predictive value in the diagnosis of SARS-CoV-2 virus infection. Hence, it is difficult to conclude in favor of HRCT thorax as first-line screening modality in all individuals.
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Shoulder capsulitis: What relation with diabetes mellitus in a moroccan population? p. 45
Yassine Errahali, Abderrahim Majjad, Jad Issouani, Jalal Kasouati, Ahmed Hicham Benomar, Mohamed Zoulati, Sanae Chakdoufi, Hamza Toufik, Mostapha Boussouga, Ahmed Bezza, Ahmed Anass Guerboub
DOI:10.4103/aam.aam_211_21  
Introduction: Shoulder capsulitis (SC) is a common musculoskeletal complication in patients with diabetes. It can be particularly disabling. It is often overlooked by clinicians. The aim of this study is to evaluate the prevalence of retractile capsulitis and to identify the risk factors in a population of Moroccan diabetic patients. Materials and Methods: We realised a cross-sectional study including patients with diabetes mellitus (DM). We recorded the demographic and diabetic characteristics of our patients. SC and vascular complications were assessed by clinical and para-clinical investigations. The prevalence of SC was calculated. The factors associated with SC were evaluated by suitable statistical tests. Results: Three hundred and Sixty-five patients were included; 84.9% had Type 2 DM (T2DM). The mean age of the participants was 52.6 ± 13.6. Shoulder capsulitis was present in 12.6% of patients. In statistical analysis, age >50 years (P = 0.001), T2DM (P = 0.03), duration of progression >10 years (P = 0.03), dyslipidemia (P = 0.013) and macrovascular complications (P = 0.009) were associated with an increased frequency of SC. Conclusion: This study shows that the prevalence of SC is higher in diabetic patients. Therefore, inclusion of this pathology in the global management of the diabetic patient is necessary.
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Assessment of common errors and subjective quality of digital panoramic radiographs in dental institution, Riyadh p. 49
Amara Swapna Lingam, Pradeep Koppolu, Rasheed Abdulsalam, Reddy Lavanya Reddy, Anupreeta Anwarullah, Deepak Koppolu
DOI:10.4103/aam.aam_213_21  
Aim: The study aims to determine the frequency of positioning errors, record the number of diagnostically inappropriate images, and assess the quality of panoramic radiographs. Materials and Methods: In this study, a total of 2629 patients for whom orthopantomogram were selected out of 3900 new patients between August 2020 and June 2021. The positioning errors of the radiographs were evaluated and categorized into ten groups. The quality of the radiographs is further assessed as “Excellent,” “Diagnostically Acceptable,” and “Diagnostically Unacceptable.” Results: Out of the total radiographs, 32.8% had no errors, and 77.2% of the radiographs had one or more positioning errors. The radiographs were analyzed in detail, and the errors found in the panoramic radiographs were recorded. The most common positioning error observed in the radiograph was error 8, failure to place the tongue close to the palate. Conclusion: The results and evaluation inferred that attention to patient positioning and focusing on reducing diagnostically indecent images could improve the quality of panoramic radiographs. Proper instructions to the patient, patient preparation, appropriate positioning of the patient, and the technician's skill plays a vital role in reducing diagnostic errors in Panoramic Radiography.
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Study of analytical error in lipase assay p. 55
Sweta Kumari, Ravi Shekhar, Rekha Kumari, Pritam Prakash
DOI:10.4103/aam.aam_135_21  
Background: Lipase and amylase are the most frequently used biomarker for the diagnosis of pancreatic diseases, especially acute pancreatitis. Lipase has better diagnostic accuracy in comparison to amylase for the analysis of acute pancreatitis. However, lipase assay in random access analyzer is sometimes difficult to perform as it is exposed to different types of samples or reagents which may act as interference. Materials and Methods: In our laboratory, we found the raised values (>500 IU/L) of lipase with normal amylase in some samples. However, the immediate rerun of these samples for lipase only showed normal (<80 IU/L) lipase level. To root out this fallacy, we performed reagent and sample carryover studies. Results: The cause of the falsely raised value of lipase was revealed by reagent carryover studies. All samples which assayed triglyceride (TGL) followed by lipase immediately after it showed elevated (>500 IU/L) lipase value. This is due to the interference of microbial lipase used in TGL reagents. This was corrected by separating the analysis of lipase and TGL into two different instruments. Conclusion: If interference testing is not done, the laboratories are prone to have an analytical error in reporting and hence lead to diagnostic error. Hence, after analyzer installation, interference testing should be included in the validation protocol.
