Kauverian - Scientific Journals

Editorial

Only a handful of medical journals choose to publish poems.
It is a very small list; the two that readily come to mind are the redoubtable NEJM, and the reflective Annals of Internal Medicine
And the KAUVERIAN!
Now you come to know why!

Editorial Board

Presenting the team that brings you critical cases and immense insights from the world of Kauvery Hospital.

Cervical collar in trauma patients - friend or foe? ~ Dr. Vidya Saketharaman

The motif of cervical collar dates back to early 1960’s during the Vietnam War. Initially rolled up towels were used to immobilize the neck. Soft foam collars made its appearance in the late 1960’s. In 1974, Glen Hare designed the first true cervical collar with medium density foam that was believed to provide greater immobilization. Semi-rigid collars of polyethylene plastic were developed during the late 1970’s and used popularly till date.

Oxygen Conservation Strategies ~ Ms. Gethsial Kiruba

The corona virus has made a great impact in the history affecting more than 18 crores of people all over the world. India has its effect of around three crores of cases so far and that is about 16% of overall cases. Corona virus has become a deadly disease as it predominantly affects the respiratory system. O2-therapy has a profound role in the treatment of COVID-19 patients that too the demand for oxygen has been increased during the second wave attack. So, the rational use of oxygen has become mandatory and need of the hour. This article will have a review on best practices in oxygen supply, management, conservation and economics.

Rare case of Flood syndrome ~ Dr. Nagarajan Appusamy, Dr. Arivarasan Kulandaivelu

Liver cirrhosis is commonly complicated with ascites (50% of cases) and umbilical hernia (20% of cases) [1]. Sudden and spontaneous rupture of umbilical hernia with a resultant abrupt rush of ascitic fluid referred to as Flood syndrome, is a rare but potentially fatal complication in a patient with liver cirrhosis and long-standing ascites [2]. The reported factors that explain the mechanism of spontaneous rupture of umbilical hernia in cirrhosis include the inherent weakness of the abdominal wall and umbilical vein dilatation and varices formation at the umbilical level secondary to hypoalbuminemia and portal hypertension, respectively, and continuous increased intra-abdominal pressure from ascitic fluid [3–6]. Among the complications of flood syndrome that have been reported include peritonitis, cellulitis, sepsis, bowel strangulation, evisceration, and death.

Chronic Periodontis ~ Dr. U. Rakesh, Dr. Kirthana Rao

Gingivitis is an inflammatory condition affecting the gingiva around the teeth. Periodontitis is defined as an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms. This results in progressive destruction of the periodontal ligament and alveolar bone with increasing probing depth formation, recession or both, ultimately leading to premature loss of teeth. Approximately 10% of the global adult population is highly vulnerable to severe periodontitis, 10–15% appear to be completely resistant to it, while the remainder vary between these two situations [1]. The etiology of periodontitis is most commonly due to accumulation of calculus around the tooth due to poor oral hygiene [2].

Erythema Multiforme in COVID-19 ~ Dr. Ivan A. Jones, Dr. G. Dominic Rodriguez

Different patterns of skin manifestations of COVID-19 infection have been reported by clinicians across the globe. These include maculo-papular rashes, urticaria, pseudo-chilbain, vesicles, livedo-reticularis, petechiae, and erythema multiforme like lesions [1].
We report a male diabetic patient, who got COVID-19 infection and developed erythema multiforme like lesions in his second week of illness.

Secondary Synovial Chondromatosis of the knee Joint-a case report ~ Dr. S. Kalaivanan, Dr. S. Chockalingam, Dr. PR. Ramasamy

Synovial chondromatosis is a rare benignant condition affecting joints. It is characterized by the development of multiple osteocartilaginous nodular loose bodies arising from the synovium of the joints. It most commonly affects the knee joint. Swelling, pain & limited range of movements are the common presentation by the patients.
Secondary synovial chondromatosis of the knee joint is a rare condition infrequently reported in the literature. We hence present one such patient with synovial chondromatosis of the knee Joint secondary to osteoarthritis due to its rarity. We also have treated this condition with knee arthroscopic technique with minimum morbidity and early recovery.

Statistical Risk Ratio (Relative Risk) Data Analysis ~ Mr. T. Dhasaratharaman

Risk is a relatively intuitive concept that we encounter every day, but interpretation of risk (especially low risk) is often inconsistent.
The risk of death while travelling to the shops to buy a lotto ticket can be higher than the risk of winning the jackpot!
Relative risk is used in “cohort studies”, prospective studies that follow a group (cohort) over a period of time and investigate the effect of a treatment or risk factor.

Journal Scan ~ Dr Suresh Venkita

Journal scan: A review of ten recent papers of immediate clinical significance, harvested from major international journals

Image Challenge - Splinter Haemorrhage ~ Dr Nagarajan

A 40 years old gentleman presented with three months history of fever and chills. He also had exertion dyspnea. On general examination, we found nail changes.

Patient story - Dignity matters ~ Dr. Bhuvaneshwari Rajendran

In today’s world, people think with advanced technology, anyone can be kept alive indefinitely but the question remains if it is only existence in many circumstances.
What is patient dignity and what was the person’s thoughts about dependency.
In India, advanced directives for refusal of treatment are not considered in situations of emergency.
However, there is a clear distinction when patient refuses a particular treatment however important it is, for prolongation of life and agrees to embark on the natural course of the disease even if it means death.

