Current Issue Volume 52, Number 4 , October-December 2018

EDITORIAL
Kiran Jangra, Dheeraj Khurana

The Need for Quality in the ICU!

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:iii]



In current times, an increasing number of patients requires admission to the intensive care units (ICU) due to the availability of life-sustaining technologies as well as therapies which require careful monitoring. Care of critically ill patients demands resources and forms a major portion of the hospital budget. These patients are most susceptible to adverse events and catastrophes if health care is suboptimal.1 Impact of quality improvement in critical care has been well established. A review by Curtis et al. outlined the practical approach to develop, evaluate, and sustain the quality improvement program in the ICU setup.2 Quality improvement is a structured process, and established models are available.3 Clinicians should work on the aspects which they are able to improve.


ORIGINAL ARTICLE
Georgy J Eralil

Comparison of Efficacy of Treatment with Oral Ferrous Sulfate or Intravenous Iron Sucrose in the Treatment of Mild to Moderate Iron Deficiency Anemia in Pregnancy

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:167-170]



Objective: To compare the effect of treatment with either oral ferrous sulphate or intravenous iron sucrose (IVIS) on hematological parameters of women with iron deficiency anemia in pregnancy.

Methods: This prospective randomized study was interventional, conducted from January 2016 to January 2017 in Department of Obstetrics and Gynecology Sree Narayana Institute of Medical sciences.

Pregnant women Singleton pregnancy, Hb < 11 gm in 1st and 3rd trimester Hb < 10gm in 2nd trimester, with hemoglobin level 7-10.9 g/dL ferritin levels less than < 13 microgram/L and peripheral smear hypochromic microcytic anemia were enrolled into intravenous iron and oral iron groups. After detailed history and examination, laboratory investigations performed were hemoglobin, mean corpuscular volume (MCV), serum ferritin and peripheral smear. The dose for IVIS dose is calculated by ganzoni equation. Total iron deficit (mg) = body weight (kg) × [Target Hb (g/L)-actual Hb (g/L)] × 0.24 + depot iron (mg). A maximum IVIS is given as 200 mg in 100 ml normal saline as infusion over 15 to 30 minutes The remaining doses were given on alternate days. Infusions were given as outpatient basis in labor room with facilities for acute emergency care. Oral iron group received ferrous sulphate supplementation.

Results: Target hemoglobin of 11 g/dL was attained by 66 %. Hemoglobin done just prior to delivery showed no statistically significant difference (p value = 0.080) [OI group 11.83 (+11.98) g/dL vs. IVIS group 16.19 (+ 11.35) g/dL]. There was significant increase in serum ferritin levels with IVIS infusion There was no significant difference in antepartum or postpartum hemorrhage, infection, preterm labor, between the two groups.

Conclusion: The study concludes that oral iron increases hemoglobin comparably with IVIS. The replenishment of iron stores was good with IVIS compared with oral ferrous sulphate.

Keywords: Anaemia, Ferrous sulphate, Iron deficiency, Iron sucrose.

How to cite this article: Eralil GJ. Comparison of Efficacy of Treatment with Oral Ferrous Sulfate or Intravenous Iron Sucrose in the Treatment of Mild to Moderate Iron Deficiency Anemia in Pregnancy. Journal of Postgraduate Medicine, Education and Research, Oct-Dec 2018;52(4):167-170.

Source of support: ARISTO pharmaceuticals supplied intravenousiron sucrose for the study.

Conflict of interest: None


RESEARCH ARTICLE
Vijaydeep Siddharth, Shakti K Gupta, Sidhartha Satpathy

Quality of Care in Medical Intensive Care Unit: A Study in an Apex Tertiary Care Teaching Hospital of Northern India

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:171-176]



Introduction: The endpoint in quality healthcare is evaluating the outcome of care being rendered. In India, the outcome of healthcare provided in intensive care units (ICUs) has not been studied extensively. The study was aimed to observe the outcome of care provided in a medical intensive care unit (MICU) at a tertiary care teaching institution in North India.

Materials and methods: The study was descriptive and cross sectional. Medical records of all patients, admitted from January to June 2011, were analyzed to study demographic, morbidity and mortality parameters. Simplified acute physiology score (SAPS II) scoring was calculated to assess the severity of the admitted patients.

Results: In medical intensive care unit (MICU) from January to June 2011, 203 patients were admitted, and 51.7% of them were admitted from the emergency department. The mean age of admitted patients was 50.62 years, and 59.3% were males. The majority (83.1%) of the patients required mechanical ventilation with an average of 3.8 ventilator days. Reintubation rate was found to be 16.9%. Bedsore rate in MICU was 9.9% of the total, 63.4% of patients required oxygen administration. Average MICU length of stay was 6.5 days with a readmission rate of 2.9%. Mean and median predicted mortality using SAPS II was 31.21% and 27.30% (range 0.1 to 96.6%) respectively. MICU mortality and Hospital mortality of MICU admitted was calculated to be 45.9% and 52.3% respectively. Mean age of the patients who died was 54.23 (range 13 to 98 years). Bed occupancy of MICU was 93.47%.