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Knowledge, attitude, and practice regarding prevention of rheumatic heart disease among primary health-care workers in sokoto metropolis, Sokoto State, Nigeria p. 61
Khadijat Omeneke Isezuo, Kehinde Joseph Awosan, Umar Mohammed Ango, Yahaya Mohammed, Usman Muhammad Sani, Usman Muhammad Waziri, Bilkisu Ilah Garba, Asma'u Adamu, Fatima Bello Jiya
DOI:10.4103/aam.aam_222_21  
Background: Rheumatic heart disease (RHD) is the only preventable cardiovascular disease that still causes significant morbidity and mortality in low- and middle-income countries like Nigeria where it is classified as a neglected disease. The inciting agent causes pharyngitis often not properly treated. Aim and Objectives: To study the knowledge and preventive practices of RHD amongst primary healthcare workers who are in contact with larger ratio of populace in order to recommend appropriate interventions. Methodology: A cross-sectional study conducted among health workers in primary health centres in Sokoto metropolis. Multi-stage sampling technique was used to recruit the study participants. A structured questionnaire and focus group discussion guide was used to collect the information. Data was analysed using IBM SPSS version 25. Results: Majority (109/182; 59.8%) had RHD inadequate knowledge of causes, risk factors and treatment of pharyngitis which predisposes to RHD. Only 49 (26.9%) of the respondents knew the name of the causative agent. The knowledge gap was related to length of training and attendance at a training (ꭓ2 = 8.38; P=0.015 & ꭓ2 = 7.92; P=0.004). Majority of the respondents with 168 out of 182 (92.3%) had positive attitude. Practice grading was adequate in only less than half of the respondents (88/182; 48.4%). Male gender and negative attitude were predictors of adequacy of preventive practices (aOR= 0.49; 95% C.I =0.267-0.929; P=0.03 & aOR= 3.87; 95% C.I =1.027-14.586; P=0.046). Conclusion: The health workers had inadequate knowledge and poor practice on prevention of rheumatic heart disease. It is necessary to upscale information available to them by medical specialists and upgrade their curriculum.
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Iron supplementation and blood donation in Nigeria: Effect on Hemoglobin, red cell indices, and iron stores – The ranferon™ study p. 70
Theresa Ukamaka Nwagha, Angela Ogechukwu Ugwu, Chinenye Nkemakolam Nwaekpe
DOI:10.4103/aam.aam_248_21  
Background: Iron-deficiency anemia is an important limiting factor to a sustainable supply of blood units, especially in low- and middle-income countries. Blood transfusion practice in Nigeria is poorly developed and structured with paucity of voluntary nonremunerated blood donors and high rate of donor deferrals resulting from low hemoglobin (Hb) levels. Aims: This study aimed to assess the effect of daily supplementation of iron using Ranferon-12 on Hb level, red blood cell (RBC) indices, iron level, ferritin level, and Hb recovery in blood donors in Nigeria. Methodology: This longitudinal study was conducted at a tertiary hospital blood transfusion center from March to July 2020. Blood samples of regular donors were collected at three points in the study for the measurement of Hb and hematocrit (HCT); RBC indices including mean cell volume (MCV), mean cell hemoglobin (MCH), and Mean cell haemoglobin concentration (MCHC); and iron stores including serum iron, serum ferritin, and serum transferrin. The first point was at recruitment before donation of one unit of blood; the second point after the blood donation; and the third point at 6 weeks post blood donation. Following donation, participants were placed on Ranferon capsules (iron fumarate - 100 mg elemental iron) and 100 mg of tablet Vitamin C, for 6 weeks. Results: There was a moderate significant positive correlation between administration of Ranferon and change in the values of HCT, MCV, MCH, red cell distribution width, ferritin, and transferring (P < 0.05). Percentage recovery of Hb, red cell indices, and iron stores parameters after 6 weeks of daily Ranferon ranged between 89% and 100%. Conclusion: Iron supplementation using Ranferon capsule daily for 6 weeks enhances recovery of Hb, red cell indices, and iron stores with attainment of benchmark Hb levels for donation.