Where does time fly to? ~ Kaanthal Manikandan

Watching the cars as they sail by
Each entrusted with a different destination, a different journey
A different comfort, a different life.
She pushed her warm brown hair off her shrugged shoulder
For a moment, suddenly, the world grew colder

Editorial

Dear kind patrons of the KAUVERIAN
Today we launch Vol 2, issue 1.
We thank our authors who made 12 issues possible in the first half of 2021. That was unimaginable when we tender footed with the first issue. Thanks a million! It has been a pleasure and privilege to carry your work.

Editorial Board

Presenting the team that brings you critical cases and immense insights from the world of Kauvery Hospital

Guest Editorial ~ Dr Vinod Gunasekaran

Pediatric Hematology and Oncology (PHO) is a relatively new area of study in medicine, yet has seen significant advances in the recent decades

Convalescent Plasma Therapy in Covid-19: A Question of Timing ~ Dr Dominic Rodriguez

Convalescent plasma therapy (CPT) has a 100-year-old history. In 1890, Behring and Kitasato, published their discovery that graduated doses of sterile broth cultures of diphtheria or of tetanus bacilli, when injected, caused the animals to produce, in their blood, substances which could neutralize the toxins which these bacilli produced (antitoxins). Behring exposed horses to diphtheria and later extracted the sera from these horses and injected it into patients with diphtheria and found that it prevented fatal complications.

High Dose methotrexate in Children with Cancer Without Drug Level Monitoring – 133 Cycles Experience ~ Dr. Vinod Gunasekaran, Dr. Suresh Chelliah, Dr. Senguttuvan Duraisamy

High dose methotrexate (HDM) is effective in decreasing extra medullary relapses in childhood leukaemia's and lymphomas. Availability of serum methotrexate level monitoring is limited to few centers in India.

Prenatal diagnosis in Thalassemia – Prevention is better than cure ~ Dr. Vinod Gunasekaran, Dr. Malathi G Prasad

Thalassemia is one of the common hereditary blood disorders. Various clinical, psychological and financial problems make huge impact in the affected family. In India, there are nearly 42 million carriers of β-thalassemia genes. Identification of carriers and preventing births of thalassemia major patients is essential to decrease the disease burden in the country.

Improving Outcomes in Children with Cancer – Our Experience ~ Dr. Vinod Gunasekaran, Dr. Suresh Chelliah, Dr. Senguttuvan Duraisamy

Outcome of children with cancer is steadily improving over the recent decades. Developing countries face a different set of problems in treating pediatric oncology patients as compared to developed world

Autologous Stem Cell Transplantation for Myeloma with CKD ~ Dr. Subbaiah RM, Dr. Prabhakaran Shankar

Multiple myeloma is a clonal plasma cell disorder comprising 10% of haematological malignancies and accounts to 1% of all malignancies [1]. It has a male sex predilection affecting more African-Americans in comparison to Caucasians [2]. The median age of patients at the time of diagnosis is about 65 years [3]. Clonal plasmacytosis can be medullary or extramedullary and may cause hypercalcemia, renal failure, anemia and lytic bone lesions. Risk stratification is based on cytogenetics. Risk adapted initial therapy followed by autologous stem cell transplantation in eligible patients is the current standard of care. Initial induction therapy usually is a triplet regimen comprising of a proteosome inhibitor, immunomodulatory agent and steroid. Renal failure may add on to the existing complications of treatment in myeloma affecting overall survival.

All Megakaryocytic Macrothrombocytopenia Are Not ITP ~ Dr. Subbaiah RM

Thrombocytopenia with adequate megakaryocytes in marrow, other possible causes being ruled out constitutes a diagnosis called immune thrombocytopenia (ITP). Hence it is a diagnosis of exclusion and an immune mediated mechanism explains the clinical consequence

Telomeropathies And Our Experience: A Case Series ~ Dr. Subbaiah RM, Dr. Vinod Gunasekaran, Dr. Thinaker Mani

Telomere is a region with repetitive nucleotide sequences at each end of a chromosome, which protects the end of the chromosome from deterioration. Progressive shortening of telomeres leads to senescence, apoptosis or oncogenic transformation of somatic cells. Inherited conditions caused by genetic defects in the telomere maintenance machinery are called telomeropathies [1]. Symptoms of these disorders are extensive and may include features of bone marrow failure, pulmonary fibrosis, liver disease, skin/mucosal pigmentary abnormalities and cancer predisposition

Neurology Update – Neurobiology of Sleep ~ Dr Prithika Chary

The earliest information about the neurobiology of sleep and wakefulness was in the 1930’s. Since then, advances in the neurosciences have been explosive and we know more about the body’s natural rhythms and the sleep/wake cycle today.
Lack of sleep and disorders of sleep/awake function is a common health problem in the modern world. Shift work, travel across time zones, maladaptive sleep habits, overuse of blue light emitting devices further compound the harm to the body’ s natural biological rhythms.
A coordinated sleep/wake cycle is necessary for us to maintain health and optimal cognitive function.

