Latest Kauverian - Scientific Journals

Volume 4 : Issue 1

Editorial

Dear colleagues,
The KAUVERIAN, Jul 01, 22 greets you as we enter the second half of the year
The editor has reviewed the book edited, and a chapter contributed, on "Rheumatic Rarities" by Dr. Sham Santhanam, Consultant Rheumatologist at Chennai. This is an exceptionally well written book, opening with a chapter by him and his colleague.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Ultrashort Case Report

A 62-year-old male with multiple myeloma and renal failure was diagnosed in March 2020 initially at Coimbatore, then at CMC Vellore.

Cochlear Implantation: Expanding candidacy and Cost Effectiveness

Cochlear implants are the most successful sensory prostheses worldwide. A cochlear implant (CI) is a surgically implanted device for the treatment of severe to profound sensorineural hearing loss (SNHL) in children and adults.

Spontaneous Pneumomediastinum in COVID 19 - Tertiary Care Centre Experience in South India

Radiological imaging plays a vital role not only in the diagnosis but also in the surveillance of patients and guides the physician in the management of patients with COVID-19 infection. The presence of spontaneous pneumomediastinum (SPM) among the varied presentations has been reported rarely as a case series. In this article, we reported our experience in spontaneous pneumomediastinum related to COVID-19 pneumonia.

Amoxycillin Induced Anaphylactic Shock: A Case Report

Anaphylaxis is an acute, potentially life-threatening, generalized, or systemic allergic reaction that is mediated by the degranulation of mast cells and basophils. Drug hypersensitivity is one of the most frequent causes of anaphylaxis [1]. Beta-lactams are the most commonly prescribed antibiotics and are responsible for the majority of hypersensitivity reactions to drugs [2,3].

An Unusual Cause of Seizures: A Case Report

Pseudohypoparathyroidism, a rare hereditary endocrine disorder, characterized by peripheral resistance to Parathormone (PTH) and preserved renal function, presents with hypocalcemia and hyperphosphatemia, along with high levels of PTH. This entity varies from hypoparathyroidism, where hypocalcemia results from low levels of PTH.

Case Report

Successful Re-Transplantation With ECMO/IABP And Inter-Atrial Septostomy As A MCS Bridge For Cardiogenic Shock Due To Cardiac Allograft Vasculopathy
Cardiac Allograft Vasculopathy is the Achilles heel of survival following heart transplantation.

Educational Strategies to Promote Clinical Diagnostic Reasoning

Clinical teachers differ from clinicians in a fundamental way. They must simultaneously foster high-quality patient care and assess the clinical skills and reasoning of learners in order to promote their progress toward independence in the clinical setting.

Rheumatic Rarities

It is not often that one gets to review a book edited by a colleague. Dr. Sham Santhanam is Consultant Rheumatologist at Kauvery Hospital, Chennai.
The book is a publication by the Indian College of Physicians, the academic wing of the Association of Physicians of India.

Types of sampling methods in statistics

Probability sampling strategies typically use a random or chance process, although there are important exceptions to this rule. Random sampling is a strategy for selecting study participants in which each and every person has an equal and independent chance of being selected. What does it mean to be independent? The researchers select each person for the study separately.

Diagnostic Image

Diagnosis: Cyanosis in congenital methemoglobinemia, finger tips in comparison to mine.

Learning from Experience - Intra Operative, Chapters 21 and 22

A 28-year-old man was admitted for Webster's procedure for bilateral gynaecomastia. He was obese, weighing 130 kg; BMI=36. No history of comorbid illness. All investigations were within normal limits. He was taken up for surgery under general anaesthesia after overnight starvation, premedicated with Glycopyrrolate 0.2 mg, and Fentanyl 100 micrograms.

The Consultation Room

This arrangement is irksome, but inevitable, in larger establishments, with several visiting consultants, coming at various times. The available consultation chambers are efficiently allotted to the 'outside' consultants, at different time slots, to accommodate maximum number, in their limited facility.

Journal Scan

A review of 20 recent papers of immediate clinical significance, harvested from major international journals
A 27-year-old man presented to the dermatology clinic with an asymptomatic rash on his back, arms, and hands that had developed 1 week earlier. He had a history of obesity and consumed a high-fat diet with frequent alcohol use.

Editorial

Dear colleagues,
The Guest Editorial comes from Dr. Karpagambal Sairam, Consultant Ob Gyn, KCH, on Covid and Pregnancy. She shares her unique Indian perspective on the recent BMJ editorial on the subject. I quote her "A happy, unique, experience of going through pregnancy turned out to be a nightmare for many."

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Diagnosis and Management of COVID-19 in Pregnancy

We know that COVID shook the entire medical fraternity and every specialty of medicine has borne the brunt of COVID infection. I am very glad that BMJ has published this excellent article which encompasses the complete spectrum of clinical features, laboratory investigations, diagnostic challenges in pregnancy and treatment protocols that differed from one unit to another as the risks to the fetus were also to be considered. COVID in pregnancy is a potential chapter for the Obstetric textbooks in the forthcoming years ...

An ultrashort report

MICS CABG with LIMA and Left Radial artery, harvested by Endoscopic technique
The patient was a 53-years-aged gentleman who had presented with unstable angina for the first time.

Ultra-Short Case Report

A 70 years male came with abdominal pain after food intake & loss of weight for 3 months.

An interesting case of Bilateral Carotid aneurysms

Aneurysms of the carotid artery are rare with multiple underlying etiologies. Treatment is largely open surgery but medical and endovascular therapies have been used based on presentation, anatomy, and etiology. Here we present a case of bilateral saccular carotid aneurysms where we have operated on the symptomatic side.

A Case Report

Coarctation of Aorta Presenting as Spontaneous Subarachnoid Hemorrhage in a Young Male
Coarctation of the aorta (CoA) is one of the common congenital cardiovascular diseases. CoA can be diagnosed over a wide range of ages, with varying degrees of severity, and in various presentations.

Uterine artery embolization: Saving a mother and her motherhood

Post-partum haemorrhage (PPH) is a dreaded complication of pregnancy. Maternal mortality is one of the crucial parameters of healthcare planning in our country. This condition is most commonly managed by hysterectomy wherein the bleeding uterus is removed to save the life of the mother. In this article we present a case of PPH where we could save the uterus along with the life of mother by a co-ordinated multispeciality management involving gynaecology and interventional radiology expertise.

Acute Abdomen - Sepsis - CIRCI: A Success Story

Evaluation of acute abdomen is difficult because various factors can obscure the presentation delaying or preventing the correct diagnosis, with subsequent adverse patient outcome. Multiple diagnoses must be considered which pose a diagnostic challenge but timely intervention is necessary to limit morbidity and mortality.

Diagnostic Image

Diagnosis: Pyoderma gangrenosum

Learning from Experience - Intra Operative, Chapters 19 and 20

A 20-year-old, well-built man presented with history of difficulty in breathing and sudden bouts of coughing on lying down. Clinical evaluation did not correlate to a respiratory tract infection or exercise-induced cardiac pathology. His oxygen saturations were 92-95% on air, hemodynamically stable. Chest auscultation revealed rales on both sides. Post-nebulisation with steroids and bronchodilators, symptoms were slightly better. He had no stridor preoperatively. He required to be slightly sat up 30 to 45 degrees to breathe without having obstructive symptoms. He had no other comorbidities.

The Consultation Room

It's very important that the Doctor gets involved in some community service activity, especially for those practicing in rural and suburban areas. Medical profession has maximum opportunity and potential to carry out humanitarian service.

Journal Scan

A review of 15 recent papers of immediate clinical significance, harvested from major international journals
Importance: The requirement of prolonged intravenous antibiotic courses to treat infective endocarditis (IE) is a time-honored dogma of medicine. However, numerous antibiotics are now available that achieve adequate levels in the blood after oral administration to kill bacteria. Moreover, prolonged intravenous antibiotic regimens are associated with high rates of adverse events. Accordingly, recent studies of oral step-down antibiotic treatment have stimulated a reevaluation of the need for intravenous-only therapy for IE.

Severe Methemoglobinemia, Unresponsive to Methylene Blue

Acquired methemoglobinemia occurs due to various poisonings such as plant fertilizers. We report a 28-years-aged female patient who consumed a plant energizer containing oligosaccharide resulting in methemoglobinemia. This was a challenging case that required modalities apart from regular treatment of methemoglobinemia with methylene blue. In spite of maximum dose of Methylene Blue (MB), methemoglobinemia was very high warranting the use of other ways. We used exchange transfusion, successfully treated and discharged in neurologically good status, and normal blood gas values.

Severe Meliodosis With Multisystemic Involvement: A Case Report

Melioidosis is a potentially life-threatening infection caused by the Gram-negative bacterium Burkholderia pseudomallei. Diagnosis of melioidosis is difficult due to its diverse clinical manifestations and ability to mimic many other diseases. We report a case of severe melioidosis in a patient known to have diabetes, who developed lung involvement, with multiple cavitating nodules in both lungs, and also mediastinal lymphadenopathy, both seen in thoracic computed tomography. He had an extrapulmonary lesion on the left side of cheek. Lesions were also seen in the infratemporal fossa with extension into left anterior temporal lobe with bony erosion. B. pseudomallei was cultured from blood sample. This case report highlights the importance of recognizing cavitating nodules as a radiological manifestation of melioidosis to facilitate the prompt administration of appropriate antibiotic treatment, thus reducing morbidity and mortality.

A Case Report

Diabetes Ketoacidosis Masks the Presence of Acute Pancreatitis from Severe Hypertriglyceridemia
The incidence of hypertriglyceridemia-induced pancreatitis is low; however, patients with risk factors such as diabetic mellitus, alcohol, medications and pregnancy can develop severe disease. Acute pancreatitis is a potentially fatal clinical entity, and results in significant mortality and morbidity. It has multiple etiologies, and it is important to identify the exact cause and provide appropriate care. In this case report, an elderly, obese, patient's initial presentation with Diabetic KetoAcidosis masked the presence of pancreatitis. She was efficiently managed with insulin infusion and with measures to lower serum triglycerides. Patient was advised lifestyle modification, diet, hypolipidemic drugs and discharged home.

Recognize Rhabdomyolysis early to prevent Acute Kidney Injury and Acute Renal Failure

Acute Kidney Injury (AKI) is a complication of rhabdomyolysis. In this article, we discuss the case of a 31-year-aged male who was found unresponsive and brought to ER in an unconscious state by an unknown person, who developed acute kidney injury and needed dialysis for long-duration. This case review emphasizes the importance of recognizing rhabdomyolysis in an unresponsive patient with severe metabolic acidosis, its aggressive management, and a thorough understanding of the precipitating causes of rhabdomyolysis in order to prevent acute renal injury which in turn may even lead to a potentially lethal complication-ESRD (end stage renal disease)

New Onset Refractory Status Epilepticus (NORSE)

Status epilepticus is a life-threatening emergency, especially if refractory. While immediate treatment of seizures is paramount, it is also important to establish the cause. Up to 20% of patients with refractory status epilepticus have a negative initial workup, these represent up to 60% of de novo refractory status epilepticus and most are previously healthy young adults and children. Such cases have been variously referred to as having new onset refractory status epilepticus (NORSE) or idiopathic catastrophic epileptic encephalopathy. They have also been classified as 'possible encephalitis', since some have a preceding febrile illness and the diagnosis of autoimmune and infective encephalitis does not require an identified pathogen or antibody. NORSE is thought to be rather rare. Here we discuss a patient presenting with NORSE.