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Nontubercular bacterial and fungal infections in patients of chronic obstructive pulmonary disease p. 77
Akash Khandelwal, Shyam Chand Chaudhary, Ajay Kumar Verma, Kamal Kumar Sawlani, Kamlesh Kumar Gupta, Dandu Himanshu, Satyendra Kumar Sonkar, Sudhir Kumar Verma
DOI:10.4103/aam.aam_186_21  
Introduction: Acute exacerbation of chronic obstructive pulmonary disease (COPD), frequently due to respiratory tract infection is the major cause of morbidity and mortality, and estimate suggests that it is currently the third leading cause of death worldwide. Aims and Objectives: This study aims to study the prevalence of nontubercular bacterial and fungal infections in patients of COPD. Materials and Methods: It is an observational study done for 1-year period from August 2017 to July 2018. A total of 100 COPD patients who fulfilled the inclusion and exclusion criteria were analyzed in the present study. These cases were classified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) combined assessment criteria and subjected to sputum or in some cases Bronchoalveolar lavage (BAL) fluid examination for nontubercular bacterial and fungal pathogens. Serum galactomannan assay, bronchoscopy, and computed tomography chest were done in selected cases. Results: The age of the study population ranged from 40 to 85 years and the mean age was 60.01 ± 9.85 years. Majority of the patients were male (81.0%) and most (78.0%) of them were smokers. Most of the patients belonged to GOLD Grades 2 and 3. Forty-six percent of the patients did show pathogenic organisms in sputum examination. Out of these, 80.4% were bacterial, mainly Gram-negative organisms (Acinetobacter, Pseudomonas, Escherichia coli, Enterobacter, Proteus, and Citrobacter) and 19.6% of cases were having fungal infections (Candida and Aspergillus). Conclusions: Increasing patient age, smoking habit, and severity of COPD were related to an increasing frequency of bacterial and fungal infections. Early detection and proper treatment could help in preventing the morbidity and mortality related to COPD.