Journal Scan ~ Dr Suresh S Venkita

For more than 12 years, I lived with undiagnosed chronic pain, spinal problems, pelvic floor dysfunction, gastrointestinal issues, bladder problems, bleeding tendency, and easy scarring, among other symptoms. I was exhausted. Living with all these problems in combination made my daily life debilitating and challenging on a practical level. But even more difficult was not being believed about my physical problems by health professionals.

The Brush Stroke ~ Kaanthal Manikandan

For every word is a drop of paint
And the universe turns into my canvas
As I watch my colors and blank space acquaint
From the proudest star to the most delicate flower

Editorial

Dear colleagues, readers, potential authors,
The KAUVERIAN, Vol 1 will close with Issue 10 by end of June. Vol 2 will be launched in July.
This issue has several " FIRSTs!"

Editorial Board

Presenting the team that brings you insights and interesting cases from the world of Kauvery Hospital

Guest Editorial ~ Dr Mani Ram Krishna

Congenital Heart Diseases (CHD) have an incidence of 0.8–1.2% irrespective of the population [1–3]. This means that approximately 1 in 100 pregnancies is complicated by CHD. In India, a substantial effort is being made by the government and private sectors to reduce the Infant Mortality Rate to globally acceptable standards.

Clinical MIS – A Clinical Analyst Review ~ N. Gethsial Kiruba

A management information system (MIS) is an information system used for decision-making, and for the coordination, control, analysis, and visualization of information in an organization. Hospital Management Information System is implemented in a hospital for managing patient care and related administrative functions. Group Clinical MIS was evolved to streamline overall clinical process, to monitor key performance indicators and to share the best practices being followed among the units. There are totally 44 major categories in which the clinical parameters are subcategorized. Analysis of these parameters and discussing it in the central forum will enable us to share insights and thereby improve overall performance of each hospital and in specific areas that are identified. This article focuses on the evolution of clinical MIS and its effectiveness in quality improvement.

Eclampsia and HELLP Syndrome: A Case Report ~ R. Nagesh, N. Mohan

The HELLP syndrome is characterized by hemolysis (H), elevated liver enzymes (EL) and low platelet count (LP). This syndrome in general complicates 0.2–0.6% of all pregnancies but its incidence increases to 4–12% in severe preeclampsia. In about 15% cases, HELLP syndrome presents without definitive criteria for preeclampsia (atypical preeclampsia).

Percutaneous Device Closure in A Toddler with PDA and Interrupted IVC ~ Dr Mani Ram Krishna, Dr Suraj Narasimhan, Dr Karuppiah

Per-cutaneous occlusion of the patent ductus arteriosus is achieved by deploying an occluder from the femoral vein. Abnormalities of the systemic venous pathway such as interruption of the inferior vena cava necessitate modification of the technique of per-cutaneous occlusion. We report a 1-year-old child with interruption of IVC and PDA in whom we closed the PDA utilizing a novel maneuver.

Paediatric Car Passenger Trauma – A Case Report and A Review of Child Safety Inside a Car ~ Dr S. Chockalingam

Car travel which was a luxury in our country in the last century, has now become a way of life for our children of this century. Cars have become better; we are able to travel faster on good roads. Hence it is essential for us to know the safety aspects when travelling with our children. The literature shows benefits of reducing fatal injuries. The non-compliance of these child safety aspects in developed countries and lack of awareness in developing countries are also quoted [3,4]. This article is written to improve the awareness of child safety during car travel. We illustrate this with a case report of a paediatric trauma patient without following recommended child safety recommendations.

Use Of Antibody Cocktail, Regn-Cov2, In Two Non-Hodgkin’s Lymphoma (NHL) Patients with Mild Covid-19 Disease, At A Tertiary Care Hospital in South India: A Case Series ~ Dr Anita Ramesh, Dr Andrew C. Fenn, Dr Sivaram Kannan, Dr Ezhilan Naganathan

Patients on active cancer treatment, who test positive for SARS-COV-2, are at high risk for progression to severe illness. REGN-COV-2 is an antibody cocktail which can be used in these patients to reduce the risk of progression to severe illness, thus improving their outcome. REGN-COV-2 should be considered in all cancer patients on active treatment within the first five days of testing positive of SARS-COV-2, prior to the initiation of endogenous immune response.

Neurology Update ~ Dr Prithika Chary

Any one who treats Parkinson Disease is familiar with the on/off syndrome which is a distressing complication of levodopa therapy in these patients. In addition to the progressive nature of the disease, as the disease advances the chances of the on/off syndrome increase. In this article which is a summary of a Medscape CME activity we discuss the modern management of this complication with newer treatment options

A review of ten recent papers of immediate clinical significance, harvested from major international journals ~ Dr Suresh Venkita

Older patients who are hospitalized for acute decompensated heart failure have high rates of physical frailty, poor quality of life, delayed recovery, and frequent re-hospitalizations. Interventions to address physical frailty in this population are not well established.

COVID Nails

Signs of COVID-19 in the skin have been noted.
But there’s another part of the body where the virus appears to have an impact: the fingernails.

The Patient Is Always Right ~ Dr Manjunath Gopal

Just before the COVID lockdown, a well-educated and articulate elderly patient was brought to my clinic in a wheelchair.