Sensitive of EFAST in trauma in correlation with CT scan

Trauma is one of the leading causes of death worldwide. It often involves many organ systems. Major trauma is best managed at dedicated centres. Death from trauma may have a trimodal pattern [1], thus time is precious. Effective management of trauma should be done within the golden window period to reduce morbidity and mortality by following Advance Trauma Life Support protocol. These patients cannot be shifted for imaging as they are haemodynamically unstable requiring resuscitation. Ultrasound in the form of Extended Focused Assessment Sonography for trauma came to the rescue in managing such patients with its advantage of being a bedside procedure, a simple, real-time, noninvasive tool. In the majority of traumatic injuries, death occurs basically because of time delay in diagnosis, often related to the time taken in the transportation of patients with major blunt injuries of the thorax and abdomen. With the use of enhanced focused assessment sonography in trauma, early detection of blunt injury and early resuscitation may help in a better outcome.

Sub Arachnoid Haemorrhage, management in Emergency and Neuro Intensive care

Subarachnoid Hemorrhage (SAH) is bleeding into subarachnoid space, often due to a ruptured aneurysm.
Aneurysm SAH is most often a devastating event. Twenty percent of strokes are hemorrhagic, including SAH and Intra Cranial Hemorrhage (ICH), each accounting for 10%. Spontaneous SAH is caused by ruptured saccular aneurysm; other causes of SAH include trauma, Arterio-Venous Malformation (AVM), fistula, vasculitis, intraarterial dissection, amyloid angiopathy, bleeding diathesis and illicit drugs (cocaine and amphetamine).

Uncommon presentation of Takayasu Arteritis as a convulsive syncope

Takayasu Arteritis (TA) is a chronic granulomatous vasculitis of the large vessels mainly involved in aorta and its main branches, is prevalent all around the world. It causes stenosis of large arteries and ischemic damage to target organs. There is usually a delay in recognizing Takayasu arteritis because of the rarity and unfamiliarity with the disease and nonspecific early symptoms.

All right sided hearts are not Dextrocardia

A 57/M, known to indulge in smoking and alcohol, presented to the ER with chief complaints of breathlessness and cough for the past four days.
He complained of worsening breathlessness, for the past four days, present at rest and on lying down, also at night, forcing him to sit up. He also had swelling in both legs. He had intermittent dry cough also for the same duration.

COVID and the Salt Story

Each wave of COVID brought with its unique presentations! Our emergency physicians learned to suspect COVID with tell-tale signs, since the definitive RT-PCR COVID results reports become available only after 6-8 h.

Acute Lower Limb Ischemia: A Clue to Underlying Aortic Dissection

Although not common, acute leg ischemia is an important element in the clinical presentation of a patient with aortic dissection. The incidence of acute lower limb ischemia as a clinical presentation of a patient with underlying acute aortic dissection is almost 26%. This report describes a case of aortic dissection in which the main feature at presentation was acute left leg ischemia. Acute aortic dissection is an acute medical emergency with high mortality rate. Aortic dissection, when suspected, is confirmed by emergency computed tomography. Aortic dissection is potentially lethal if misdiagnosed or if recognition is delayed.

Globe Injury with Orbital Blow Out Fracture

This case report describes the diagnosis and treatment of a left-sided orbital floor fracture with globe injury, a brief discussion about the indication of surgery, and about recovery from orbital floor fractures. Globe injury with orbital blowout fracture is uncommon. However, the current case illustrates that such an occurrence should be in the differential diagnosis and should be considered when confronted with impact injuries involving a foreign object.

The heat-stricken life - Treatment in time only saves lives!

Heatstroke is the most hazardous condition in a spectrum of illnesses progressing from heat exhaustion to heatstroke, in which a shared finding is hyperthermia (i.e., the rise in core body temperature when heat accumulation overrides heat dissipation during exercise or exposure to environmental heat stress). In this case series, we discuss about acute onset presentations of heat stroke which mimic as sepsis and discuss the treatment, management and prognosis of heat stroke in patients. This work emphasizes on early recognition and swift treatment to improve the outcome of a patient suffering with heat stroke and avoiding the utter tragedy of mortality.

Pneumoperitoneum, does it have any clinical significance?

Pneumoperitoneum is a life-threatening diagnosis that requires timely diagnosis and action. We present a case series of patients with perforated hollow viscus who were accurately diagnosed by emergency physicians using point-of-care ultrasound (POCUS) while in the emergency department (ED). It can also be detected on x-ray, but small amounts of free peritoneal air may be missed and are often detected on computerized tomography (CT) [1]. The most common cause of a pneumoperitoneum is a perforation/disruption of the wall of a hollow viscus.

Hypertensive Emergency in the ED

Hypertension is a common chronic medical condition with around 30% prevalence in India. Around 1-2% of patients with hypertension develop a hypertensive crisis during their lifetime. Uncontrolled hypertension can progress to a hypertensive crisis defined as a systolic blood pressure >180 mmHg or a diastolic blood pressure >120 mmHg.

Role of a paramedic in inter-hospital transfer

As soon as I got over with my daily routine work, as I was wrapping up and getting ready to go home, my phone rang. I immediately gathered that I have been paged to transport a patient from the critical care unit of our hospital to another hospital.

Golden Hours in Safer Hands

Ambulance services play an important role in the healthcare system when it comes to handling any accidents or acute illnesses outside the hospitals. The emergency medical services team are the true first responders to any situation be it an accident, an assault, an industrial injury, an acute cardiac event, acutely worsening neurological event, an attempted suicide, or any other medical or surgical emergency that occurs outside the hospital premises. The patients are frequently transported by ambulance to the hospital's emergency departments (EDs). Only on arrival at the ED, the responsibility for the patient's further care is transferred from the emergency medical technician (EMTs) to ED staff.

Through rough, crowded roads and stagnant waters - we race against time to reach you!

There is never a day that is not challenging! Every single day poses us different challenges - often we tread through rough roads, and climb through treacherous heights, to reach the patient. There have been times when we had to swim through deep and dirty waters (especially during the Chennai floods), search the location of a wrong address shared, break open locked doors, walk through tiny corridors, and unravel the mystery of why our patient landed up being the way he/she was found. We evaluate, stabilize, inform the status to our ER and rush back. Almost every time we race, both ways, against time to save a patient's life.

Editorial

Group Medical Director, Kauvery Hospitals, India

Evolution of Emergency Medicine in India and the Emergence of the MEM Program at Trichy

Emergency medicine is the medical specialty concerned with treating acute illnesses, (medical and surgical, including trauma), among all age groups, that require immediate attention and redressal.

Welcome to the Dance floor: The Emergency Room

"Medicine is more art than it is science."
While we spend our initial years of medical school in understanding disease, illness, and sickness: clinical practice and teamwork help us in understanding health, healing and wholeness.

Life of An Emergency Physician

Parental advisory: If you are suffering from anxiety symptoms, and have underlying serious cardiac issues, it is suggested you seek medical attention before proceeding to read this article.

A Racing Heart Beat: To Shock or Not

Ventricular tachycardia (VT), which most commonly occurs in patients with structural heart disease, can be associated with an increased risk of sudden death [1]. The most common cause of ventricular fibrillation is acute coronary ischemia, whereas a myocardial scar from prior infarct is the most common cause of sustained monomorphic VT in patients with structural heart disease. More benign forms of idiopathic VT can also occur in the absence of structural heart disease. Treatment of VT involves both emergent management and prevention of recurrence with medical and device therapy. The left ventricular ejection fraction is most frequently used to stratify patients who are at risk of sudden death. This article the importance of recognizing a sustained pulsed VT, and preventing it from progressing into a cardiac arrest with appropriate treatment involving synchronized cardioversion, thereby reducing the chances of cardiac arrest.

Being Calm Amidst Chaos: Tips on How to Be an Expert Emergency Nurse

There are days when you find that everything is in a crisis mode for you - work deadlines nearing and pressures mounting! Days when you rush to reach work but, en-route, the transport breaks down. And, when you reach breathless and run in, you bang your head on the door. Despite how efficient you are, there are days when you fail to balance work and life.

COVID COVID everywhere, but not a place to run away from!

"Don't worry mom, we are safe", I kept repeating over the phone to my anxious mother who was contemplating to take me home, scared of this pandemic.

Proud to be an Emergency Nurse: Life in the fast lane!!!

The day of a nurse in the 'Emergency' is unpredictable. It is a roller coaster ride over the rails of expectations, emotions, endeavor, and excitement when you see off your patient to a safe destination. One moment you are high, the next moment you could get low! At the peak, you feel great when you save a patient, at the low point you could break down and cry when you lose!

The Journey of a Fresher Nurse in the ED

"A Nurse is one who opens the eyes of a newborn, and gently closes the eyes of a dying man. It's indeed a blessing to be the first and the last to witness the beginning and the end of life".

Ready, Steady, Go!!!

A brief on Green Corridor activation in Organ TransplantationThat is what they say in organ transplantation as soon as the team receives a live alert for organ harvesting and transplantation.

An Elevator Story!!!

I was posted in CCU, on a routine afternoon shift. When I was on my way to visit my ER team on the seventh floor, I got dropped off on the sixth floor and walked to the seventh floor using the stairs. When I stepped onto the seventh floor, the elevator door was wide open, and there was a small group of people holding an unconscious, unknown person. I immediately called for help, to give a hand to the people who were carrying him from the elevator to the ED. Within those few seconds of shifting, my brain was bombarding me with questions: "What happened? Who's he? When did this happen? Is there anyone with him?". Soon I was sensing my own adrenaline-provoked tachycardia in my chest as my heart raced, wondering what was really wrong with this man...

Veno-occlusive mesenteric ischemia: A case report

Small bowel ischemia, also called mesenteric ischemia (AMI), is a potentially "time sensitive" and life-threatening condition that reduces blood flow to the small intestine (duodenum, jejunum, or ileum). Symptoms can range from mild to severe depending on the etiology. In severe cases, loss of blood flow to the intestine can damage intestinal tissue and possibly lead to tissue death - gangrene. Bowel ischemia due to compression of the superior mesenteric vein is less common. Hence, we report a case of veno-occlusive mesenteric ischemia in which timely diagnosis and management achieved salvage of bowel, avoiding resection.