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Outcome and safety of colistin usage in pediatric cancer patients with carbapenem-resistant enterobacteriaceae bacteremia at children cancer hospital Egypt p. 82
Nagla Adel, Reham Khedr, Mervat Elanany, Hala F Zaki, Hanafy Hafez, Hanan El-Abhar
DOI:10.4103/aam.aam_209_21  
Background: Carbapenem resistant Enterobacteriacae (CRE) bloodstream infection (BSI) causes complicated infections, especially in immunocompromised patients. This study aimed to assess the renal toxicity and the efficacy of therapy with colistin in a cohort of pediatric cancer patients with BSIs due to CRE and sensitivity to colistin. Patients and Methods: This was an observational, prospective cohort study from May 2017 to October 2017 in Children's Cancer Hospital Egypt 57,357. All patients who had blood stream infections due to CRE receiving intravenous colistin were prospectively enrolled. We used a standardized case form to record patient characteristics, including age, sex, weight, underlying comorbidities, type of infection, causative organism, and antibiotic susceptibility testing. Daily doses, duration of colistin therapy, and co-administered antibiotics (aminoglycosides, vancomycin) were collected. Furthermore, clinical and microbiological responses to treatment were reported. The dosing schedule was based on a loading dose of 5 MU and a 5-MU twice-daily divided maintenance dose, titrated on renal function. Clinical cure, bacteriological clearance, and daily serum creatinine were recorded. Results: One hundred and forty-one Blood Stream infectious episodes mainly due to Klebsiella Species (pneumoniae and Oxytoca) (27%) and Escherichia coli (68%) were analyzed. All strains were susceptible to colistin with Minimum inhibitory concentration (MICs) of 0.19–1.5 mg/L. Patients were predominantly females (69%), with a mean age of 7 years. It was used as a combination therapy with carbapenems (69.2%) or aminoglycosides (80%). The median duration of treatment was 9 days (Range 1–50 days). Clinical and microbiological cure was observed in 110 cases (80%). Acute kidney injury developed during five treatment courses (4%) in which colistin was used in combination with amikacin. No renal replacement therapy was required and subsided within 7 days from colistin discontinuation. Conclusions: Our study showed that colistin had a high efficacy without significant renal toxicity in severe infections due to CRE Gram-negative bacteria.
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Comparison between intermittent epidural bolus of levobupivacaine 0.125% and ropivacaine 0.2% with fentanyl as adjuvant for combined spinal epidural technique in labor analgesia: A double blinded prospective study p. 88
Srinivas Hebbal Thammaiah, Rashmi Hosahalli Sreenath, Akshay Hiryur Manjunatha Swamy, Girish Bandigowdanahalli Kumararadhya, Sushant Satya Priya
DOI:10.4103/aam.aam_249_21  
Objective: This study aims to compare levobupivacaine 0.125% and ropivacaine 0.2% with fentanyl as epidural drugs for labor analgesia using combined spinal epidural (CSE) technique regarding time for onset, duration of analgesia achieved by first epidural bolus dose and to compare the quality of labor analgesia. In addition, the study is also designed to assess the maternal and fetal outcome, incidence of instrumental delivery, degree of motor blockade, and maternal satisfaction. Materials and Methods: Following approval from Institutional Ethical Committee, 50 American Society of Anesthesiologists Physical Status II pregnant women requesting labor analgesia, satisfying the inclusion criteria were randomly divided equally into Groups L and R. CSE performed, 0.5 ml hyperbaric bupivacaine 0.5% with fentanyl 25 mcg administered intrathecally. IEBs 10 ml of study drugs given through epidural catheter as demand dose. Results: The mean onset of analgesia with Group R and group L were 16.280 ± 1.59 min and 21.480 ± 1.32 min(P = 0.000) respectively. The total duration of analgesia in Group R = 72.08 ± 1.97 min, whereas Group L = 82.160 ± 2.07 min (P = 0.000). There was no difference between the groups in terms of maternal demographic traits, mode of delivery, maternal and fetal outcome, and maternal satisfaction. Both 0.125% levobupivacaine and 0.2% ropivacaine produce excellent-quality of analgesia. Conclusion: Ropivacaine produces an early onset of analgesia than levobupivacaine but levobupivacaine had significantly prolonged analgesia compared to ropivacaine. Both drugs were found to be safe for labor analgesia. Maternal satisfaction and fetal outcome were similar with both the drugs.