Humanity’s Most Cherished Fiction ~ Kaanthal Manikandan

Every human is tied to the strings of ‘Strange’
Not one, have I encountered, who fits in Normal’s range

Editorial

The only way to out-smart COVID-19 is to practice 2021- 22 Science, whether it be in Public Health or Clinical Medicine.
Let us outplay COVID 19 by smart moves - by blocking every move by a counter move, by pushing it to a tight corner, and checkmating it on a chessboard of Science and common sense.
Both the KAUVERIAN and the CHRONICLE have only one objective, to carry our thoughts and experience; by expressing our thoughts and actions, through words and images, all of them as clear as a bell, and as sharp and bright as lightning.
As COVID, Wave 2, rises to its peak this week, the KAUVERIAN is matching it, by also rising to its peak

Editorial Board

Presenting the team that brings you insights and interesting cases from the world of Kauvery Hospital.

SARS-CoV-2 vaccination before elective surgery ~ Dr S Velmurugan

I was having a brief conversation with one of my colleagues from a different surgical specialty about the difficulties faced in providing perioperative care to surgical patients during this COVID-19 pandemic. He said he had recently deal with a 65-year-old patient who had major elective surgery and developed severe COVID-19 infection few weeks later and struggled hard to recover back to normal. This patient did not have his vaccination for COVID preoperatively, even though there was a national call for all senior citizens to get vaccinated. He didn’t have the vaccine because he was very much concerned about the side effects. Could this have been prevented by preoperative COVID vaccination after adequate counselling and consenting?

A guideline for patients with diabetes mellitus, towards self-assessment of their feet, during the COVID-19 pandemic times ~ Dr V B Narayana Murthy

Diabetic limb salvage goals of prevention, preservation and protection of the foot from amputation (PPPA) were violently disrupted by the pandemic. The need for reviewing practice guidelines for managing diabetic foot in Indian subjects during the COVID-19 Pandemic became a compelling issue in the context of many challenges that were posed in providing continuity for these vulnerable patients.
With the second wave of the pandemic now in full swing in India in 2021, we have to rethink about how to plan again. What we had planned in 2020 seemed to be the right thing, but never got around to implementing it on a large scale. It is time to rethink.

Evolution of Dashboards and its effectiveness in performance management and efficient utilization of time and energy ~ Ms Kirubha

A dashboard is an information management tool that tracks and simplifies complex data sets and leverages data visualizations, allowing the users to gain quick insight into dynamics of current performance. Dashboards are commonly used for business reviews in various sectors. In a single hospital all critical reports of patients are reviewed and analysed every day. But for a health care organization which consists of more than 5 hospitals, review of the reports is difficult as well as time and energy consuming. Analysis of reports manually has several challenges especially uncertainty of the quality of the data collected. This article focuses on the evolution of dashboards in healthcare setup and its effectiveness in performance management and in efficient utilization of time and energy.

Understanding and Use of Sensitivity, Specificity, and Predictive Values ~ Mr Dhasarathan

We shall discuss the basic knowledge to calculate Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV). We shall also discuss the advantage and limitations of these measures and how we should use these measures in our day-to-day clinical practice. I illustrate below how to calculate sensitivity and specificity, combining two tests and how to apply these results to our day-to-day practice.

Anorexia Nervosa with Compulsive Exercising - A Case Report ~ Dr Yamini Kanappan

A 14-year-old girl with history of amenorrhea, compulsive exercising, and restricting food intake had come for treatment. With a significantly low BMI of 10.6 kg/m2, she was immediately admitted for refeeding, psychometric assessments were also conducted. She was diagnosed with Anorexia Nervosa, restricting type (F50.01) and initiated on Adolescent Focused Psychosocial Interventions. Family-focused Interventions were also provided with the involvement of the parents after care assessment of family dynamics. Within a period of eight months amenorrhea abated, and her BMI reached 18 kg/m2.

A review of recent papers of immediate clinical significance, harvested from major international journals ~ Dr Suresh Venkita

A review of recent papers of immediate clinical significance, harvested from major international journals

Image Challenge ~ Dr Nagarajan

Question: Dark pigmentation that appears in one endocrine disease.

The sequalae of a sea-voyage ~ Anonymous

N and R were a very devoted couple. He was a big built man, an ex-sports man. She resigned from work to indulge him. They had a recent holiday in the Pacific, on a cruise ship, during which he stressed a lot on board, walking and climbing. They returned uneventfully but he noticed vague pains Lt leg and chest, along with a cough.
Few days later, while driving back from their farm house, she suddenly found him breathless and coughing, He was collapsing; she managed to drive him to our ER, while trying to keep him conscious and safe in route.

The Un-relished Performance ~ Kaanthal Manikandan

No lone particle of nature, a shrub or colossal glacier
With the knowledge of never being relished

Editorial

If we study one case well, one patient's problem thoroughly, the education and experience shall last a lifetime. Even our patient's story this week is one such case study. How much time does it take for our DMOs and PG Residents to write a case report? Writing an article and speaking at a CME calls for practice, practice, practice! The fine art of effective communication is learned the hard way, there are no shortcuts.

Editorial Board

Presenting the team that brings you insights and interesting cases from the world of Kauvery Hospital.

To Crush or Not to Crush? Don't Rush to Crush! ~ Ms Surya Prabha

An audit of “Modification of oral medicines for patients with swallowing difficulties or on enteral tubes” – A clinical pharmacist’s point of view.