Stridor: An Alarming Sign in Emergency

Stridor represents an emergency situation and may require urgent respiratory assessment or ENT opinion. We herein, present a case of 77-years-aged gentleman with supraglottic mass who came with stridor and hoarseness of voice. CT neck showed asymmetric circumferential thickening involving bilateral aryepiglottic folds, false & true vocal cords, paraglottic space, and anterior part of thyroid cartilage, with transglottic extension into the subglottis. Emergency tracheostomy was done under MAC. Under GA, direct laryngoscopy revealed ulceroproliferative growth which was debulked and sent for HPE. Biopsy revealed moderately differentiated cell carcinoma - Grade II. Patient was stridor free after the emergency tracheostomy and was advised to follow up in oncology OPD for further management.

Amnesia in the ER: That Ghajini Moment!!! A Case series

Being a department of variety and unpredictability that baffle and keep the adrenalin pumping, we often see a number of unique presentations. I have herewith compiled a case series on patients who presented to ER with amnesia.

Survival After Paraquat Ingestion: A Case Series

Paraquat is a broad spectrum, bright green, pungent liquid herbicide widely used across the world in agricultural applications and general weed control. Paraquat is commercially available as dichloride salt and dimethyl sulphate [1]. It belongs to a chemical group called quaternary ammonium salts and are generally known as quats. It is registered in India with CIBRC - Central Insecticide Board And registration committee and categorized as highly toxic [2]. Paraquat consumption leads to the formation of superoxide anion, singlet oxygen with hydroxyl and peroxyl radicals in cells, especially affecting lungs, kidney and liver. These reactive oxygen species leads to destruction of cell organelles inevitably leading to cell death. Cases of paraquat intoxication usually results from suicidal attempts and accidental ingestion rather than homicides. Gramaxone and Weedol are usually available brands in India [1].

When you save one life, you save a family

On a busy evening on 23 Mar 21, I was engaged with my patients in the ER, but stealing a look at my watch from time to time to plan my handover by 9 pm, the end of my shift, so that I can get home to take my son who was looking forward to a nice dinner at his favorite restaurant.

Editorial

Dear colleagues,
The KAUVERIAN, 15 May 22 edition shall be delighted to present a galaxy of outstanding authors writing about their exceptional work.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Interventional Nephrology

Interventions have always been part of every nephrologist's day-to-day practice. Nephrologists were routinely creating vascular accesses and were mini surgeons doing Arterio-Venous Shunts. They were even called for help by others in their interventions- to assist cardiologists with their pace maker insertions and anaesthesiologists with jugular catheterisations [1]. The relevance of interventional nephrology in a developing country was well appreciated as early as 1989, when nephrologists were creating AV Shunts and were converting them to AV Fistulas [2]. Till recently it was rather inappropriate to call Interventional Nephrology a new entity.

Amplified Ears and Listening Brains

The Role of Cochlear Implantation in Severe to Profound Sensorineural Deafness
Hearing loss may be caused by interference with the transmission of sound from the outer to the inner ear (conductive hearing loss) or damage within the cochlea, the auditory nerve, or auditory centres in the brain (sensorineural hearing loss).

Love makes life worth living

The greatest moment of satisfaction, which is also the most unforgettable and encouraging for an ICU nurse, is when she sees the happiness on the face of patients who come back to thank her for all the services rendered by her during the tumultuous course of their illness at the hospital.

Usage of Dapagliflozin in Elderly

Dapagliflozin has emerged as a possible cardio-renal game changer. The article summarizes the cardioprotective and renal beneficial effects of dapagliflozin. It is focused mainly on the side effects of the class of SGLT2 Inhibitors.

Severe Methemoglobinemia Treated Successfully with Oral Ascorbic Acid

Methemoglobinemia is one of the rare causes of hypoxemia and central cyanosis. Unless there is high clinical suspicion, the diagnosis of such a condition can be delayed in patients with normal cardiac and respiratory function especially if the only presenting symptom and signs are breathlessness and cyanosis. Methylene blue and ascorbic acid are the two main treatment options for the condition depending on the severity of the illness, with the former being preferred in severe cases and the latter being an alternative treatment option. Here, we report a case of severe methemoglobinemia successfully managed with oral ascorbic acid.

The new imitator

A 7-year-old obese child presented with fever, vomiting, irrelevant and slurred speech with abnormal movements of upper limbs. Acute CNS infection was considered and IV antibiotics and antivirals were started pending blood culture report. MRI Brain showed Cytotoxic Lesion of Corpus Callosum (CLOCCs). Covid IgG was positive raising a suspicion of MIS-C. Methylprednisolone was given. At around the same time. blood culture revealed growth of S.typhi. Antimicrobials other than Ceftriaxone were stopped. His sensorium gradually improved. Obtaining cultures before antibiotic use improve the chances of identifying the offending microorganism and guides appropriate care.

Liver Cyst

Liver cysts can be diagnostic and therapeutic challenges to both clinicians and patients. Simple Liver cysts are the commonest of them. Ultrasound and MRI are diagnostic. Simple liver cysts are usually harmless and untreated

Diagnostic Image

Diagnosis: Dapsone induced skin erythema and hermolytic anemia

Learning from Experience - Intra Operative, Chapters 17 and 18

A 23-year-old girl with no known comorbidities was posted for excision of bilateral fibro adenoma of the breast. She was assessed preoperatively as fit and well, with ASA 1 status. No abnormalities were detected on airway assessment. Results of investigations were within normal limits.

The Consultation Room

There is no better example than Covid-19, which devastated the entire world and many healthcare workers (over 500 Doctors and 2,000 nurses) lost their lives in the process of carrying out their noble services to the victims. As much as it's our 'god-given' duty, it's more important to protect ourselves, by all means possible.

Journal Scan

A review of 15 recent papers of immediate clinical significance, harvested from major international journals
In my 40-plus years as a clinician, I have found that a strong, empathic physician-patient relationship builds the trust that is fundamental to successful patient care. The best way to achieve that trust is by taking the time to get to know a little more about my patients. Showing that I was interested in them as individuals made our bond stronger, and I am convinced that this resulted in better outcomes.

Editorial

Dear colleagues,
Why do we write the eternal evolution of Medicine through articles, and publish them?
Because there is a story to be told, to be read over and again, to reflect over and lessons to be learned.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

SIGARAM - The Club for Children with Diabetes

In the ever-evolving field of medicine, the complications of, and the solutions for, any disease go hand in hand.
A problem that is steadily increasing in prevalence among patients with Diabetes is Diabetes Burnout.
Diabetes burnout is a state in which someone with diabetes grows tired of managing their condition, and then simply ignores it for a period of time, or worse, forever.

The hope for a better tomorrow

A 3-years-aged child suffered burns (scalds) due to accidental spillage of hot boiling water over the entire lower half of the body, below both hips, when his parents were not at home. He was severely burnt a very large % of his body was affected. Doctors said there was almost zero chance that he would live. He was in the hospital for weeks. However, and amazingly, he pulled through, and is alive today!

An unusual complication of polytrauma

A patient with acetabulum fracture fixation develops Guillain-Barre Syndrome, precipitated by trauma/surgery - A case report
A rare instance of post-traumatic Guillain-Barré syndrome (GBS), an acute, autoimmune, inflammatory, demyelinating polyneuropathy affecting the peripheral nervous system and a potentially life-threatening cause of muscle weakness, is presented.

An enigma at the ER

On a busy Monday morning at the ER, we received 30 years aged female, with a history of acute onset of breathing difficulty for a few hours, following which she became unresponsive in a few minutes. She was brought in a taxi.
The patient had severe chest discomfort, along with bilateral upper abdominal pain, since the previous afternoon.

Dynamic examination of airway

A pivotal tool in anaesthetic management of mediastinal mass excision
A 60 year old woman with superior mediastinal mass was scheduled for videoâ€‘assisted thoracoscopic surgery. Her complaints were dry cough, dyspnoea, and swallowing difficulty. Cough and dyspnoea worsened in a supine position. The mass was 8 cm (craniocaudal) × 5.5 cm (anteroposterior) × 8.7 cm (transverse) in dimensions.

Journal Club

Myhrvold SB, et al. Nonoperative or surgical treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386:1409-1420.
Whether surgical repair of an acute Achilles' tendon rupture by an open-repair or minimally invasive approach is associated with better outcomes than nonsurgical treatment is not clear.

Journal Club

Greene MF, Williams WW. Treating Hypertension in Pregnancy. 2022.
Hypertension has been a largely multifactorial and difficult issue to treat in pregnancy. While we have well-defined protocols to predict, assess, prognosticate and treat pre-eclampsia, Chronic hypertension has been on a back seat with recommendations mainly about the teratogenicity of antihypertensives, pre-conceptional modification, and look out for superimposed preeclampsia.

Journal Club

Ekhart C, et al. Neuropsychiatric reactions with the use of Montelukast. BMJ 2022;376:e067554.
Montelukast, used in the treatment of asthma and allergic rhinitis, can cause serious mental health adverse effects such as nightmares, aggression, depression, and suicidal ideation. These adverse effects have been reported in patients of all ages, with and without pre-existing psychiatric disease, while taking montelukast or rarely after discontinuation.

Conditional Probability

It is the probability of some event A, given the occurrence of some other event B. Conditional probability is written P(A|B), and is read as "the probability of A, given B".

Diagnostic Image

Dr. S. Chockalingam*
Senior Consultant, Orthopaedic Surgeon, Kauvery Hospital, Trichy, India
What is your diagnosis?

Learning from Experience - Intra Operative, Chapters 15 and 16

A 56-year-old woman, weighing 90 kg was posted for a laparoscopic cholecystectomy under general anaesthesia. She gave no significant history except for hypertension which was controlled with 5 mg Amlodipine. She was premedicated with Glycopyrrolate 0.2 mg, Tramadol 50 mg IM, Pantoprazole, and Ondansetron intravenously half an hour prior to surgery.

The Consultation Room

The main reason for the quacks (unqualified Doctors) to proliferate and flourish, is the maldistribution of qualified Doctors in our country and their unwillingness to settle down in rural areas.

Journal scan

A review of 20 recent papers of immediate clinical significance, harvested from major international journals

Editorial

The lead article reflects the very inspiring outcome of Dr. S. Aravindakumar, Chief of Cardiology, Kauvery Heartcity, Trichy mentoring Dr. Yogeswaran, MEM Resident, to learn echocardiography, and undertake a bedside evaluation of Pulmonary Hypertension in the CCU.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Research Article

Early diagnosis of Pulmonary Artery Hypertension in CCU patients, using Echocardiography, helps towards a better clinical outcome
Pulmonary Arterial Hypertension (PAH) is a chronic and progressive disease affecting pulmonary arteries which results from increased pulmonary arterial pressures and consequent pulmonary vascular resistance.

Research Protocol

Left Main Coronary Artery Stenting - An EMR based Single Tertiary Care Centre Experience
The left main coronary artery supplies at least two-thirds of the left ventricle. Patients with significant LMCA disease are often symptomatic due to compromised blood supply that affects a large area of the myocardium.