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Hospital-acquired pneumonia pattern in the intensive care units of a governmental hospital: A prospective longitudinal study p. 94
Mina Yakoub, Fayek Elkhwsky, Ayman El Tayar, Iman El Sayed
DOI:10.4103/aam.aam_178_21  
Background: Epidemiological data on Hospital-Acquired Pneumonia (HAP) are scarce inside Intensive Care Units (ICUs). Aim: This study aims to quantify the incidence of HAP, determine the predictors of HAP, calculate HAP-related mortality risk ratio as well as pinpoint the different risk factors contributing to mortality. Subjects and Methods: A prospective longitudinal study was conducted at a governmental hospital's general ICUs over 12 months. We included adult patients admitted for at least 72 h before signs appear. We utilized a logistic regression model for fatality outcome and cox proportional hazard model for HAP outcome. Results: Of 356 patients, 133 patients developed Ventilated-Acquired Pneumonia (VAP), 76 patients with Non-Ventilated HAP (NV-HAP), as well as 147 patients did not acquire HAP. The incidence of HAP was 28 cases of HAP per 1000 person-days, as well as the mortality rate was 74 per 100 days, while the Attributable Risk Percentage (ARP) was 85%. This high fatality rate was clarified by independent predictors as reintubation (odds ratio [OR] = 8.99, P < 0.001), ICU duration ≥5 days (OR = 7.29, P = 0.02), HAP outcome (OR = 6.49, P = 0.001), diabetes mellitus (DM) (OR = 2.98, P = 0.004), APACHE II ≥17 (OR = 2.76, P = 0.004), as well as neurological diseases (OR = 2.20, P = 0.03). The most common independent HAP predictors were Pseudomonas aeruginosa (Hazard Ratio [HR] = 2.27, P < 0.001), Klebsiella pneumoniae (HR = 1.81, P = 0.003), tracheostomy (HR = 1.72, P = 0.04), and APACHE II ≥17 (HR = 1.54, P = 0.04). Conclusion: High incidence rate of HAP was linked with P. aeruginosa, K. pneumoniae, tracheostomy, and APACHE II ≥17. Furthermore, a high mortality rate was strongly correlated with reintubation, duration in ICU ≥5 days, HAP outcome, DM, APACHE II ≥17, and neurological diseases.
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Positron emission tomography - Computed tomography for staging of mediastinal lymph nodes in patients with non-small cell lung cancer p. 101
Georgi Prisadov, Anja Blume-Vulin, Martin Scharpenberg, Katrin Welcker, Emeka Blessius Kesieme, Albert Linder
DOI:10.4103/aam.aam_12_22  
Background: The tumor involvement of lymph nodes (LN) in N2 station is a very important factor for the further therapy decision and the prognosis of lung cancer patients. Today, integrated positron emission tomography-computed tomography (PET-CT) is considered to be the new standard in the staging of bronchial carcinoma. The aim of this study is to investigate the correctness of the clinical staging of the mediastinal LNs in operated patients and to investigate the sensitivity and specificity of the PET-CT examination for mediastinal LNs. Subjects and Methods: In the years 2010–2014, 359 patients underwent surgery for bronchial carcinoma. The histological examination of all mediastinal and hilar LNs was used as a reference to the data from the PET-CT examinations. The correctness of the PET staging, overestimation, and underestimation for the N stage was analyzed. In addition, the “sensitivity,” “specificity,” and “overall accuracy” of the PET-CT examination with regard to the N2 LNs were calculated. Results: It was found that in 8.9% the staging of the mediastinal N2/N3 LN stations was rated too high by the PET and in 11.2% too low. The study showed a sensitivity of 47.37%, a specificity of 90.07%, and an accuracy of 81.01% for the mediastinal LNs. Conclusion: Our study confirms the limited ability of integrated PET-CT in staging the mediastinal LNs. We, therefore, recommend a histological examination of the LNs in patients with PET-positive N2 LNs to avoid false-positive results and to initiate correct therapy.