Effectiveness of Pre – Clinical Competency Certification Program on Improving Knowledge of Clinical Practice Among Nursing Internship Students ~ Ms Kirubha

Nursing competencies are core abilities that a nurse must have to fulfil her role. This is basic to nursing and a significant parameter for freshmen nurses’ job readiness to begin their career in health care. A study was conducted to assess the level of clinical competency among nursing students and to assess the effectiveness of Pre-Clinical competency certification program among nursing students.

Medical Statistics in Clinical Research ~ Mr. Dhasarathan

Inferences on medical statistics in clinical researching deriving the mean, median, mode, standard deviation and so on.

Vertebral artery dissection with thrombosis causing neuralgic amyotrophy ~ Dr Aslesha Sheth

A 34 years old female, with no known comorbidities presented to emergency room (ER) with multiple complaints.

Atypical Electrical Alternans Due to Large Left Pleural Effusion ~ Dr. Vijay Sekar

Electrical alternans refers to beat to beat alteration in amplitude, axis or duration of any of the components of the electrocardiogram. QRS alternans – beat to beat variation in QRS amplitude has been classically described in pericardial tamponade. We report a case of electrical alternans in a middle-aged female in the absence of pericardial effusion.

Early presentation of a rare disorder ~ Dr. Suresh Chelliah

Autoimmune hepatitis (AIH) is a necroinflammatory liver disease of unknown etiology that occurs in the children of all ages. It was identified in the 1940’s and formerly called chronic active hepatitis. AIH has a wide range of presentation, from asymptomatic individuals with lab abnormalities to cirrhosis, characterized by liver transaminase elevation in the presence of autoantibodies, elevated gamma globulin levels, interface hepatitis on histology and a good response to corticosteroids.

Image Challenge ~ Dr Nagarajan

A middle-aged man who was a diabetic on oral hypoglycaemic drugs was admitted for evaluation of acute febrile illness diagnosed to have acute viral pneumonia due to COVID 19. He was hospitalized and treated as a patient for 2 weeks and discharged with oral steroids and other supportive medications. Two weeks later he came with complaints of proptosis of the left eye with restricted movements along with nose block.

The trip on the step ~ Anonymous

An 85 years aged RK was enjoying her visit to family abroad, in the company of her two daughters, which was shortly coming to a close. She was walking down the stairs when she tripped on the last two. A daughter had noticed her swaying and hitting the side of her head on the wall. But she did not seem worse for the wear and coped

The Brush Stroke ~ Kaanthal Manikandan

For every word is a drop of paint
And the universe turns into my canvas
As I watch my colors and blank space acquaint
From the proudest star to the most delicate flower.

Editorial

The KAUVERIAN, whether during pandemic or pandemonium, appears on time! I thank the authors and our production team. It shall be with you on or before 01 May 2021! Thought-provoking articles appear in the KAUVERIAN, Vol 1, Issue 6.

Editorial Board

Presenting the team that brings you insights and interesting cases from the world of Kauvery Hospital.

Hypertension - A renal disease ~ Dr. K. Abirami

What’s new in hypertension guidelines starts with the way we record blood pressure. All the new guidelines talk about standardised office BP measurement.
In the title of the inner page on top left it has to be added under : REVIEW

A new cause for confusion or concern ~ Dr Dominic Rodriguez

The year 2020 was unique experience many physicians will enjoy talking about to students and juniors in the years to come. Present scenario differs from the previous year in the way patients present to us having symptoms and signs of familiar but, confounded by presence of acute or past COVID-19 infection.
In the title of the inner page on top left it has to be added under : CASE SERIES

A rare case of acute aortic dissection secondary to a penetrating aortic ulcer in the ascending aorta ~ Dr Aslesha Sheth

A 63 years old lady who is a known hypertensive on ayurvedic treatment, presented to the emergency room (ER) with the history of sudden onset chest pain radiating to back and profound giddiness with three to four episodes of non-projectile, non-bilious, vomiting since that morning associated with profuse sweating.
In the title of the inner page on top left it has to be added under : CASE REPORT

Pacemaker in children – Big shoes to fill for small foot ~ Dr. Joseph Theodore

A 3-year-old barely weighing 13 kg presented with failure of her epicardial pacing system and was implanted a transvenous single chamber successfully taking all due precautions.
In the title of the inner page on top left it has to be added under : CASE REPORT

The Eight Roles of the Medical Teacher – The purpose and functions of a teacher in the healthcare professions ~ Dr. Vasanthi Vidyasagaran

Teaching has always played a central role in medical education, and with the transition to Competency-Based Medical Education, the presented framework may be particularly timely for the Indian context, as it can serve as a basis for newly adapted programs of faculty development and teacher assessment.
In the title of the inner page on top left it has to be added under : BOOK REVIEW

Reducing the stock items – Need to look at the whole picture ~ Mrs Shanthi

Reducing the stock items (medicines and consumables) to save the quality-hours of nurses has been a priority item in the agenda in ward management of hospitals.
In the title of the inner page on top left it has to be added under : MANAGEMENT PAGE