Saving the unsavable

One lesson that I could never forget in the course of our nursing education and service was this: We are not allowed to get attached to our patients because that is against the code of conduct.

Case Report

Triple trouble - anaesthetic management of a child with TMJ ankylosis with retrognathia and OSA
Bilateral temporomandibular joint (TMJ) ankylosis with retrognathia and obstructive sleep apnoea (OSA) is relatively uncommon in children. The present case describes the anaesthetic management of a similar toddler who was posted for TMJ release and Interposition Arthroplasty.

Case Report

Six years of gastritis got a label - Superior mesenteric artery (SMA) syndrome/Wilkie's syndrome
Superior mesenteric artery (SMA) syndrome (known as Wilkie's syndrome) is a rare cause of upper gastrointestinal obstruction. It is an acquired disorder in which acute angulation of the SMA causes compression of the third part of the duodenum between the SMA and the aorta.

Letters to the Editor

Zoe Paskins, et al. Clinical effectiveness of one ultrasound guided intra-articular corticosteroid and local anaesthetic injection in addition to advice and education for hip osteoarthritis (HIT trial): single blind, parallel group, three arm, randomised controlled trial. MJ 2022;377:e068446.
To compare the clinical effectiveness of adding a single ultrasound guided intra-articular hip injection of corticosteroid and local anaesthetic to advice and education in adults with hip osteoarthritis.

Diagnostic Image

Diagnosis: Right T10-T12 Dermatomal involvement in Herpes Zoster

Learning from Experience - Intra Operative, Chapters 13 and 14

A 19-year-old girl weighing 51 kg was posted for FESS with septoplasty. On examination, her pulse rate was 98/min, BP was 110/70, and no abnormality was detected on examination of cardiac and respiratory systems. She was an ASA 1 patient. After antibiotic administration and aspiration prophylaxis she was taken up for surgery under GA.

The Consultation Room

The media, both print and electronic, may request for a 'short clip' from you on some current medical issue, more so if you are a senior Doctor, holding a position in some medical organization. If the subject doesn't directly concerns you or if you are not the expert in that subject, you may decline to do so.

Journal Scan

A review of 10 recent papers of immediate clinical significance, harvested from major international journals
Catching Covid may cause changes to the brain, a study suggests.
Scientists found significant differences in MRI (magnetic resonance imaging) scans before and after infection.

Editorial

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Caring for nobody's baby

In my last guest editorial, I had attempted to portray the need for a comprehensive pediatric cardiac facility in central Tamil Nadu. I had stressed the importance of timely recognition of critical congenital heart disease (CHD) in the newborn baby and the improved outcomes in the surgical and percutaneous repair of CHD. A baby with any form of critical CHD can hence expect to lead a near-normal life based on most health-related quality of life (HR-QoL) parameters.

Special Report

Thalaivi award, bestowed by a grateful and appreciative public, on six Kauverian role models at Trichy in honor of International Women's Day
Our world would mean nothing without women. Women are the epitome of strength and courage. Every year, March 8 is celebrated as Women's Day. On this day, we appreciate the strong, intelligent, talented, and extraordinary women in our lives. Working women of today's world contribute a lot to their work as well to their families and it is not easy being a working woman.

Research Article

Prevalence of diabetes-related distress in patients with type 2 diabetes, attending a tertiary care hospital
According to the International Diabetes Federation, there are 382 million people worldwide affected by diabetes and India has 65.1 million people with diabetes. The majority of the guidelines on diabetes care focus on the medical aspects of disease management without addressing the psychological needs of the patient. These psychosocial problems can eventually develop into depressive or other psychological disorders.

The curious case of a migrating needle on the chest wall

The patient, a 26 years aged male, married, working in a store, presented to a hospital with chest pain, for the past 3 days. ECG showed ST changes. CT scan imaging showed the presence of needles in the anterior chest wall, lateral chest wall, and mild pericardial effusion.

Foreign body: A boon at times

A 56-year-old female, a known patient of bronchial asthma, presented with increasing symptoms for four weeks, with a history of aspiration of foreign body (nose pin screw) one month back.

Cardiorenal Syndrome

S.J. Kabilan*
Consultant Interventional Cardiologist, Kauvery Hospital, Salem, India

What My Grandmother Knew About Dying

Comments of Dr. Karthikeyan, Consultant in Geriatrics and Palliative Care, Kauvery Hospital, Salem
My memories go back a few years ago. When I assisted a bronchogenic carcinoma patient, in his 85+ years, with malignant pleural effusion.

Endovascular Therapy for Acute Stroke with a Large Ischemic Region

Endovascular therapy for acute ischemic stroke is generally avoided when the infarction is large, but the effect of endovascular therapy with medical care as compared with medical care alone for large strokes has not been well studied.

Letter to the Editor

Analyzing Proton Pump Inhibitor (PPI) induced dysbiosis and growing role of probiotics: Review
Comprising a diverse plethora of bacterial species, the human intestinal microecology is considered a complex community.

Clinical outcomes of Coronary Artery Disease in Octogenarians

Coronary artery disease (CAD) is a major cause of morbidity and mortality in patients above 80 years of age. Understanding the pathophysiology, epidemiology, and optimal means of diagnosis and treatment of CAD in older adults is crucial in improving outcomes in this high-risk population. It is crucial to identify the knowledge gaps in the diagnosis and management of CAD in this vulnerable population as most clinical trials and studies tend to exclude older patients altogether or include those at lower risk.

Diagnostic Image

A 12-year girl presented with acute gastroenteritis with severe dehydration. She was incidentally found to have this finding

Learning from Experience - Intra Operative, Chapters 11 and 12

A 58-year-old man presented to the emergency department with stridor. He was a known case of CA thyroid for which a total thyroidectomy was done six years ago, followed by 5 cycles of I131. The patient was hemodynamically stable: PR=108/min, BP =140/80, but his saturation with oxygen mask was only 89%.

The Consultation Room

Specific time may be allocated to see medical representatives, to avoid interruptions during regular times. It's ethical that we don't make them wait inordinately in our office, since they are considered as 'paramedical' professionals.

Journal Scan

A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Colours

What is yellow?
Yellow is a shiny bright wall
Yellow is the color of gold
Yellow is like a ripe yellow plum
Yellow is like a bright yellow sun

Editorial

Dear readers of the Kauverian,
The 15th March issue of the KAUVERIAN is a very exciting one for us in production.
For one very important reason.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

March - the Month for Minds to dwell on Multiple Myeloma

March is Multiple Myeloma Awareness Month
Multiple myeloma is a malignancy of plasma cells which are an important component of immunity.

Covid Report

Voices from the field!
Nursing leaders speak from the first battlefront to open, on the war against COVID-19 at Kauvery Hospital, Tennur, Trichy

Research Protocol

The clinical profile, management, and outcome of young patients presenting with the acute coronary syndrome at a tertiary care health facility
Coronary Artery Disease (CAD) is the single most cause of mortality and loss of Disability Adjusted Life Years (DALY) globally. A large number of the global burden is limited to the Low and Middle-income countries (LMIC). Twenty-five percent of all deaths in India are attributable to Cardiovascular Diseases (CVD).

New Arrows in our Quiver, to direct against SARS-CoV-2 variants

Background: New treatments are needed, to be administered early in the evolution of the disease, to reduce the risk of progression of coronavirus disease 2019 (COVID-19).

Out-of-hospital cardiac arrest

Out-of-hospital cardiac arrest (OHCA) has attracted increasing attention over the past years because outcomes have improved impressively lately. The changes for neurological intact outcomes have been poor but several areas have achieved improving survival rates after adjusting their cardiac arrest care. The pre-hospital management is certainly key and decides whether a cardiac arrest patient can be brought back into a spontaneous circulation. However, the whole chain of resuscitation including in-hospital care has improved also. This article describes aetiologies of OHCA, risk and potential protective factors, and recent advances in the pre-hospital and in-hospital management of these patients.

Last on the list: A diagnosis seldom considered in males

Autoimmune diseases are generally more common in women than men. Sex hormones, especially oestrogen (but also prolactin and testosterone), play important roles in these diseases. Oestrogens are generally considered to enhance autoimmunity and have multiple effects on the immune system through various cell types and molecular pathways. There is much evidence supporting the role of oestrogen in the pathogenesis of systemic lupus erythematosus (SLE); the disease occurs much more frequently in women, especially during the years of child-bearing potential, and commonly flares up during pregnancy. We report a case of SLE in a young male who presented with pyrexia of unknown origin.

Giant T wave inversion associated with Stokes: Adams syndrome

Stokes-Adams or Adams-Stokes syndrome is a periodic fainting spell in which there is intermittent complete heart block or other high-grade arrhythmias that result in loss of spontaneous circulation and inadequate blood flow to the brain.

Learning from Experience - Intra Operative, Chapters 9 and 10

A 75-year-old man was admitted in the emergency for a swelling on the left side of his neck which was expanding rapidly. He had undergone carotid endarterectomy 15 days ago. During his previous procedure, his intraoperative and postoperative period had been uneventful and he was discharged on the 5th day.

The Consultation Room

There is no bar against a private practitioner to treat accidents, poisonings or other medicolegal cases, provided prescribed procedure is followed. As mentioned already, the Doctor has to exercise extreme caution in taking history given by them for granted. Proper recording of history, physical findings and initiate immediate treatment required.

Definitions of probability

There is a number of definitions of probability proposed by many authors.
However, the majority of definitions can be divided into three groups

Journal Scan

A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Diagnostic Video

The genus Dirofilaria includes vector-borne filarial nematodes, which are usually associated with carnivore hosts. Some Dirofilaria spp. are zoonotic; the most commonly seen species in human patients are D. repens, D. tenuis, and D. immitis (the dog heartworm).

A Thanksgiving to Cardiac Surgeons

A 74-year-old lady presented for the first time in an emergency, with acute decompensated heart failure. She was evaluated and found to have Severe Calcific Aortic Stenosis with LV Dysfunction and was in heart failure. She had neglected the symptoms of Severe Aortic stenosis and allowed LV dysfunction to set in, leading onto heart failure. She was advised Aortic Valve Replacement and after multiple counselling sessions, very reluctantly agreed to surgery. After medical optimization, she underwent MICS Aortic Valve replacement with a 19 mm Edwards Bioprosthetic valve.

Editorial

Dear readers of the Kauverian,
Abraham Lincoln went from a log cabin to the White House.
Dr. Paul Farmer grew up in a mobile home in a trailer park in Florida, and went on to advise five presidents in the White House on global health.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

An obituary, farewell to a very dear friend

I lost a very dear friend sometime during the night of Sunday, February 20th.
Dr. Paul Farmer, internationally revered as the "Doctor for the world's poor", died in his sleep on Sunday night in Rwanda where he had built Africa's best model of comprehensive rural health and medical and nursing school.

'Vitamin D': One vitamin, many claims!