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Brain stem auditory evoked potentials in type 2 diabetes mellitus patients at varying frequencies p. 107
Indira Sushil Mishra, Ranjana Shingne, Nitu Kumari Roy
DOI:10.4103/aam.aam_13_22  
Introduction: As per the World Health Organization, in 2005, more than 180 million people had diabetes worldwide. This figure will be more than double by 2030. Neuropathy is common and late complication of diabetes mellitus (DM). Sensory neural hearing loss which is severe at higher frequencies has been reported in Type 2 DM patients. Auditory nerve tract damage increases the latency and reduces the amplitude of the response. Evoked potential recordings evaluate the neural pathways in the central nervous system. Brainstem auditory evoked potentials (BAEP) localize anatomic structures using different waves and detect acoustic and central neuropathy (CN). Hence, brainstem evoked response of audiometry (BERA) is used widely in clinical set up. Aims: Primary: 1. To record BERA waves in normal subjects with normal blood sugar levels (hemoglobin A1C [HbA1C] <5.4. 2. To record BERA waves in Type 2 DM patients. (HbA1C >6.5). Secondary: To study the BERA parameters with the normal subjects with blood sugar subjects and compare them with Type 2 DM patients. Materials and Methods: n = 30, Type 2 DM patients between the age of 35–50 years of either sex were chosen from the Diabetic Clinic of GMC, Aurangabad, Maharashtra. HbA1C test for glycemic control and BERA waves to assess CN were recorded. n = 30 normal subjects with normal blood sugar with age and sex-matched above tests were performed. Statistical Analysis: Unpaired Student's t-test. Results: Mean ± Standard deviation of the absolute latency and interpeak latency of BERA waves at 2, 4, and 6 KHz at 80 dB in Type 2 DM patients were delayed and found to be significant as compared to control group. Conclusion: The above study explains that if BAEP is recorded at higher frequencies like 6 KHz and at 80 dB, CN involvement can be detected earlier in diabetic patients. Hence, it is recommended to carry out BERA in diabetic patients at least once in a year.
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A study of hormonal and anthropometric parameters in polycystic ovarian syndrome p. 112
Tushar Kambale, Komal Devanand Sawaimul, Supriya Prakash
DOI:10.4103/aam.aam_15_22  
Introduction: Polycystic Ovarian Syndrome (PCOS) is an endocrinopathy with a complex metabolic disorder. PCOS is characterized by reproductive hormonal imbalances leading to the clinical presentation of hyperandrogenism and infertility. PCOS is also showing an increased prevalence of several other conditions such as obesity, dyslipidemia, hypertension, metabolic syndrome and type 2 diabetes mellitus (DM2) when compared with women without PCOS. The principal symptoms in patients with PCOS are irregular menstruation, acne, and excessive amounts of androgenic hormones. The Rotterdam PCOS consensus workshop has given specific criteria to establish PCOS diagnosis only after exclusion of other known disorders. Obesity is a common finding of women with PCOS, but it is not part of the diagnostic criteria. PCOS has metabolic characteristics that include prominent defects in insulin action and beta-cell function, defects that confer a substantially increased risk for obesity and type 2 diabetes mellitus. PCOS women have an increased level of luteinizing hormone (LH) and a decreased level of follicle-stimulating hormone (FSH), which leads to disorders in the regulation of the menstrual cycle. The values of LH and FSH are dependent on the day of the menstrual cycle in which the hormones are measured. Obesity also has an influence on these values. Objectives: The objective of this study was to compare the hormonal and anthropometric parameters in women with PCOS and healthy control group. Materials and Methods: This study was carried out in the Department of Pathology, Dr. D Y Patil Medical College and Research Centre, Pune, Maharashtra. Fifty female patients aged 16–40 years diagnosed with PCOS by known criteria were included in the study and compared with 50 healthy control group females. Conclusion: Elevated levels of thyroid-stimulating hormone, LH, FSH, and prolactin along with increased body mass index and waist-to-hip ratio were predictors of PCOS and the early metabolic abnormalities.