Image Challenge ~ Mr Nagarajan

A 42-years-old lady came with complaints of two weeks’ history of epigastric pain, more since that morning. She also had nausea, and reduced intake of food for the past two months. Pain was relieved by symptomatic treatment from a local hospital
In the title of the inner page on top left it has to be added under : DIAGNOSTIC IMAGE

Mountain behind a mountain

A 33-year-old YX did not expect this ancient French Caribbean proverb to come true in his life. The Proverb said, in pidgin French, that ‘Deye mon gaye mon’. It warned that there could be another mountain on your path, beyond the mountain you just climbed
In the title of the inner page on top left it has to be added under : PATIENT'S STORY

The Disappearing Act ~ Kaanthal Manikandan

Are we as significant as we think ourselves to be?
Am I nothing but a frivolous entity?
When my arms I sway
And patterns I engrave
Does it set off a grain in the milky way?
In the title of the inner page on top left it has to be added under : POEM

Editorial

Honouring the World Purple Day to promote epilepsy awareness, Dr. Prithika Chary writes to us on "Difficult to treat epilepsy syndromes" for the benefit of non-neurologists. Dr. Suresh Chelliah and colleagues gift the journal with an original article, taking over the baton from Dr. Balaji who published Kauvery Research in the last issue. It is our dream that this new found initiative and enthusiasm will blaze forth. Closely on his heels, we have Dr. Ivan Jones, presenting a case series on fungal infections in Covid, a very topical and disturbing complication in Covid. We shall look forward to receiving more such case series.

Editorial Board

Presenting the team that brings you insights and interesting cases from the world of Kauvery Hospital.

Difficult to Treat Epilepsy: A Management Primer for Non-Neurologists ~ Dr. Prithika Chary

Epilepsy is a disorder of recurrent seizures with serious implications especially when seizures are frequent, severe and of long duration.

Such patients have difficult to treat epilepsy and can present a challenge in diagnosis and treatment. More significantly the epilepsy grossly impairs quality of life and has psychosocial implications and carries high morbidity and risk of mortality (SUDEP – Sudden Unexpected Death in Epileptic Persons).

Despite several attempts at various definitions a common ground is not present to decide when a patient fits the criterion of refractory or drug resistant epilepsy, in my practice I choose to have a broader category as difficult to treat epilepsy.

Clinical audit: A Simplified Approach ~ Ms. Surya Prabha

Clinical audit, the cornerstone of clinical governance, ensures that the strategy is executed as planned, and in the process provides a framework to highlight and enable changes to be incorporated ensuring improved patient care. This paper reviews basis of clinical auditing, its methods.

Rationalise and restrict antibiotic use by utilizing a proactive justification form and comparing with earlier antibiotic usage in the same paediatric unit in a tertiary care centre ~ Dr Suresh Chelliah

introduction of justification form, usage of antibiotics decreased by 26.9% (p < 0.001), with increase in de-escalation (p < 0.001) and decrease in duration (p < 0.001).

COVID-19 and fungal infection - an opportune time: a case series ~ Dr. Ivan A. Jones

Four patients recovered and one patient succumbed to infection and thrombotic complication. Meticulous glycemic monitoring, insulin therapy, minimizing antibiotic use and very safe handling of intravenous lines should be practiced to prevent these serious infections.

Thymidine phosphorylase (TYMP) gene stop mutation, G38X, in a familial case of mitochondrial neurogastrointestinal encephalomyopathy ~ Dr. Bhuvaneshwari

Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare mitochondrial disease with a spectrum of neurological and gastrointestinal involvement and characterized Mutations in the thymidine phosphorylase (TYMP) gene.

Image Challenge ~ Dr A Nagarajan

A middle-aged man with no other comorbidities came with complaints of progressive exertional breathlessness since morning. He used to do routine walk for 5 km in a day. With the present condition, he could not make even 100 m without dyspnoea. He drove the car from Trichy to Chennai, on previous day to attend a family function, and returned to Trichy on same day after spending few hours in Chennai.

A Covid survival celebration - I could have danced all night ~ Anonymous

Admitted with COVID, at the age of 97, I knew the probability was high that I would leave the ward, feet first. Age was a bad card to hold in hand as I negotiated my way through the hospital, contemplating my odds of survival from the new C. I would learn about many such bad cards during the days that followed. I watched, listened, and sensed the events that happened around me, hoping to acquire an education before time ran out on me.

Forced to be Human ~ Kaanthal Manikandan

Is it right to be plagued by humanly needs? Mere objects which dilute in oblivion with time Wanting to be the dearest of the lot Or to be encircled by loving accomplices

Call Me ~ Prithika Chary

When others forget your name,
When you have no fame,
Call me

Who is There? ~ Dr. Prithika Chary

When things go wrong, and you need to be strong
ME
Who is there?
When your heart fills with fears, and your cheek wets with tears
ME

Editor's Message - Dr Venkita S Suresh

The KAUVERIAN is delighted to bring you three unique and hopefully memorable publications. The first collaboration between a Kauvery author and our "content creation" team appears in this issue as a pilot project. Dr. Balaji Kirushnan’s study on COVID-19 and Dialysis at Kauvery Hospital Chennai received the full support of our content team and is now ready for national or international publication. I have described the process that shall be put into place when authors and KAUVERIAN shall work together on increasingly more complex and sophisticated clinical research projects.