The relationship between vitamin D and chronic disease-related clinical outcomes is controversial. In recent times, many benefits from the administration of vitamin D in various clinical settings have been claimed, starting with claims of miraculous recovery from severe and critical COVID-19 in early 2020. The recent reports of such claims were compiled and examined. Vitamin D deficiency is widespread and linked to a variety of disorders. Several studies have looked into the significance of vitamin D supplementation in many of these contexts. However, not all of them found it to be beneficial.

Implantation of Leadless Pacemaker in a middle-aged patient: An ultra-short case study

A 58-years old gentleman presented with a history of multiple episodes of pacemaker erosion since 2017. The patient had been previously implanted with a conventional lead pacemaker four to five times, on both the left and right side of the chest, which kept getting eroded.

ABO-incompatible renal transplant at ease

The shortfall between organ donors and kidney transplant recipients is ever-growing. The number of patients waiting on a deceased donor renal transplant program is increasing every year according to the UNOS data. To overcome this deficit, strategies like ABO-incompatible renal transplantation, paired kidney exchange program, SWAP transplants are performed at various centres.

Basal cell adenoma parotid: A case report

Basal cell adenoma is a very rare form of parotid tumor. Diagnosis of this disease is extremely challenging. We present a 51 yr old lady who is a known cause of an uncommon disease myasthenia gravis with this rare tumor

A case report

Correction of Cubitus varus (Gunstock deformity) deformity in a 12-year-old child with Lateral Closing Wedge osteotomy
Malunited supracondylar humerus fracture in children usually results in cubitus varus deformity. Cubitus varus deformity is less common in the present time because of the availability of image intensifiers for fracture reduction and fixation. Cubitus varus deformity is nothing but outward angulation of the elbow with the supinated forearm.

Learning from Experience - Chapters 7 and 8

A 60-year-old woman presented to the emergency room with diffuse painful swelling in the femoral area. She had the swelling for nearly 10 years, slowly increasing in size, and developed severe pain over the last 24 h. She had no other comorbidities. It was diagnosed as an obstructed femoral hernia and case was booked as urgent surgery.

The Consultation Room - Chapters 51 to 55

'Doctors make worst patients', but may not apply to all. Medical etiquette dictates that an early appointment be given to a Doctor or at a time convenient to him, if possible. As a matter of courtesy to a fellow practitioner, he may be called in as early as possible, keeping the waiting time to minimum. Similar privilege may be extended to a Doctor, if he is accompanying a patient, who may or may not be related to him.

Journal Scan

First-line chemotherapy for advanced esophageal squamous-cell carcinoma results in poor outcomes. The monoclonal antibody nivolumab has shown an overall survival benefit over chemotherapy in previously treated patients with advanced esophageal squamous-cell carcinoma.

Diagnostic Video

As the face conveys many important and educative lessons in clinical diagnosis, we regret that the general features could not be masked.

Poem from Staff Nurse

Ms. R. Sneha,
Staff Nurse, Department of Oncology, Kauvery Hospital, Tennur, Trichy

Editorial

Dear readers of the Kauverian,
Novelty is the spice of life; so, we begin with a new section, "Letters to the editor!".
We invite you to post your thoughts on articles published elsewhere on which you have a clear view to express.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Male V. Menstruation and COVID-19 vaccination

Vaccination against COVID-19 provides protection against the potentially serious consequences of SARS-CoV2 infection, but as the vaccines were rolled out into younger age groups, clinicians were increasingly approached by patients worried that the vaccine had caused a change to their periods.

Efficacy and doses of Ulinastatin in treatment of Covid-19 a single centre study

Ulinastatin is a glycoprotein extracted from fresh human urine. It inhibits the activity of various proteolytic enzymes. Patients with severe covid-19 exhibit elevated serum levels of proinflammatory cytokines IL-6, Tumour necrosis factor, IL-I Beta, characterised as cytokine storm, which is believed to progress, leading to deterioration and death.

Electronic registries in health care

Clinical registries are organized systems that collect data on patients diagnosed with a disease or condition or who undergo a certain procedure. Managing a conventional register is resource-intensive and time-consuming. Electronic Registers are conventional registers integrated with information technology.

A case report

Monoarticular large joint arthritic presentation of rheumatoid arthritis
Rheumatoid arthritis (RA) is a chronic, symmetrical, inflammatory arthritis that usually involves small joints. Mono articular arthritis involving a single large joint is not part of EULAR 2010 algorithm for the presentation of rheumatoid arthritis. Here we report a late diagnosis of large joint monoarticular rheumatoid arthritis presented to our department after two surgical procedures.

Anaemia in pneumonia: A case report

The pneumococcal vaccine has drastically reduced the incidence of invasive pneumococcal disease in Western countries. In India, the actual disease burden is not known because of the use of antibiotics before blood culture and the lack of utilization of lab services. Pneumococcus affects many systems and we present a case of pneumococcal pneumonia/sepsis with a rare complication.

Successful treatment of two cases of rare Movement Disorders

Movement disorders can manifest in numerous ways, with symptoms ranging from subtle to disabling. The first step to diagnosis depends critically on an accurate description of the abnormal movement. The neurological examination needs to be tailored to the clinical history in many cases.

Analysis of variance Two-Way ANOVA

The two-way ANOVA is an extension of the one-way ANOVA. The "two-way" comes because each item is classified in two ways, as opposed to one way. For example, one-way classifications might be gender, political party, religion, or race. Two-way classifications might be by gender and political party, gender, and race, or religion and race.

Learning from Experience - Chapters 5 and 6

A 39-year-old man was admitted for a fracture neck of femur, posted for a hemiarthroplasty. During the preoperative visit, history revealed that patient was paraplegic for the past 3 years following a road traffic accident. The current situation was due to a fall from his wheelchair and there was difficulty in nursing.

The Consultation Room - Chapters 46 to 50

It's important to extend due courtesies to patients referred by a Doctor and the patient appreciates that because of that, some extra attention was given. This is not to say proper attention need not be given to other patients, but such gestures would keep the referring Doctor in 'good humor', though ultimate treatment may not change.

Journal Scan

There is considerable uncertainty over whether adults with asthma should be offered booster vaccines against SARS-CoV-2 and, if so, who should be prioritised for booster vaccination. We were asked by the UK's Joint Commission on Vaccination and Immunisation to undertake an urgent analysis to identify which adults with asthma were at an increased risk of serious COVID-19 outcomes to inform deliberations on booster COVID-19 vaccines.

Diagnostic Image

Diagnosis: Itch mite scabies causing burrows.

Poem from Staff Nurse

Ms. V. Jayalakshmi,
Staff Nurse, Department of Oncology, Kauvery Hospital, Tennur, Trichy

Editorial

The KAUVERIAN launches its 01 February 2022 issue (vol 3, issue 3), with two debut articles from senior consultants.

Author Instruction

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Cardiothoracic surgery in the COVID era: Revisiting the surgical algorithm

The COVID-19 pandemic has led to unprecedented challenges on a global scale that has not been seen for many years.

Review

Liver Transplantation is successfully done for liver failure and liver cancer in selected patients. Liver transplantation for metabolic disorders due to genetic defect is rare and done in children mostly.

Corona warrior award

Nursing is a profession within the healthcare sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life.

Case Series

Osteogenic benign vertebral neoplasm is a relatively rare entity with a spectrum of treatment options. Optimal treatment decision is vital for definitive tissue diagnosis, reducing recurrence, and avoiding post-operative spinal instability.

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a close differential diagnosis of acute coronary syndrome, and can present with chest pain and breathlessness.

Learning from Experience - Chapters 3 and 4

A 28-year-old woman, with polycystic ovarian disease was posted for a laparoscopic ovarian cystectomy. She had no other medical illness and was assessed under ASA 1

The Consultation Room - Chapters 41 to 45

Some drugs, which may have duel effect, may be conveniently used, if the patient has both the symptoms.

Journal scan

Little evidence has been available to support the use of thiazide diuretics to treat hypertension in patients with advanced chronic kidney disease.

Diagnostic Image

Incidentally found osteoblastic clusters in a bone marrow aspirate smear

Poem from Staff Nurse

Editorial

Dear colleagues.
Rising to the occasion, from Kauvery Hospital, ECB, leads this issue, from Dr. Muralidhara and his eight colleagues, the most multi- authored paper ever to be published in the KAUVERIAN.

Author Instructions

Title: The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

Review

Modification of Management Strategies, And Innovations, During SARS Cov2 Pandemic Improved the Quality, Criticality and Outcomes in In-Patients

Guest Editorial

Time in Range (TIR) In Diabetes: A Concept of Control of Glycemia, Whose Time Has Come.
It has been more than two years since the release of recommendations from the International Consensus Guidelines on Time-in-Range (TIR) in patients with diabetes who are on continuous blood glucose monitoring (CGM), but awareness is poor about the importance of TIR as a metric for the understanding of the duration of euglycemia (70-180 mg/dl) and as an useful measure of the risk of developing long term complications.

Review

Kauvery Heart Failure Registry- A Concept.
Heart failure (HF) is a global public health issue that affects all countries, rich or poor, developed or developing. It is a progressive clinical syndrome.

Research

Shorter Course of Remdesivir In Moderate Covid-19 is as Efficacious as Compared to Standard Regime: An Observational Study
Remdesivir is an RNA polymerase inhibitor with potent antiviral activity in vitro. It is the current recommended antiviral treatment in moderate to severe COVID-19.

Case Report

Small Intestinal Tuberculosis Presenting as Massive Gastrointestinal Bleed: A Case Report.
Massive bleeding per rectum is an uncommon presentation of small intestinal tuberculosis. We report a patient who presented with hematochezia and hypotension.

Case Report

Lymphoepithelial Carcinoma: A Case Report of a Rare Tumour of The Vocal Cord.
Lymphoepithelial carcinoma (LEC) of the vocal cord is an extremely rare malignancy accounting for 0.2% of laryngeal cancers.

Case Report

Diabetic Keto Acidosis (DKA), Associated with Failed Thrombolysis with Streptokinase in Acute Myocardial Infarction
Streptokinase has been used as a thrombolytic agent in the treatment of AMI ever since 1958 when Sherry and others started using streptokinase in acute MI.

Learning from Experience - Chapters 1 and 2

The intra-operative period is most fascinating, as we could experience a wide variety of surprises in spite of thorough checklists.

The Consultation Room - Chapters 36 to 40

With increasing level of literacy and the plethora of information in various media, it's no surprise, many patients do lot of 'home work', before coming to us and we have to carefully watch our words, while interacting with them.

Journal scan

A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Diagnostic Image

Hypersegmented polymorphs and macrocytosis on Vitamin B12 deficiency.

POEM - Notes to Nocturne

When the antique organ is played, The crowd they dont hooray.

Editorial

Dear colleagues.
We at the KAUVERIAN wish you a Merry Christmas! The KAUVERIAN shall launches its new year edition with many crackling and sparkling reports from young minds.

Author Instructions

Title: The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study. When gene or protein names are included, the abbreviated name rather than full name should be used.