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Association of vitamin D with the severity of disease and mortality in COVID-19: Prospective study in central India p. 117
Bharatsing Deorao Rathod, Ashok Kumar Ahirwar, Sitikantha Banerjee, Prashant P Joshi, Rajashree Sanjay Khot, Amol H Dube, Sunita D Kumbhalkar, Sandeep B Dabhekar
DOI:10.4103/aam.aam_21_22  
Background: Many factors have been proposed to be associated with the severity of disease and mortality in COVID-19. Vitamin D had recently been reviewed as one of these factors. Aim and Objectives: To evaluate the association between Vitamin D and the disease severity and mortality in COVID-19. Materials and Methods: After approval from Institutional Ethics Committee, this prospective cohort study was carried out in selected tertiary care teaching medical institutes of Central India. Participants were COVID-19 patients of the age group of 18 years and above admitted during the study period. They were categorized into four groups as asymptomatic (Group A), mild (Group B), moderate (Group C), and severe (Group D) based on clinical symptoms, respiratory rate, oxygen saturation, and chest imaging. Serum level of Vitamin 25(OH) D was measured using chemiluminescent immunoassay. The outcome of the disease was classified as recovery and death during hospitalization. The association of sociodemographic and medical characteristics with treatment outcome was studied using an appropriate statistical test. A full logistic regression model was built for the assessment of the relationship between treatment outcomes with Vitamin D level. Further, one receiver operating characteristic curve was developed to examine the prognostic significance of Vitamin D levels in COVID-19 patients. Results: Out of 748 enrolled patients, 44 (5.88%), had severe disease (Group D). A total of 721 cases (96.39%) recovered and were discharged, whereas 27 (3.61%) died during hospitalization. Mean Vitamin D level was found to be significantly different in discharged patients compared to those who were deceased. Increasing age-adjusted odds ratio (AOR) (95% confidence interval [CI]=1.07 [1.02–1.12]), known hypertension AOR (95%CI) = 3.38 (1.13–10.08), and diabetes mellitus AOR (95%CI) =28.5 (6.04–134.13) were found to be significant predictors of death among COVID-19 patients. Increasing Vitamin D level was found to be protective against COVID-19-related death (AOR (95% CI = 0.87 [0.80–0.94]). Conclusion: Vitamin D was significantly associated with the disease severity and mortality in COVID-19.
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CASE REPORTS Top

Hepatocellular carcinoma presenting as right shoulder pain p. 124
Senyo Tagboto
DOI:10.4103/aam.aam_257_21  
We report an uncommon presentation of liver cancer in a 33-year-old woman who presented with persistent right shoulder pain with a normal physical examination of her shoulder and normal X-rays. An abdominal ultrasound scan and a computed tomography scan subsequently revealed a large liver cancer in this patient who was subsequently found to be hepatitis B positive. Extrinsic causes of shoulder pain should be considered when shoulder movement is normal and does not alter the character of the pain. Subdiaphragmatic liver lesions should be considered in the differential diagnosis of right shoulder pain. In any geographical area with a high incidence of hepatitis B infection, hepatocellular carcinoma should be included in the differential diagnosis of shoulder pain if a clear local cause is not identified.
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Tenofovir as a cause of acquired fanconi's syndrome p. 128
Monisha Simon, Ameena Meah
DOI:10.4103/aam.aam_198_21  
Fanconi's syndrome is a disorder that results in generalized involvement of the proximal tubule of the kidney. It is characterized by variable degrees of phosphate, glucose, and amino acid wasting in the urine and a hyperchloremic normal anion gap metabolic acidosis – secondary to defective hydrogen ion excretion and bicarbonate ion absorption. There are hereditary variants such as cystinosis (most common), hereditary fructose intolerance, galactosemia, tyrosinemia, Dents disease, and acquired variants of Fanconi's syndrome. Toxins, drug-induced diseases, and systemic diseases (multiple myeloma, Sjogren's syndrome) are the most common acquired causes of Fanconi's syndrome. The case report describes a middle-aged female patient, a known case of human immunodeficiency virus (HIV)-positive status who developed tenofovir disoproxil fumarate-induced Fanconi's syndrome, an increasingly recognized cause of acquired Fanconi's syndrome in HIV-positive patients.
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