The Editorial Board

Presenting the team that brings you interesting case reports and stories from the world of Kauvery Hospital.

Neurobiology of romantic love - Dr Prithika Chary

Love is an innate emotion hardwired into humans.

It takes many forms – maternal love – the first manifestation of love we experience/romantic love which we feel in our youth and a necessary social need to bond with others of the same species for procreation and propagation of the species to survive and thrive.

An interdisciplinary approach to treatment of juvenile OCD - a case report - Dr Aishwariya Ramesh

Identification and diagnosis of OCD for children can be arduous as they may not be forthcoming with their problem. Using a combination of pharmacotherapy and psychotherapy is insisted over just one treatment method

Fanconi Anaemia - Need to look at the whole picture - Dr. Suresh Chelliah

Fanconi Anemia is a rare inherited disorder, characterized by chromosomal instability, wide clinical presentation and a predisposition to cancers, especially Acute myeloid leukemia.

The Art and Science of Preparation and Publication of Medical Research from Kauvery Hospitals - Dr Venkita S Suresh

During the nine months from April to December 2020, Kauvery Hospitals admitted over 7,000 patients of COVID-19, with moderate, severe, or critical disease, and sent 95% of patients safely home. We also treated well over 100 doctors in the community and sent 98% of them safely home.

Those outcomes owe their genesis to the practice of Evidence-Based Medicine. That evidence now deserves to be published.

Fundamentals of Statistics - T. Dhasaratharaman

Understanding the fundamental of statistics and their definitions.

Image Challenge - Diagnostic Challenges

A 65 years old man presented with complaints of fever, and cough with sputum for the past 2 weeks.

A Wake-up Call from the Anaesthesiologist - Dr Senthil Kumar

Anaesthesiologists play a pivotal role in all surgical procedures and emergency health services (as analogized with the pilot in an aircraft, by the author). The author Dr. Vasanthi Vidhyasagaran is a versatile teacher and mentor to a significant number of Anaesthesiologists for more than three decades. She is also a renowned, highly regarded and efficient anaesthesiologist with vast experience in various aspects of Anaesthesiology.

The Child who never knew play

A 11-year-old girl from Africa came to Kauvery to tell us that she had never played in her life. Long back she and the family were told that she had seizures for which she must take medicines life long and avoid physical activity. When her friends and class mates ran about, chased each other, climbed trees, swam, and played football she sat and watched, drowsy and awkward under the effect of medications. Her mother was unhappy and brought her to Kauvery. Read her story.

The Fallacies of Perfection - Kaanthal Manikandan

The human soul, distant from the horrifying divinity of perfection
Takes upon its troubled mind the deed and tries to drown in retrospection
Retrospection of the conscience, they don’t choose
But retrospection of all illusions of vain

Editor's message - Dr Venkita S Suresh

We are delighted to feature three new authors. Dr. Vinoth brings to you a deeply moving report from Trichy, on a 5-year-old child with Acute Lymphoblastic Leukemia. Kauvery Hospitals is committed to offering our patientpopulation a dynamic haemo-oncology service which shall strive to achieve optimal clinical outcomes.

Preparing your manuscript

Dr. Prabhaharan Renganathan, Technical Editor, Kauvery Hospitals

Everything you need to prepare a detailed manuscript.

Pulmonary valve endocarditis

Dr D Senguttuvan, Dr P Vijay Shekar

We report a case of pulmonary valve endocarditis, who presented with fever and pulmonary regurgitation murmur, and was successfully treated with appropriate antibiotics.

Upper limb replantation at different anatomical levels

Dr Kiran Petkar

The author presents three consecutive cases presenting with such injuries at different anatomical levels that were managed at Kauvery Hospitals during the COVID-19 pandemic. Three cases were operated and in all the cases salvage of the part was possible and good recovery to functionality was seen.

Re-challenging asparaginase after cerebral venous sinus thrombosis in 5-year-old with acute lymphoblastic leukemia

Dr Vinod Gunasekaran, Dr Akila Narasimhan, Dr D Senguttuvan, Dr Suresh Chelliah

A 5-year-old boy developed multiple painful large joint swellings with restricted movements for two weeks, fever for 10 days with bilateral cervical lymphadenopathy. A diagnosis of T-cell acute lymphoblastic leukemia was made and chemotherapy was started. He developed PRES and subsequently thrombosis of left transverse sinus and sigmoid sinus while on induction regimen. He improved with anticoagulation, antiepileptic and anti-hypertensive treatment. Chemotherapy was restarted. During re-induction, he was successfully re-challenged with PEGylated asparaginase along with thromboprophylaxis and plasma transfusions based on serum fibrinogen level monitoring. Re-challenge was tolerated without complications. Child had complete neurological recovery.

Prevalence of vitamin B12, folate deficiency and homocysteine elevation in ASCVD or venous thrombosis

Dr Dominic Rodriguez, Dr Stephy George

Vitamin B12 and folate are essential components for the metabolism of homocysteine. Elevated homocysteine has been associated with increased risk of atherosclerotic cardiovascular disease. The aim of the study is to evaluate the prevalence of vitamin B12, folate deficiency and hyperhomocysteinemia in patients presenting with any atherosclerotic cardiovascular disease or venous thrombosis.