Conclusion: Sepsis with septic shock was the major cause of mortality. Standardised mortality was found to be 1.47.

Clinical significance: This study focuses on the quality of care in an intensive care unit setting, which is not a priority in developing countries like India. There have been so to say negligible literature on the same especially in developing countries. This study will help us identify the various parameters to measure the quality of care.

Keywords: Critical care, Medical intensive care unit, Outcome of care, Quality of care, Simplified acute physiology score II

How to cite this article: Siddharth V, Gupta SK, Satpathy S, Quality of Care in Medical Intensive Care Unit: A Study in an Apex Tertiary Care Teaching Hospital of Northern India, Journal of Postgraduate Medicine, Education and Research, Oct-Dec 2018;52(4):171-176.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Kirti Sharma, Ravi Sharma

A Case Report of an Adult-onset Niemann–Pick Disease Type C Presenting as Bipolar-affective Disorder

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:177-179]



Aim: We are presenting a case report of an adult-onset Niemann- Pick disease type C (NP-C) presenting as a bipolar-affective disorder.

Background: The NP-C is a rare autosomal recessive lysosomal storage disorder. Clinical presentations of NP-C feature a range of systemic and neurological signs that arise at different ages and progress at different rates. Many of the neurological and psychiatric signs of the disease are shared with other neurological conditions, and NP-C is therefore often overlooked.

Case Description: A 43-year male was under psychiatric treatment for the last 20 years without any improvement in the diagnosis of “bipolar-affective disorder.” Presence of vertical gaze palsy with cerebellar ataxia, extrapyramidal symptoms and cognitive decline over a long progressive course of illness made Niemann-Pick (NP) disease as a possible diagnosis. The diagnosis was confirmed by low sphingomyelinase levels.

Conclusion: Early diagnosis of the disease is helpful in providing appropriate psychiatric and neurological management along with genetic counseling. To ensure rapid diagnosis and proper management, it is important that clinicians are familiar with this obscure condition.

Clinical significance: The gradual progression of NP-C poses a diagnostic challenge. This patient was managed for psychiatric illness without improvement. The gradual appearance and progression of neurological symptoms was either masked by the behavioral disturbances or was attributed to the use of psychotropic medication. The psychiatric manifestations can overshadow the subtle neurological signs of NP-C, which leads to significant delays in the detection and diagnosis of NP-C.

Keywords: Bipolar-affective disorder, Niemann-Pick disease type C (NP-C), Vertical gaze palsy. How to cite this article: Sharma K, Sharma R. A Case Report of an Adult-onset Niemann-Pick Disease Type C presenting as Bipolar-affective Disorder. Journal of Postgraduate Medicine, Education and Research, Oct-Dec 2018;52(4):177-179.

Source of support: Nil

Conflict of interest: Nil


CASE REPORT
Majed AB Momin, KM Reddy, B Saroj K Prusty

Mycoplasma Pneumonia with Cold Agglutinin Autoimmune Hemolytic Anemia: Analytical Discrepancies and Spurious Results–A Rare Case Report

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:180-182]



Aim: To highlight the discrepancies in hemogram parameters and blood grouping related to cold agglutinin hemolytic anemia cases which not only helps to the diagnosed underlying pathogen but prevents its complication.

Background: Cold agglutinin hemolytic anemia is a rare form of autoimmune hemolytic anemia caused by cold-reacting autoantibodies. The automated hematology analyzer hemogram analysis of these patients sample is related to analytical discrepancies and spurious result. Immunohematology workup including peripheral smear findings, warming the ethylenediamine- tetra-acetic acid (EDTA) sample and cold agglutinin titer helps to resolve such discrepancies and gives a diagnostic clue of rare presentation of atypical pneumonia which responds to specific antibiotics.

Case report: A 55-year old male presented with fever, shortness of breath and cough for two weeks. A blood sample drawn for hemogram show high mean cell hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC) and low red blood cells (RBCs) count and hematocrit with discrepancies in blood groupings. Peripheral blood film show significant autoagglutination of RBCs and infective changes in white blood cell morphology suggest cold agglutinin secondary to mycoplasma pneumonia. Further immunohematology workup and serological investigation confirm cold agglutinin autoimmune hemolytic anemia with mycoplasma pneumonia.

Conclusion and clinical significance: This case report emphasizes blood count analytical and blood grouping problems related to cold agglutinins and also sensitize to search underlying etiology like mycoplasma pneumonia to start specific antibiotics and to reduce morbidity and mortality.

Keywords: Analytical discrepancies, Cold agglutinin, Management, Mycoplasma pneumonia.

How to cite this article: Momin MAB, Reddy KM, Prusty BSK. Mycoplasma Pneumonia with Cold Agglutinin Autoimmune Hemolytic Anemia: Analytical Discrepancies and Spurious Results-A Rare Case Report. Journal of Postgraduate Medicine, Education and Research, Oct-Dec 2018;52(4):180-182.