Review

Junior nurses in Kauvery Hospital on the frontline against the COVID-19 pandemic

Guest Editorial

Emergency Medicine has been an emerging speciality across the world as the Leading Light on the entrance to the Healthcare pathway.
It has become the public face of the hospital to the patient and his family, especially when in distress. And in recent times, it has become an integral part of a successful hospital, as "Time is Life", and saving a life, or a limb, in time, is the ultimate goal of emergency services.

Case Report

Battle of two drugs: Who won? - An unusual presentation
Organo-phosphate/insecticide ingestion is the most common modality of suicide in India, which causes excessive secretions (cholinergic effect) in our body.

Case Report

Return of the native and a resurrected foe: A case of Rhinocerebral Mucormycosis
A 66 years aged woman presented to our Emergency Department with the complaints of: Decreased sensorium and drowsiness for 2 days Decreased oral intake for 2 days

Case Report

Covert invader- atypical presentation of neuronal migration disorder
Importance of MRI Brain as the investigation of choice in emergency department in Epilepsy is illustrated in this case report. Antenatal history/developmental history is relevant for diagnosis, even for adults.

Case Report

Fragile heart: an unusual cause of chest pain
Eosinophilic Myocarditis (EM) is an acute life-threatening inflammatory disease of the heart. It is often an elusive diagnosis but treatment is straight forward.

Case Report

The dangerous massage: vertebral artery dissection
An acute cause of neck pain and arm weakness is most commonly due to cervical radiculopathy. Rarely an extracranial vertebral artery dissection may cause a radiculopathy in the absence of brainstem ischemia.

Diagnostic Image

Goldberger's ECG sign in Left Ventricular Aneurysm
Ventricular aneurysm is a well-known complication post MI. The term aneurysm is used to describe dyskinesis or local expansile paradoxical wall motion.

Case Report

Congenital absence of bilateral Internal Carotid Artery: A case report
Agenesis of bilateral Internal Carotid Artery (ICA) is a rare and infrequent abnormality. People with this abnormality would have adequate collateral circulation and remain asymptomatic.

The Power of Purple

The Power of Purple
I stood in front of the mirror staring at my reflection, with that purple mark on my face."But how...?" I asked myself. " There are only two elements you can master, blue:water, red:fire; what even is purple!?"

POEM - Beads of Nature's Rattle

What simple re-arrangement can accomplish! To not just tidy the sweet home

Editorial

Dear colleagues.
How is the "KAUVERIAN'' different? Asked a very dear colleague of mine last week! She was asked by her colleagues, so she asked me!

Author Instructions

Guest Editorial

Pre-eclampsia is one of the most dreaded complications in pregnancy and puerperium for the obstetrician and the patient alike.
It is the hypertensive disorder of pregnancy with elevated blood pressure. It is often accompanied by signs and symptoms suggestive of multi-organ dysfunction, usually liver and kidneys.

Case Report

Cerebrospinal fluid-cutaneous fistula after neuraxial procedure and management: a case report
Cerebrospinal fluid (CSF) -cutaneous fistula occurrence following neuraxial technique is very rare with incidence 1:220000 and less reported in India.

Case Report

Impella CP assisted recovery of acute COVID 19 fulminant myocarditis presenting as out of hospital cardiac arrest and cardiogenic shock
The mortality rate due to Cardiogenic shock, due to acute fulminant myocarditis is very high, and in a patient with out of hospital cardiac arrest, it is even worse.

Case Report

Ischemic stroke after Russel's Viper snake bite, an infrequent event: a case report
Snake bites are a well-known medical emergency in many parts of the world including India. This results in tens of thousands of deaths every year and many chronic disabilities in South Asian countries.

Nutrition needs of preterm babies

More and more preterm babies weighing 600-700 g born in good centres are surviving in India with improvements in the obstetric and NICU services. Abnormal neurodevelopment is one of the major concerns in these preterm survivors. Inadequate early postnatal nutrition appears to result in abnormal neurodevelopment.

Learning from Experience - Chapters 17 and 18

A 65-year-old man was admitted for TURP. He had symptoms from chronic benign prostate hypertrophy. He reported to have undergone cardiac transplant 3 years ago for end stage ischemic heart disease and dilated cardiomyopathy. He was a known diabetic. He had been functioning well post- surgery on Diltiazem, Insulin and immunosuppressant drugs.

The Consultation Room - Chapters 31 to 35

In busy consultation time, recording the conversation with the patient/attendant, is not always possible in our set up, but this is routinely done in some western countries, to avoid misunderstanding later. In some centres, the entire proceedings are video recorded and preserved, to be reviewed in the event of a dispute. The office secretary transcribes the conversation dictated by the Doctor, prints it in the file. The patient, while leaving, reads and signs it, to indicate his agreement with what transpired.

Journal scan

A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Diagnostic Image

Reactive thrombocytosis (12 lakhs/cu.mm) in a patient with iron deficiency anaemia.

POEM - Tick Talk

We sometimes call it precious. And sometimes call it vicious.

Editorial

Dear colleagues.
The Children's Day - India edition of the KAUVERIAN comes to you Pediatric - Power packed.
Like a true leader Dr. D. Senguttuvan leads the Pediatric team of five dedicated and accomplished authors who give us their views on current and major concerns in child health, with insightful "guest" editorials. Dr. Senguttuvan and Dr. Suresh Chelliah most graciously accepted my request to review AFIs and ILIs in children seen at Trichi. COVID hovers above that scene as a dark and menacing cloud.

Author Instructions

Transfusion-related acute lung injury

The transfusion of blood products is occasionally complicated by acute lung injury (ALI), which can progress to the acute respiratory distress syndrome (ARDS).

Case Report

Equalizing leg length by "lengthening the shorter leg" by surgery: a case report
Limbs can be unequal in length due to many reasons. Common causes are trauma leaving one leg shorter, infection of bone affecting growth in a child and congenital deficiency of growth of one limb. Congenital deficiency of growth of one limb has different sub types. We will limit to "congenital lower limb discrepancy" in this article.

Case Report

VKA induced catastrophic bleeding management with Prothrombin Complex Concentrate (PCC): a practice changer
Vitamin K antagonists (VKA), which were once used as rodenticides decades ago, became lifesaving drugs later in managing thromboembolic disorders. However, they have a narrow therapeutic window and may lead to bleeding if not used or monitored cautiously.

Case Report

"Kanvali Kizhangu" Toxicity - A Curious Case Report
A 23-year-old male came to our ER with alleged history of consumption of tubers (8/9 numbers).

Orthopaedics case series

A 17-year-old boy sustained an RTA and presented to our emergency department. He was diagnosed to have open Grade-1 transphyseal separation of distal femur-right with diminished pulse. CT Angiogram was done and ruled out arterial injury.

Health research fundamentals - a course review

The objective of this review is to encourage the PGs to do this course. This course is useful for individuals interested in pursuing health research as study investigators, clinical/public health researchers (physicians, counsellors, research associates, social scientists, nurses, pharmacists, technicians, data and quality managers etc.), scientists, ethics committee members and project managers.

Morbidity and mortality meetings for improved patient care

Morbidity and Mortality (M&M) meetings, also referred to as Mortality and Morbidity Audits, are a very necessary component of contemporary hospital medicine. Despite this, there is currently a lack of evidence-based guidance on how they should be conducted.

DNB Thesis

Significance of waist to height ratio as an early predictor in developing metabolic syndrome in children of age group 5-12 years in a tertiary care centre in Trichy: Part IV

Learning from Experience - Chapters 15 and 16

A 34-year-old, primiparous woman at 37 weeks' gestation, well-built weighing 84 kg was brought to the outpatient department for consultation. She complained of cough, cold and fever for the past 4 days. No history of any comorbidity in the past. Pregnancy had been normal so far.

The Consultation Room - Chapters 26 to 30

It's said 'three important things in the management of any disease are, Diagnosis, Diagnosis & Diagnosis'. 'If you make a rare diagnosis, you may be rarely correct'. But it's also said 'if we don't diagnose rare conditions, they become still rarer'.

Journal scan

A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Measuring Association in Case-Control Studies

The cohort studies or clinical trials in which we compared either cumulative incidence or incidence rates among two or more exposure groups. However, in a true case-control study we don't measure and compare incidence. There is no "follow-up" period in case-control studies.

Diagnostic Image

Oral Graft versus host diseases in a post allogeneic bone marrow transplant patient with Myelofibrosis

POEM - The Stream of Life

Life is like a sturdy stream, And with it flows our wavy dreams

Editorial

Author Instructions

Guest Editorial

Children commonly suffer from seasonal respiratory infections. They have always been the face of viral respiratory infections. Though this was not the case with the recent COVID pandemic, they risk among being its biggest victims, in particular by the socio-economic impacts and migration issues [1].

World Prematurity Day: Reflections of a Neonatologist

I am delighted that, after having worked for the health and welfare of premature babies for over two decades, and having been at forefront of Human Milk Banking in Karnataka, I have been invited by Editor-in-Chief Dr. Venkita S Suresh to share my experience through a Guest Editorial for the Children's Day, Nov 14th - India special edition of KAUVERIAN, the electronic medical journal of Kauvery Hospitals.

Epilepsy in Kids: Problems Beyond Seizures

An 8-year-old male child, second child born of non-consanguineous parentage, presented with history of seizures since the age of 5 years. There were total of five episodes of seizures since then. Semiology was described as Generalised Tonic-Clonic seizures, the trigger being fever most of the time. Last episode was one month prior, during which child had seizure cluster during tapering of Valproate. He required ICU care. Child was started on phenytoin during admission as he had gained weight and lost hair while on Valproate. He was placed on phenytoin 5mg/kg/day and valproate 30mg/kg/day.

Case Report

A 4-year-old boy presented with fever, skin infection and abdominal distension on 04 May 2019. On examination, he had pallor and hepatosplenomegaly. Investigations revealed Hb 5.9, WBC 4700, platelets 19000 and peripheral smear showing blasts.

Case Report

Vaccine Induced Cerebro Venous Thrombosis with Thrombocytopenia (VITT) - A Case Report

Ultra Short Report

A 42-years-old male presented to OPD for giddiness.
Family history of two RTA related deaths.
Elder brother died three months back while driving speaking on mobile phone.

DNB Thesis

Significance of waist to height ratio as an early predictor in developing metabolic syndrome in children of age group 5-12 years in a tertiary care centre in Trichy: Part III

Kauvery 4th Annual Nursing Conclave N4 - 2021

Namma Nurse Nalla Nurse (N4), is a central forum conducted every year in Trichy where nursing leaders along with their team participate to share best practices and improve bond between Kauvery sister concerns. The 4th Kauvery Annual Nursing Conclave - N4 2021 was conducted on 16 October 2021 at Hotel SRM, Trichy. It was summoned at 9:15 am with a welcome address. and the unfolding of the theme for this year N4 "Nursing Informatics and Tech based Nursing Care" by Ms. Gethsial Kiruba, Senior Executive - Quality and Training.

Learning from Experience - 13 and 14

An 18-year-old boy with facial deformity, presented for cosmetic correction. There was also a huge convoluted mass arising from the scalp, covering the lateral aspect of his forehead. He was diagnosed as a case of Cutis Verticis Gyrata, though his features were not very typical of the disease.

The Consultation Room - Chapters 21 to 25

The consultant's memory is fresh about the entire picture, soon after the initial interview. Subjected to the results of the investigations, that is the best time to formulate a tentative prescription in his notes. When the patient returns with all the reports, if they are found to be normal, prescription can be simply copied from the notes, if necessary with some modifications.

Journal Scan

A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Diagnostic Image

A 65-year-old man presented with a 5-day history of a painful, symmetric rash on his hands and elbows.

An Anthology Of Poems - From Sand to Sky

There are some who characterize their time with mocking words
There are some who attempt to tame the other with their cons
There are some who construct walls to colonize free minds and their sounds

Editorial

Dear Colleagues,
A week from today, a new edition of the KAUVERIAN shall be winging its way to you.
What gems are being held this time for you, in the beak of the bird?!

Editorial Board

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

Repurposing anti-rheumatic drugs in COVID

The pandemic has taught us many things. Right from the importance of being together as a family, supporting fellow humans and be grateful for each moment gifted to us, we have learnt it all. The medical community has witnessed how a collaborative team work could enable us to overcome a novel virus and gruesome pandemic. The scientific forums, journals and websites experienced a flood of research related to COVID, that almost we need to keep ourselves updated every day. To me, as a clinical immunologist and rheumatologist it is a moment of reckoning to see a medical knot getting untangled very evidently.

An Effective Journal Club Presentation: A Guide

A journal club is a dedicated meeting where medical practitioners gather to discuss published articles from peer-reviewed journals. These meetings help fellows and residents keep up with current research findings, exercise their critical thinking skills, and improve their presentation and debating abilities. A journal club is a core element of residency and fellowship training in almost every medical specialty.

A Masquerader Vasculitis as Usual: Time Is Tissue

Wegener's granulmatosis is a rare idiopathic inflammatory disorder affecting blood vessels of upper respiratory tract sinuses, lungs and kidneys. Histopathologic evidence of necrotizing granulomatous inflammation and pauci-immune small-vessel vasculitis though non-pathognomonic, is essential for a diagnosis [1]. Serologic evidence of antineutrophil cytoplasmic antibodies also supports a diagnosis.

A Sinister Swelling: A Case Report

An 11-year-old, previously well girl was admitted with complaints of low back pain for 2 months, gradually increasing in severity.

DNB Thesis

Significance of waist to height ratio as an early predictor in developing metabolic syndrome in children of age group 5-12 years in a tertiary care centre in Trichy: Part II

Statistical Regression Analysis

The Regression Analysis is a technique of studying the dependence of one variable (called dependent variable), on one or more variables (called explanatory variable), with a view to estimate or predict the average value of the dependent variable in terms of the known or fixed values of the independent variables.

Learning from Experience - 11 and 12

A 28-year-old primigravida, known case of Myasthenia Gravis was posted for an elective LSCS. She was on tablet Pyridostigmine 60 mg twice daily. She had grade 2a disease, well controlled under medications. All other routine preoperative investigations were within normal limits. She was asked to continue Pyridostigmine up to the morning of surgery. It was decided to proceed with spinal anaesthesia. She was administered a stress dose of hydrocortisone. Spinal was given with a 25G needle, and 1.8 ml of 0.5% Bupivacaine heavy was administered. After ensuring adequate level of block the surgery was allowed to proceed. It was completed successfully in 40 minutes and the patient had an uneventful recovery

The Consultation Room - Chapters 16 to 20

Respecting the value of time of everyone, we should try to be as punctual as possible. An anxious patient tends to be more and more emotionally disturbed, if he has to wait for hours, to see the Doctor. If the Doctor is held up in an emergency, the reception should brief the waiting patients about it and indicate the approximate time Doctor is expected to be in the office.

Journal Scan

From the desk of the Editor-in-Chief
(1). Grant RW, et al. Updated USPSTF screening recommendations for diabetes, identification of abnormal glucose metabolism in younger adults. JAMA Intern Med. 2021;181(10):1284-6.
The diabetes epidemic in the US continues unabated hand in hand with the concurrent epidemics of obesity and physical inactivity.

Diagnostic Image

An 89 years aged gentleman, with past history of hypertension and Coronary Artery Disease (CAD), presented to Emergency Department (ED) with an alleged history of accidental fall at a temple while climbing down the stairs. He sustained injury on the right hip and right hand. Patient could not bear body weight since the fall.

An Anthology Of Poems - Stained not torn

From the perception
Of my minds still novice eye
Every person is a sheet of white paper
And emotions, clinking glass bottles of each uniquely staining dye

Editorial

Introducing a new author! Dr. Muralidhar, Consultant, Critical Care, a COVID Care Champion from Kauvery-Bengaluru, paraphrases the eternal predicament raised in William Shakespeare's 'Hamlet'- "To Boost or not to boost, that is the question?". He places the evidence in front of you from which you may seek the answer.

Editorial Board

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

To Boost or Not to Boost? Indian Perspectives - COVID Vaccination

COVID vaccination is the only protection against the ongoing pandemic. Rapid development of efficacious vaccines, and immunization of the general population is an ongoing success story and is an effective strategy for reducing both viral transmission and disease burden. Initial hesitancy in general population and care workers in enrolling for COVID vaccination programme was the biggest challenge. Gradually vaccination drive gathered pace, with the states organizing even special drives. It has been a welcome change.

DVT in a child: A case to introspect

Deep vein thrombosis (DVT) is rare presentation in paediatric age group. DVT as a cause of leg pain in children is often misdiagnosed, because the index of suspicion is low in children. The incidence of venous thrombo embolism increases with age, from 0.7 to 2 per 100000 in children to 100 to 150 per 100000 in adults. We present such a case where in hindsight, clinical clues correlated with investigations.

Rainbow within a storm

T. Joseph
Consultant Interventional Cardiologist & Electrophysiologist, Kauvery Hospital, Trichy Heartcity, India

Reversal of Dabigatran in patients with intracerebral haemorrhage - a narrative review

The objective of this review is to provide an overview on the current development of the specific reversal agent for Dabigatran. Anticoagulation is key to the treatment/prevention of thromboembolic events. The primary complication of anticoagulation is serious or life-threatening haemorrhage, which may necessitate prompt anticoagulation reversal. High Cost and limited availability are the main disadvantages of reversal of Dabigatran.

DNB Thesis

Significance of waist to height ratio as an early predictor in developing metabolic syndrome in children of age group 5-12 years in a tertiary care centre in Trichy: Part I

Stereotactic Body Radiotherapy - VT Treatment

Stereotactcic Body Radiotherapy (SBRT), which involves targeting a volume of tissue with radiotherapy was available for use for treatment of intracranial lesions.

Statistical Non-Parametric Mann - Whitney U test

Non-parametric statistics are used when the data are not normally distributed and so are not appropriate for "parametric" tests.

Learning from Experience - Chapters 8 - 10

An 89-year-old, diagnosed with operable carcinoma of the rectum, was posted for anterior perineal resection. Her past medical history was highly significant comprising of an entire list of co-morbidities including insulin dependent diabetes mellitus, hypothyroidism on replacement Eltroxin 50 µg, hypertension on treatment with Hydrochlorothiazide and Amlodipine 10 mg. She had suffered inferior wall MI 4 years ago, with witnessed cardiac arrest during hospital admission, from which she was revived successfully.

The Consultation Room - Chapters 10 to 15

If a patient by mistake comes to your office, with reference letter addressed to another consultant from his family Doctor, it's ethical to explain this to the patient and advise him to go to the Doctor, to whom he was referred, even though you may also belong to the same specialty.

Journal Scan

A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Diagnostic Image

Small vessel vasculitic lesions involving left thumb and foot in a patient with Wegener granulomatosis
Left LMN type facial Palsy in a patient with Aplastic anemia and Herpes zoster
Palpable purpurae in Henoch Schonlein purpura

An Anthology Of Poems - Valiant Velvet Paws

Under the warmth of velvet paws
While through days of tinted air and almond-scented breeze you stroll.
Sheltered with love and gifted with an old sock
When you think yourself the most evil soul

Editorial

The lead article is Dr. Andrew Fenn's update on the Tumor Board at Chennai, a very professional, thoughtful and thorough session which our oncologists hold every Thursday without fail.

Editorial Board

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

Guest Editorial

We studied COVID-19 associated mucormycosis based on 17 cases reported nationwide and assessed the differences with India. They differed by frequencies of diabetes mellitus (47% in France versus 95% in India), hematological malignancies (35% versus 1%), anatomical sites (53% lung versus >80% rhino-orbito-cerebral) and prognosis (>80% mortality versus <50%)

Rare cause of pyrexia of unknown origin

Primary gastrointestinal non-Hodgkin's lymphoma (PGINHL) is a rare lymphoproliferative disorder characterised by lymphomatous involvement of gastrointestinal tract in the absence of generalised lymphadenopathy, blood and bone marrow involvement. It can rarely present as intermittent fever without other localising features.

Impact of multi-disciplinary tumour board (MDT) on cancer care

A multi-disciplinary tumor board (MDT) is a meeting of doctors and other health care professionals from different specialties to help formulate treatment plans for individual patients or to get second opinions on proposed treatment plans

WPW pathway ablated from uncommon location

Drug resistant SVT due to WPW syndrome in a 17-year-old with history of failed ablation because of high risk location of the accessory pathway.
Figures 1-5 illustrate the successful performance of a high-risk procedure from an unusual location.

Statistical hypothesis - using the t-test

The t-test is a statistical hypothesis test in which the test statistic follows a Student's t-distribution under the null hypothesis.
A t-test is most commonly applied when the test statistic follows a normal distribution if the value of a scaling term in the test statistic is known. When the scaling term is unknown and is replaced by an estimate based on the data, the test statistics (under certain conditions) follow a Student's t distribution.

Learning from Experience - Chapters 6 and 7

A 65-year-old man, weighing 50 kg presented with severe throat pain, difficulty in talking and swallowing for two days. He gave history of his denture getting displaced while eating and trapped in his throat.

The Consultation Room - Chapters 4 to 9

"Sometimes we have to see to believe, when happenings are unanticipated"
To discourage unqualified 'Doctors' (quacks) from practicing, it is prudent that every qualified practitioner displays his academic qualifications, Medical Council registration certificate, as well as any other awards and appreciations received in profession, in the consultation room or the waiting hall.

Journal Scan

Journal scan: A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Diagnostic Image

Raccoon eyes may be used to describe large dark rings around the eyes. They can signify a few different conditions that cause internal bleeding near the eyes.

Patient's Story

He was a very dignified man who had a very distinguished life, in service of the state and country. He was well over ninety. The lamp of his life was flickering from far advanced heart failure. Yet another hospitalization was called for and he was benefitting.

An Anthology Of Poems

The grinding voice of silence
Screamed past the lonely staircase
Climbing combined infinity, with trips the steps make alliance
So you crouch and cry with hands on ears and misery on face

Save Farmers, Save Future

Once upon a time, there lived a boy named Arnav. He was born in Madurai. His father was a farmer. He loved agriculture.

Editorial

Whatever clouds may hover on the horizon, whether monsoon or the third wave, YOUR GOOD WORK shall be carried by the KAUVERIAN every fortnight!

Editorial Board

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

Dilemma of shadows

Multiple ring-enhancing lesions in the brain have various differential diagnoses including neoplastic and non-neoplastic diseases. Infectious, vascular and inflammatory are non-neoplastic causes and primary brain tumour and metastasis are important etiologies for neoplastic disorders.

Challenges in Neuroanaesthesia and Neurointensive care

It's been a year since we started the Department of Neurosciences at Kauvery Hospital Bangalore and Hosur. It has been a learning experience with some unique challenges but overall a very satisfying one so far. We present here some of the interesting patients we came across through the year, and their management.

Leadless pacemakers: The future of pacing?

As we look back at the history and evolution of pacemakers, permanent pacemakers were indicated for diseases of the cardiac conduction system that could disrupt normal conduction pattern and can result in symptomatic bradycardias. Pacing was developed using external devices and alternating current, which subsequently evolved to "wearable" transistorized battery powered pacemakers. A paradigm shift occurred with the introduction of the entirely implantable pacemaker systems.

Clinical Therapeutics: The polymyxins, existing challenges and new opportunities

The global rise in nosocomial pneumonia caused by multidrug-resistant (MDR) pathogens and the increasingly limited antibiotic treatment options are growing threats to modern medicine. As a result, older antibiotics such as polymyxins (colistin and polymyxin B) are being used as last-resort drugs for MDR-nosocomial pneumonia. The review provides pharmacokinetic/pharmacodynamic data in order to redefine appropriate dosing strategies and also ensure safety from toxicity.

Decision to Take Up a Patient in The Presence of Arrhythmias

A 50-year-old man was brought to the emergency department for an obstructed inguinal hernia. He was a chronic smoker and was also under the influence of alcohol at that time. Relevant medical history was that he was a known case of cardiac arrhythmia (atrial fibrillation) and had discontinued his medication.

Why growing public dissatisfaction about medical profession?

Though medicine is advancing leaps and bounds, ironically patients' dissatisfaction is also on the rise.

Journal Scan

Journal scan: A review of 10 recent papers of immediate clinical significance, harvested from major international journals

Diagnostic Image

It is a type of non-cancerous tumour that arises in the lining of a joint. The knee is most commonly affected; however, it can affect any joint

Patient's Story

Teenager MS did not know a happy and healthy day since early childhood which was a great worry for her mother. MS has ITP which is a complex blood disease called Idiopathic Thrombocytopenic Purpura.

The Waiting Room

Is Earth just a waiting room?
A transit to someplace else?
Is life just a waiting time?
Alike to standing in line,

Editorial

We publish a "patient's voice" - a patient's perception of pulmonology.

Instructions for Authors

The title of your manuscript should be concise, specific and relevant. It should identify if the study reports trial data, or is a systematic review, meta-analysis or replication study.

COVID-19 and mucormycosis: the dual threat

India has experienced two waves COVID-19, the latter more devastating in every parameter. The associated outbreak of mucormycosis caused very high morbidity and mortality in the country.

COVID-19 associated mucormycosis: efforts and challenges

The world is still trying to come to terms with the new and strange coronavirus disease 2019 (COVID-19) which made its landfall in Dec 2019 and was declared a pandemic towards the end of January 2020.

Saccular abdominal aortic aneurysms: a case series

Abdominal aorta is the most common site for aneurysms in the arterial tree. Abdominal aortic aneurysms are classified as fusiform or saccular based on the morphology.

Trauma and OCD - A Case of a Boy with Dark Fears

Obsessive-compulsive disorder (OCD) is a common disorder that often begins in childhood and is frequently unrecognized, underdiagnosed, and undertreated.

Anaphylaxis to Antibiotic

A 36-year-old primigravida was admitted for an elective LSCS. She had conceived following infertility treatment.

Journals Scan

Ahead of the 2020 Tokyo Olympics and Paralympics, The Lancet launched its third Series on physical activity (previous Series-2012 and 2016) on the importance of regular physical activity and sport to our health and wellbeing.

The Consultation Room - Introduction

Practice of medicine is more an art than science".
"The time I spend in my office is more taxing on my expertise,
than when I'm in the operation room.

Diagnostic Image

On examination, she was alert and active. Her vitals were stable.

A Patient's Perception of Pulmonology

I was admitted to the emergency facility of the Kauvery Hospital on the 7 th of August, coughing continuously for two days, and passing blood due to this extreme effort.

Blinding Colors

As the music played by the tea kettle
A raven haired girl sat by the glass window
Watching the flying leaves settle
Gently on the dew of the fresh grass floor

Editorial

Dear colleagues
KAUVERIAN"s first Independence Day issue is here!

Editorial Board

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

ABO incompatible renal transplant in a post COVID patient with COVID antibodies

COVID-19 pandemic has resulted in challenges to renal transplantation in many countries...

Neuromyelitis Optica early presentation of an adult disorder

Neuromyelitis optica (NMO) is a severe autoimmune disease of the CNS characterized by recurrent inflammatory events primarily involving the optic nerves and spinal cord. NMO is infrequent in children, but early recognition is important to start adequate treatment.

The gamut of neurological disorders associated with COVID-19

COVID-19 has led to unprecedented clinical challenges worldwide. Its clinical manifestations range from asymptomatic infection to multi-organ failure and death.

Anaesthetic management of patients with Takayasu arteritis

A 30-year-old woman presented to the assessment clinic for pre-anaesthetic evaluation. She was to have abdominoperineal resection for rectal malignant tumour.

My Pains and Gains in Becoming A Doctor

The British landed in India at Surat on August 24, 1608.
The British East India Company came to India as traders in spices, a very important commodity in Europe back then as it was used to preserve meat. Apart from that, they primarily traded in silk, cotton, indigo dye, tea and opium.

Significance testing of correlation coefficient

Where there is a linear relationship between two variables there is said to be a correlation between them. Examples are height and weight in children, or socio-economic class and mortality.

Journal scan

SGLT2 inhibitors and GLP-1 receptor agonists are used in patients with type 2 diabetes as glucose lowering therapies, with additional benefits of weight loss and blood pressure reduction.

Diagnostic Image

A 73-year-old gentleman was diagnosed to have of Hypertrophic cardiomyopathy with Left Ventricular Outflow Tract Obstruction (LVOTO) on straining, of 38 mm hg gradient, Systolic Anterior Motion (SAM) of Mitral Valve, grade 2, with moderate Mitral Regurgitation and severe Pulmonary Artery Hypertension.

Patient's Story

A 30-year-old MV did not think much of the Chickenpox that attacked her. She was reconciled to an appearance of the pox vesicles, fever and discomfort that would last a week or two. Even in modern times, elders in the family invoked village deities to grant an uncomplicated recovery.

AN ANTHOLOGY OF POEMS - Subliminal Sublimes

Excerpt from "The See-Saw Souls" by Kaanthal Manikandan

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.

~ 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.

~ 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.

~ Dr M Banupriya

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

~ 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

- Dr Arunagiri Viruthagiri, Dr Nedunchezhian Manjini

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

- 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.

- 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

- 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.

- 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.

Kauverian - Scientific Journals

Volume 4 : Issue 1

Editorial

Author Instruction

Ultrashort Case Report

Cochlear Implantation: Expanding candidacy and Cost Effectiveness

Spontaneous Pneumomediastinum in COVID 19 - Tertiary Care Centre Experience in South India

Amoxycillin Induced Anaphylactic Shock: A Case Report

An Unusual Cause of Seizures: A Case Report

Case Report

Educational Strategies to Promote Clinical Diagnostic Reasoning

Rheumatic Rarities

Types of sampling methods in statistics

Diagnostic Image

Learning from Experience - Intra Operative, Chapters 21 and 22

The Consultation Room

Journal Scan

Recommended Readings

Volume 3 : Issue 12

Editorial

Author Instruction

Diagnosis and Management of COVID-19 in Pregnancy

An ultrashort report

Ultra-Short Case Report

An interesting case of Bilateral Carotid aneurysms

A Case Report

Uterine artery embolization: Saving a mother and her motherhood

Acute Abdomen - Sepsis - CIRCI: A Success Story

Diagnostic Image

Learning from Experience - Intra Operative, Chapters 19 and 20

The Consultation Room

Journal Scan

Recommended Readings

Volume 3 : Issue 11-2

Severe Methemoglobinemia, Unresponsive to Methylene Blue

Severe Meliodosis With Multisystemic Involvement: A Case Report

A Case Report

Recognize Rhabdomyolysis early to prevent Acute Kidney Injury and Acute Renal Failure

New Onset Refractory Status Epilepticus (NORSE)

Sensitive of EFAST in trauma in correlation with CT scan

Sub Arachnoid Haemorrhage, management in Emergency and Neuro Intensive care

Uncommon presentation of Takayasu Arteritis as a convulsive syncope

All right sided hearts are not Dextrocardia

COVID and the Salt Story

Acute Lower Limb Ischemia: A Clue to Underlying Aortic Dissection

Globe Injury with Orbital Blow Out Fracture

The heat-stricken life - Treatment in time only saves lives!

Pneumoperitoneum, does it have any clinical significance?

Hypertensive Emergency in the ED

Role of a paramedic in inter-hospital transfer

Golden Hours in Safer Hands

Through rough, crowded roads and stagnant waters - we race against time to reach you!

Volume 3 : Issue 11-1

Editorial

Evolution of Emergency Medicine in India and the Emergence of the MEM Program at Trichy

Welcome to the Dance floor: The Emergency Room

Life of An Emergency Physician

A Racing Heart Beat: To Shock or Not

Being Calm Amidst Chaos: Tips on How to Be an Expert Emergency Nurse

COVID COVID everywhere, but not a place to run away from!

Proud to be an Emergency Nurse: Life in the fast lane!!!

The Journey of a Fresher Nurse in the ED

Ready, Steady, Go!!!

An Elevator Story!!!

Veno-occlusive mesenteric ischemia: A case report

Stridor: An Alarming Sign in Emergency

Amnesia in the ER: That Ghajini Moment!!! A Case series

Survival After Paraquat Ingestion: A Case Series

When you save one life, you save a family

Volume 3 : Issue 10

Editorial

Author Instruction

Interventional Nephrology

Amplified Ears and Listening Brains

Love makes life worth living

Usage of Dapagliflozin in Elderly

Severe Methemoglobinemia Treated Successfully with Oral Ascorbic Acid

The new imitator