Henoch Schoenlein Purpura

Dr A Nagarajan Dr Pushkala M

Henoch-Schoenlein purpura (HSP) is a self-limited, systemic, non-granulomatous, autoimmune complex, small vessel vasculitis, with multi-organ involvement.

Life turns upside down for a young couple and family

Dr Suresh Venkita

When she rang up her fiancé from another city, and found his speech repetitive and incoherent, and mind confused with regard to time and day, she rushed down. He had been through considerable financial stress but did not have a history of affinity for alcohol or drugs. She also found him emotionally very unstable, with features of hallucination and delusion (false sensory perceptions and false beliefs). His level of consciousness was fast deteriorating and the body was becoming very rigid.

The Humblest Wonder

Feels so close feels so near
Like the most graceful illusion
But science tells me you’re real
Drifting so low in the earthly sky

Editor's Message - Dr Venkita S Suresh

The Kauverian hopes to reach you every fortnight.

The articles come in a new font and format, designed by Dr. Prabhaharan, our technical editor, I hope you would find them attractive.

We lead the issue with two case reports, from Drs. Bhuvaneswari and Pushkala. Case reports will never lose their charm. They briefly and briskly convey a clinical encounter and spark a lesson that emits light for a while. Case series can carry that torch forward. We welcome both case reports and case series. So write away!

The Editorial Board

Presenting the team that brings you interesting case reports and stories from the world of Kauvery Hospital.

Rare and complex type of MS, tumefactive multiple sclerosis

~ Dr Bhuvaneshwari Rajendran, Dr Gayathri Ramkumar

We present a patient with tumefactive multiple sclerosis (TMS) with a typical relapsing and remitting course initially but later exhibited secondary progression.

Decoding a difficult fever

~ Dr Pushkala Mittur Sundararajan

A 13-year-old previously healthy adolescent presented with a prolonged high grade fever, lethargy, pharyngotonsillitis and hepatosplenomegaly. Investigations done were inconclusive. His presentation mimicked a bacterial infection. However, his illness persisted and worsened despite appropriate antibiotic therapy. Finally, a serological test was done which was strongly positive for EBV infection. The antibiotics were stopped and he recovered with symptomatic management without any complications.

Excitement of setting up the first tumor board

~ Dr M Banupriya

The excitement of setting up the first tumor board – multidisciplinary team meeting in oncology at Kauvery hospitals.

'Image Challenge - Diagnostic Imaging

~ Dr A Nagarajan

A 65-years-old gentleman presented with complaints of loss of consciousness and vomiting for the past two days. He was diagnosed to have systemic hypertension, diabetes mellitus, and chronic renal failure on hemodialysis. Non-contrast computed tomography of the brain was done.

Patient's Voice - A bolt from the blue

What felt like a muscle pull, but wasn't so simple!

The unique mind - An anthology of poems

Yet another tear drop cruised down her dimple-less cheek. Her face was too numb for her to feel. The wet glistening tear offering all the comfort it could

Kauverian : The Electronic Medical Journal of Kauvery Hospitals

Editorial Message from Dr. Manivannan, Founder and Managing Director of Kauvery Hospitals; and Dr. Venkita Suresh, Group Medical Director of Kauvery Hospitals and Editor-in-Chief of Kauverian Medical Journal

Vascular COVID Diaries

- Dr Arunagiri Viruthagiri, Dr Nedunchezhian Manjini

A collection of the most critical COVID-related vascular complications.

Autoimmune Encephalitis: A success story

- Dr Akila Narasimhan, Dr PV Nimisha, Dr Suresh Chelliah, Dr Duraisamy Senguttuvan, Dr Sivagurunathan Panchanathan, Dr Bichalu Mythili

Autoimmune encephalitis is being increasingly and frequently diagnosed in children with acute and sub-acute encephalopathy because of advances in imaging and molecular diagnostic tests.

Intracoronary Imaging: A case study

- Dr S. Aravinda Kumar, Dr P. Vijay Shekar, Dr Suraj Narasimhan

Intracoronary imaging modalities (IVUS and OCT) are being increasingly used to aid and attain optimal results during percutaneous interventions/angioplasties. We report three cases where intracoronary imaging was used in preprocedural lesion assessment and aided in optimization of angioplasty results.

A patient's voice

What goes on in a patient's mind, as written by one of our patients

'Cure' by Kaanthal Manikandan

A warrior sent by the true ruler
To quieten the battle cries of the self-proclaimed ones
Taking control and taking lives

Seizure in a new born

- Dr Suresh Chelliah, Dr Senthilkumar Kalyanasundaran, Dr Abinaya Sethupathy, Dr Meganathan Pachamuthu

A 17-days-old growing preterm, admitted for feed assessment following parental concern about nasal regurgitation of feeds, developed recurrent seizures requiring multiple anti-epileptic drugs. After the common causes were ruled out, exome sequencing was done. 22q11 deletion conclusive of DiGeorge syndrome was diagnosed.

SLGT 2 inhibitors in Kidney Disease

- Dr R. Balasubramaniyam, Dr Balaji Kirushnan

It is interesting to note that SGLT2 inhibitors beyond diabetic control has emerged as the major treatment with cardio vascular and renal benefits. Every trial has proven their role in reducing their superiority over placebo in reducing the morbidity and mortality associated with cardio vascular and renal diseases.