Source of Support: Nil

Conflict of Interest: None


CASE REPORT
Tulika Singh, Madhurima Sharma, Upasana Sinha, Seema Chopra, Niranjan Khandelwal

Rare Triad of Spontaneous Ovarian Hyperstimulation Syndrome, Ovarian Torsion and Intestinal Obstruction in Pregnancy: Diagnosed with Ultrasound

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:183-186]



Ovarian hyperstimulation syndrome (OHSS) is a known iatrogenic complication of assisted reproductive techniques. Spontaneous OHSS in the absence of ovulation induction is very rare, which can be more rarely complicated by ovarian torsion. Prompt diagnosis of ovarian torsion is desirable to preserve the viability of ovary. However, the background of OHSS can make it difficult to diagnose ovarian torsion. A careful evaluation of ovary on ultrasound can make a diagnosis of ovarian torsion. Intestinal obstruction is also rare in pregnancy. We describe a rare case of spontaneous OHSS in pregnancy presenting with torsion and intestinal obstruction, which was diagnosed on ultrasound.

Keywords: Doppler ultrasonography, Ovarian hyperstimulation syndrome (OHSS), Pregnancy, Torsion, Ultrasonography (USG).

How to cite this article: Singh T, Sharma M, Sinha U, Chopra S, Khandelwal N. Rare Triad of Spontaneous Ovarian Hyperstimulation Syndrome, Ovarian Torsion and Intestinal Obstruction in Pregnancy: Diagnosed with Ultrasound. Journal of Postgraduate Medicine, Education and Research, Oct-Dec 2018;52(4): 183-186.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Sanjay Yadav, Saurabh Singh, Rajkumar Arya, Divyansh Sharma

Volar Perilunate Dislocation with Acute Median Nerve Compression: A Case Study and Literature Review

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:187-189]



Introduction: Perilunate dislocations, lunate dislocations, and perilunate fracture-dislocations are rare injuries (< 10% of all wrist injuries). Volar lunate dislocations are severe carpal injuries occurring after high-energy trauma to a wrist and fall on outstretched hyperextended hand.

Case study: We present a case of a 35-year male who developed paraesthesia in the distribution of median nerve after injury. On examination, there was the prominence of lunate on the volar aspect of the hand. Wrist dorsiflexion was 30°, volar flexion 45°, radial deviation 10°, and ulnar deviation 20°. A full range of pronation and supination was possible. The sensation was reduced in the distribution of the median nerve. No thenar, hypothenar or intrinsic muscle wasting was present. Plain radiograph and CT scan revealed volar lunate dislocation.

Management and results: Manual reduction was tried in an emergency under sedation. Then the patient was shifted to the operating room for open reduction and stabilization. The volar approach was used. Carpal tunnel release was done simultaneously. Lunate was reduced and stabilized with scapholunate and lunotriquetral K-wires. Scapholunate ligament was repaired. Above elbow, slab support was given postoperatively. Sutures were removed two weeks after surgery. Slab support was removed after four weeks. Wrist splint was given for further four weeks. Gentle wrist physiotherapy was started. At final follow-up, wrist dorsiflexion was 45°, palmar-flexion was 70°, the ulnar deviation was 30°, and the radial deviation was 20°.

Conclusion: Volar lunate injuries are uncommon. Compression of the median nerve can occur due to a volar displacement of lunate. These injuries need to be identified and treated appropriately for better outcomes.

Keywords: Compression, Dislocation, Median nerve, Perilunate

How to cite this article: Yadav S, Singh S, Arya R, Sharma D. Volar Perilunate Dislocation with Acute Median Nerve Compression: A Case Study and Literature Review. Journal of Postgraduate Medicine, Education and Research, Oct-Dec 2018;52(4):187-189.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Shuchi Lakhanpal, Manju Gupta, Anita Singla

A Rare Case of Lipoleiomyoma of the Uterus

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:190-192]



Lipoleiomyoma is an infrequent benign neoplasm of the uterus and is considered as a variant of uterine myomas. Their incidence varies from 0.03 to 0.2% in various reports. Lipoleiomyomas are made up of a varying proportion of mature adipocytes and smooth muscle cells. Lipoleiomyomas usually occur in asymptomatic perimenopausalor menopausal obese women. We, hereby, report a case of uterine lipoleiomyoma of the uterus.

Keywords: Benign tumor of uterus, Leiomyoma, Lipoleiomyoma.

How to cite this article: Lakhanpal S, Gupta M, Singla A. A Rare Case of Lipoleiomyoma of the Uterus, Journal of Postgraduate Medicine. Education and Research, Oct-Dec 2018;52(4):190-192.

Source of support: Nil

Conflict of interest: None


CLINICOPATHOLOGICAL CONFERENCE REPORT (CPC)
Ritambhra Nada, Kirti Gupta, Lokesh Saini, Gargi Kapatia, Meenu Singh, Anmol Bhatia, D Behera

Little Heart had too much to Bear!

[Year:2018] [Month:October-December] [Volumn:52 ] [Number:4] [Pages:35] [Pages No:193-202]



A 7-month-old infant boy presented with chief complaints of fever and cough since 20 days and rapid breathing for 15 days.


© JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD.