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Kumar A, Kuttalam S, Tanwar D, Choudhary B, Garg MK, Gopalakrishnan M. First report of clinically significant bites due to Platyceps ventromaculatus (GRAY, 1834) from Thar Desert region, Rajasthan, India. Toxicon 2024; 240:107638. [PMID: 38311255 DOI: 10.1016/j.toxicon.2024.107638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Platyceps ventromaculatus is a non-front-fanged colubrid snake of unknown medical significance. In this study, we highlight the clinical manifestations and outcomes of P. ventromaculatus bites. We also emphasise the need to create awareness among clinicians and the public for its potential to be confused with serious venomous bites such as Echis carinatus sochureki. METHODS This series is part of an ongoing observational clinical study from our tertiary care hospital in Jodhpur, India on the profile and outcomes of snakebite envenoming. Data was collected after approval from Institute Ethics Committee. The date and time of the bite, geographical location, type of human-snake conflict, time-to-reach a healthcare facility, antivenom used (dose), and outcomes were recorded. We retrospectively examined our clinical data for images suggestive of P. ventromaculatus and present the clinical details of these patients. The photographs were identified utilising taxonomic keys for species identification. RESULTS A total of four images and three patients with bites due to P. ventromaculatus were identified. The clinical effects included mild local erythema, pain, transient local bleeding, and edema. All bites occurred during daylight hours, 2 during agricultural activities, and one at home. Twenty-minute Whole Blood Clotting Test was persistently prolonged for 12 h after the bite in one patient. All patients were treated symptomatically, observed at the emergency department, and discharged within 24 h. None of the patients received antivenom. CONCLUSIONS To our knowledge, P. ventromaculatus has so far not been reported to result in envenoming or medically significant bites. This study highlights that Platyceps bite can present with clinically significant local and possibly systemic findings that may lead to confusion with saw-scaled viper (Echis) envenoming. Clinicians must receive appropriate training so as to be aware and recognize regional snake species that do not require antivenom so as to avoid unnecessary antivenom administration.
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Affiliation(s)
- Akhilesh Kumar
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, India
| | - Sourish Kuttalam
- Molecular Ecology and Evolution at Bangor, School of Natural Sciences, Bangor University, Environment Centre Wales, Bangor, LL57 2UW, Wales, UK; Society for Nature Conservation, Research and Community Engagement (CONCERN), Nalikul, Hooghly, West Bengal, 712407, India; Captive & Field Herpetology Ltd, 13 Hirfron, Llaingoch, Holyhead, Anglesey, LL65 1YU, Wales, UK
| | - Divya Tanwar
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, India
| | - Bharat Choudhary
- Department of Trauma and Emergency (Paediatrics), All India Institute of Medical Sciences, Jodhpur, 342005, India
| | - Mahendra Kumar Garg
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, India
| | - Maya Gopalakrishnan
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, India.
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Kumar A, Goyal S, Garg MK, Gopalakrishnan M. Scorpion Sting Envenomation, a Neglected Tropical Disease: A Nationwide Survey Exploring Perspectives and Attitudes of Resident Doctors from India. Am J Trop Med Hyg 2023; 109:957-964. [PMID: 37696517 PMCID: PMC10551078 DOI: 10.4269/ajtmh.23-0194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/01/2023] [Indexed: 09/13/2023] Open
Abstract
Scorpion sting envenomation (SSE) is a commonly encountered and a significant problem in the tropics, affecting rural and marginalized communities. However, it is not formally listed as a neglected tropical disease (NTD) by the WHO. We designed this cross-sectional study to explore medical graduates' and resident doctors' perspectives on SSE as an NTD and to assess their experiences, knowledge, and confidence in managing these patients. An online questionnaire was developed, validated, and administered to interns and resident doctors across India. Adjusted odds ratios were calculated for factors predicting high self-reported confidence scores for managing scorpion stings using multivariable logistic regression. The final questionnaire contained 26 items including participant background, perspectives about SSE being an NTD, experiences, knowledge, and skills needed to manage, and prevent stings effectively. Of 454 participants, 69% opined that SSE was an NTD, and > 60% felt that SSE was inadequately addressed within undergraduate training. Predictors of high self-reported confidence scores in management competencies were residency in a clinical branch that commonly encountered SSE (internal/emergency medicine or pediatrics, P < 0.0001), having ever managed an SSE patient alone or as a part of a team (P < 0.0001), and attending a class or teaching session on SSE during undergraduate training (P = 0.048). Our results suggest that residents across India believe that there is an urgent need to declare SSE an NTD to increase its visibility, further paving the way for innovative multilevel cross-cutting solutions for mitigation. Designing authentic learning experiences can help produce competent and empathetic physicians in managing and preventing SSE.
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Affiliation(s)
- Akhilesh Kumar
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shilpi Goyal
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mahendra K. Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Kachhwaha A, Kumar A, Garg P, Sharma A, Garg MK, Gopalakrishnan M. Delayed Compression Paralysis Following an Iliopsoas Hematoma 30 Days After Saw-Scaled Viper (Echis carinatus sochureki) Envenoming: A Case Report. Wilderness Environ Med 2023; 34:366-371. [PMID: 37179190 DOI: 10.1016/j.wem.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 05/15/2023]
Abstract
Snakebite envenoming is a neglected tropical disease disproportionately affecting the rural and marginalized population in low-middle-income countries. The saw-scaled viper (Echis carinatus) is a clinically important snake that causes serious morbidity and mortality in the Indian subcontinent. Even though it is within the so-called big-four snakes against which polyvalent antivenom is available throughout India, reports of antivenom ineffectiveness are emerging in saw-scaled viper envenoming, especially around Jodhpur, Rajasthan, India. This case report highlights a patient with saw-scaled viper envenoming with an ineffective antivenom response complicated by acute kidney injury as well as local and systemic bleeding complications, which subsequently resulted in a pelvic hematoma that compressed the lumbosacral nerves, causing lower-limb weakness and sensory deficits. He was successfully managed with hematoma aspiration and supportive care. This case brings into focus the challenges of managing saw-scaled viper envenoming in this region with antivenom ineffectiveness, resulting in delayed and significant coagulopathy and its complications leading to prolonged hospital stay and morbidity. Our report spotlights less emphasized aspects of long-term morbidity in snakebite survivors, such as loss of working days and productivity. We also highlight the need for an organized system of long-term follow-up of snakebite survivors to screen for possible complications and manage them early.
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Affiliation(s)
- Arjun Kachhwaha
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Akhilesh Kumar
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Pawan Garg
- Department of Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Ankur Sharma
- Department of Anesthesiology and critical care, All India Institute of Medical Sciences, Jodhpur, India
| | - Mahendra K Garg
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Maya Gopalakrishnan
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, India.
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Bava D, Kumar PHA, Gupta A, Mandal S, Bajpayee A, Gopalakrishnan M, Khan MA. Redefining the role of therapeutic plasma exchange in complications of Echis carinatus sochureki envenomation refractory to anti-snake venom: A case series. Asian J Transfus Sci 2023; 17:295-300. [PMID: 38274951 PMCID: PMC10807517 DOI: 10.4103/ajts.ajts_49_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Saw-scaled viper (Echis carinatus) belongs to the Viperidae family. Its venom is hemotoxic and contains several small peptides and proteins affecting the coagulation system. Commonly used anti-snake venom (ASV) products in India are reported to be ineffective or less effective in cases with bites by Echis carinatus sochureki which are commonly found in desert areas in Rajasthan. Although therapeutic plasma exchange (TPE) has been successful in patients with snakebite envenomation in the past, American Society for Apheresis guidelines 2019 included this indication under category III with grade 2C recommendation. AIM AND OBJECTIVES To report the safety and efficacy of therapeutic plasma exchange procedures in the setting of ASV refractory E. c. sochureki envenomation. MATERIALS AND METHODS Four patients admitted to our institute in 2021 September with an alleged history of snake bites and who underwent at least one cycle of therapeutic plasma exchange were assessed for clinical outcome, laboratory parameters, and blood product consumption. RESULTS Three adult patients and one pediatric patient are included in this case series, all of them males. Indication for TPE in one case was suspected diffuse alveolar hemorrhage (DAH), while in all the other cases was thrombotic microangiopathy (TMA). All received a variable number of sessions from 2 to 5 and 1.3-1.5 plasma volume was removed on an average per cycle. The endpoint of TPE was the resolution of DAH in one while a reduction in lactate dehydrogenase and an increase in platelet count was in TMA cases. Consumption of blood products was drastically reduced in all four patients after starting the procedure. All the adult patients fared well on follow-up while the child had developed acute cortical necrosis and was dialysis-dependent. It has been noted in the previous studies too that a subset of snakebite-induced TMA cases was getting converted to chronic kidney disease and becoming dialysis dependent in the long run. CONCLUSIONS In regions where ASV treatment failure is very common, therapeutic plasma exchange is a safe and effective complementary treatment modality along with supportive care.
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Affiliation(s)
- Davood Bava
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - P H Akhilesh Kumar
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Anubhav Gupta
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Saptarshi Mandal
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Archana Bajpayee
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Maya Gopalakrishnan
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Md Atik Khan
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Bhaumik S, Di Tanna GL, Beri D, Bhattacharya A, Kumar P, Giri S, Gopalakrishnan M, Raut S, Hartalkar A, Majgi SM, Jagnoor J. Effect of COVID-19 containment measures on access to snakebite care in India. Rural Remote Health 2023; 23:7881. [PMID: 37400940 DOI: 10.22605/rrh7881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
INTRODUCTION The extensive spread of COVID-19 meant action to address the pandemic took precedence over routine service delivery, thus impacting access to care for many health conditions, including the effects of snakebite. METHOD We prospectively collected facility-level data from several health facilities in India, including number of snakebite admissions and snakebite envenoming admissions on modality of transport to reach the health facility. To analyse the effect of a health facility being in cluster-containment zone, we used negative binomial regression analysis. RESULTS Our findings suggest that that health facilities located within a COVID containment zone saw a significant decrease in total snakebite admissions (incidence rate ratio 0.64 (0.43-0.94), standard error 0.13, p≤0.02)) and envenoming snakebite admissions (incidence rate ratio 0.43 (0.23-0.81), standard error 0.14, p≤0.01) compared to when health facilities were not within a COVID containment zone. There was no statistically significant difference in non-envenoming admissions and modalities of transport used to reach health facilities. CONCLUSION This article provides the first quantitative estimate of the impact of COVID-19 containment measures on access to snakebite care. More research is needed to understand how containment measures altered care-seeking pathways and the nature of snake-human-environment conflict. Primary healthcare systems need to be safeguarded for snakebite care to mitigate effects of cluster-containment measures.
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Affiliation(s)
- Soumyadeep Bhaumik
- The George Institute for Global Health, University of New South Wales, Sydney, Australia; and The George Institute for Global Health, New Delhi, India
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Sydney, Australia; and Department of Innovative Technologies, University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
| | - Deepti Beri
- The George Institute for Global Health, New Delhi, India
| | | | | | - Surajit Giri
- Demow Community Health Centre, Sivasagar, Assam, India
| | | | | | - Amol Hartalkar
- Dr. Amol Hartalkar's Cardio-Diabetes Clinic, Pune, Maharashtra, India
| | | | - Jagnoor Jagnoor
- The George Institute for Global Health, University of New South Wales, Sydney, Australia; and The George Institute for Global Health, New Delhi, India
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Gopalakrishnan M, Khichar S, Saurabh S, Vijayvergia P, Thangaraju K, Tripathi S, Devarakonda HV, Kumar A, Kumar PS, Garg MK. Effectiveness of early awake self proning strategy in non-intubated patients with COVID-19 hypoxemia: an open-labelled randomized clinical trial from Jodhpur, India. Monaldi Arch Chest Dis 2022; 93. [PMID: 36524853 DOI: 10.4081/monaldi.2022.2431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
Awake self-proning is being used widely as respiratory support in COVID-19 hypoxemia, in resource-limited settings. We aimed to investigate the effectiveness of early awake self-proning in preventing mortality and the need for intubation in adults with moderate COVID-19 hypoxemia. In this randomized clinical trial with inten-tion-to-treat analysis, we enrolled eligible adults with COVID-19 hypoxemia (SpO2 <94%), requiring supplemental oxygen via nasal prongs or facemask from a tertiary-care setting in Jodhpur, India between June 15 to December 24, 2020. Awake proning comprised of 4-hour cycles with prone position maintained 2 h per cycle. The control group did not maintain any specific position. All participants received standard care. The primary outcomes were 30-day mortal-ity and requirement for mechanical ventilation. Of 502 participants included, mean (SD) age was 59.7 (12.7) years with 124 women (24.6%); 257 were randomized to awake-proning, 245 to control group and all 502 were included for follow-up mortality analysis. Mortality at follow-up was 16.3% in the awake-prone and 15.1% in the control group [OR:1.10 (0.68-1.78), p=0.703). The requirement of mechanical ventilation was 10% in both groups (p=0.974). Survival time (in days) was not significantly different between the groups [Log-rank test, HR: 1.08 (95% CI, 0.70-1.68), p=0.726]. Likewise, time to intubation was comparable (Log-rank test, HR: 0.93 (95% CI, 0.56-1.70), p=0.974). Hence, awake self-proning did not improve survival or requirement of mechanical-ventilation in non-intubated patients with mild to moderate COVID-19 hypox-emia. Trial Registration: Clinical trial registry of India, ID: CTRI/2020/06/025804. The trial is accessible from WHO's International Clinical Trials Registry Platform (ICTRP) at https://trialsearch.who.int *************************************************************** *Appendix Authors list Deepak Kumar1, Gopal Krishna Bohra1, Nishant Kumar Chauhan2, Nikhil Kothari3, Vijaya Lakshmi Nag4 Sanjeev Misra5 1Department of Internal Medicine; 2Department of Pulmonary Medicine; 3Department of Anaesthesiology and Critical Care; 4Department of Microbiology; 5Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, India.
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Affiliation(s)
- Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur.
| | - Satyendra Khichar
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur.
| | - Suman Saurabh
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur.
| | - Parag Vijayvergia
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur.
| | - Karthikeyan Thangaraju
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur.
| | - Swapnil Tripathi
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur.
| | | | - Akhilesh Kumar
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur.
| | - Pranav S Kumar
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur.
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur.
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Ronan K, Hughes Driscoll C, Decker E, Gopalakrishnan M, El Metwally D. Resource utilization and convalescent care cost in neonatal opioid withdrawal syndrome. J Neonatal Perinatal Med 2022; 16:49-57. [PMID: 36530095 DOI: 10.3233/npm-221060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND: Neonatal opioid withdrawal syndrome (NOWS) is a growing public health problem associated with complex and prolonged medical care and a significant resource utilization burden. The objective of this study was to compare the cost of different convalescent care settings for infants with NOWS. METHODS: Retrospective comparison study of infants with NOWS discharged directly from NICU, transferred to an acute care pediatric floor (PPCU) or rehabilitation hospital (PRH). Primary outcomes were length of stay (LOS) and cost of stay (COS). RESULTS: Infants had 1.3 (95% CI: 1.1,1.6) times and 2.5 (95% CI: 2.1,3.1) times significantly longer mean LOS for PPCU and RH discharges compared to NICU discharges. NICU discharged infants had the lowest mean COS ($25,745.00) and PRH the highest ($60,528.00), despite PRH having a lower cost per day. PRH discharged infants had higher rates of methadone and benzodiazepine and less buprenorphine exposure than NICU/PPCU discharged. Infants born to mothers on marijuana and buprenorphine had a 28% lower mean COS compared to unexposed infants. Median treatment cumulative morphine doses were six-fold higher for PRH than NICU discharge. CONCLUSIONS: Infants transferred to convalescence care facilities had longer and more costly admissions and received more medication. However, there may be a role for earlier transfer of a subset of infants at-risk for longer LOS as those exposed to methadone and/or benzodiazepines. Further studies exploring differences in resource utilization, convalescent care delivery and cost expenditure are recommended.
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Affiliation(s)
- K. Ronan
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
- Women’s and Babies Hospital, Lancaster, PA, USA
| | | | - E. Decker
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
- The College of Physicians and Surgeons at Columbia University, NY, USA
| | - M. Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, MD, USA
| | - D. El Metwally
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
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Sireesha Y, Shree R, Nagappa M, Patil A, Singla M, Padma Srivastava MV, Dhamija RK, Balaram N, Pathak A, Ramachandran D, Kumar S, Puri I, Sharma S, Panda S, Desai S, Samal P, Choudhary A, Vijaya P, Ferreira T, Nair SS, Sinha HP, Bhoi SK, Sebastian J, Sharma S, Basheer A, Bhartiya M, Mathukumalli N, Jabeen SA, Lal V, Modi M, Sharma PP, Kaul S, Singh G, Agarwal A, Garg D, Jose J, Dev P, Iype T, Gopalakrishnan M, Upadhyay A, Bhatia R, Pandit AK, Singh RK, Salunkhe M, Yogeesh P, Reyaz A, Nadda N, Jha M, Kumar B, Kushwaha PK, Chovatiya H, Madduluri B, Ramesh P, Goel A, Yadav R, Vishnu VY. Impact of COVID-19 on Guillain-Barre Syndrome in India: A Multicenter Ambispective Cohort Study. Ann Indian Acad Neurol 2022; 25:1116-1121. [PMID: 36911481 PMCID: PMC9996522 DOI: 10.4103/aian.aian_523_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/01/2022] [Accepted: 07/10/2022] [Indexed: 03/14/2023] Open
Abstract
Introduction/Aims Studies conducted during the coronavirus disease 2019 (COVID-19) pandemic have reported varied data regarding the incidence of Guillain-Barre syndrome (GBS). The present study investigated demographic and clinical features, management, and outcomes of patients with GBS during a specified period of the COVID-19 pandemic, and compared these features to those of GBS in the previous year. Methods A multicenter, ambispective cohort study including 26 centers across India was conducted. Data from a pre-COVID-19 period (March 1 to August 31, 2019) were collected retrospectively and collected ambispectively for a specified COVID-19 period (March 1 to August 31, 2020). The study was registered with the Clinical Trial Registry India (CTRI/2020/11/029143). Results Data from 555 patients were included for analysis: pre-COVID-19 (n = 334) and COVID-19 (n = 221). Males were more commonly affected during both periods (male:female, 2:1). Gastroenteritis was the most frequent antecedent event in 2019 (17.4%), whereas fever was the most common event in 2020 (10.7%). Paraparesis (21.3% versus [vs.] 9.3%, P = 0.001) and sensory involvement (51.1% vs. 41.3%; P = 0.023) were more common during COVID-19 in 2020, whereas back pain (26.3% vs. 18.4%; P = 0.032) and bowel symptoms (20.7% vs. 13.7%; P = 0.024) were more frequent in the pre-COVID period. There was no difference in clinical outcomes between the two groups in terms of GBS disability score at discharge and 3 months after discharge. Independent predictors of disability in the pre-COVID period included areflexia/hyporeflexia, the requirementfor intubation, and time to bulbar weakness; in the COVID-19 period, independent predictors included time from onset to admission, intubation, and intubation requirement. The mortality rate was 2.3% during the entire study period (13/555 cases). Discussion Results of this study revealed an overall reduction in the frequency of GBS during the pandemic. The lockdown likely reduced the risk for antecedent infections due to social distancing and improved hygiene, which may have resulted in the reduction of the frequency of GBS.
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Affiliation(s)
- Yareeda Sireesha
- Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Ritu Shree
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhu Nagappa
- National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Anuja Patil
- Krishna Institute of Medical Sciences Hospital, Secunderabad, Telangana, India
| | | | | | - RK Dhamija
- Lady Hardinge Medical College, New Delhi, India
| | | | - Abhishek Pathak
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Sujit Kumar
- Apollo Hospitals, Sheshadripuram, Bangalore, India
| | - Inder Puri
- PBM Hospital, Sardar Patel Medical College, Bikaner, India
| | - Sudhir Sharma
- Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India
| | - Samhita Panda
- All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Soaham Desai
- Shree Krishna Hospital and Pramukhswami Medical College, Bhaikaka University, Karamsad, Anand, Gujarat, India
| | | | | | - Pamidimukkala Vijaya
- Lalitha Super Specialities Hospital Private Limited, Guntur, Andhra Pradesh, India
| | | | - S. S. Nair
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - H. P. Sinha
- NH MMI Narayana Superspeciality Hospital, Raipur, Chattisgarh, India
| | - S. K. Bhoi
- All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | | | - Sanjay Sharma
- Ramakrishna Care Medical Sciences Private Limited, Raipur, India
| | - Aneesh Basheer
- Pondicherry Institute of Medical Sciences, Pondicherry, India
| | | | | | | | - Vivek Lal
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Modi
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - P Praveen Sharma
- National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Subash Kaul
- Krishna Institute of Medical Sciences Hospital, Secunderabad, Telangana, India
| | | | - Ayush Agarwal
- All India Institute of Medical Sciences, New Delhi, India
| | | | - James Jose
- Government Medical College Kozhikode, Kerala, India
| | - Priya Dev
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Thomas Iype
- Government Medical College, Thiruvananthapuram, Kerala, India
| | | | | | - Rohit Bhatia
- All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | - P.M. Yogeesh
- All India Institute of Medical Sciences, New Delhi, India
| | - Alisha Reyaz
- All India Institute of Medical Sciences, New Delhi, India
| | - Nishant Nadda
- Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India
| | - Menkha Jha
- All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Bismay Kumar
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - PK Kushwaha
- NH MMI Narayana Superspeciality Hospital, Raipur, Chattisgarh, India
| | - Harshadkumar Chovatiya
- Shree Krishna Hospital and Pramukhswami Medical College, Bhaikaka University, Karamsad, Anand, Gujarat, India
| | | | - P Ramesh
- Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Abeer Goel
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rahul Yadav
- Shree Krishna Hospital and Pramukhswami Medical College, Bhaikaka University, Karamsad, Anand, Gujarat, India
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Kalapurakal J, Wang Y, Ghoreishi-Haack N, Wang W, Wang X, Xi G, Burdett K, Zhang H, Gopalakrishnan M, Mehta M, James C, Horbinski C. CDK 4/6 Inhibitors are Potent Radiosensitizers in Retinoblastoma Protein Positive Meningiomas. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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10
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Teo P, Randall J, Bajaj A, Lou B, Shah J, Gopalakrishnan M, Kamen A, Das I, Abazeed M. Lung Tumor Motion and its Impact on Deep Learning Prediction of Local Recurrence. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Bhaumik S, Gopalakrishnan M, Kirubakaran R, Jagnoor J. Antibiotics for preventing wound infections after snakebite. Hippokratia 2022. [DOI: 10.1002/14651858.cd015114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Soumyadeep Bhaumik
- The George Institute for Global Health, Faculty of Medicine; University of New South Wales; Sydney Australia
- Meta-research and Evidence Synthesis Unit; The George Institute for Global Health; New Delhi India
| | - Maya Gopalakrishnan
- Department of Internal Medicine; All India Institute of Medical Sciences, Jodhpur; Jodhpur India
| | - Richard Kirubakaran
- Cochrane India-CMC Vellore Affiliate, Prof. BV Moses Centre for Evidence Informed Healthcare and Health Policy; Christian Medical College; Vellore India
| | - Jagnoor Jagnoor
- The George Institute for Global Health, Faculty of Medicine; University of New South Wales; Sydney Australia
- Injury Division; The George Institute for Global Health; New Delhi India
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Vijayan N, Vijayvergia P, Bohra GK, Garg MK, Gopalakrishnan M. Clinical characteristics and outcomes of digital gangrene in connective tissue disorders: a longitudinal single-centre experience from Jodhpur, India. Clin Rheumatol 2022; 41:3543-3549. [PMID: 35780227 DOI: 10.1007/s10067-022-06265-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 11/26/2022]
Abstract
Epidemiology, clinical presentation, and outcomes for digital gangrene in connective tissue disorders (CTD) remain underreported from tropical countries like India. In this series, we aimed to explore the clinical profile and outcomes of patients who presented with digital gangrene and a diagnosis of CTD. Hospital-based longitudinal observational study. Patients with digital gangrene and underlying diagnosis of CTD presenting to our tertiary-care centre in Jodhpur, India between1st January 2018 and 31st June 2021 were included. Clinical outcomes including mortality, limb outcomes, functional status and other systemic involvement were assessed. Of the 312 patients registered in the rheumatology clinic during this period, 22 (7%) patients were found to satisfy the inclusion criteria. Mean age was 46 years and 90% were females. The most common underlying diagnosis was Mixed connective tissue disorder (MCTD). Digital gangrene was the presenting symptom in 13 (60%) patients. Half of the patients received only corticosteroids as immunosuppression. Two died due to systemic complications. Complete resolution occurred in 17 (85%), autoamputation in 3, and infection requiring surgical drainage in one patient. All surviving patients reported good functional limb outcome on 6 months follow-up. MCTD is an important cause of digital gangrene in rheumatology practice. In patients presenting with digital gangrene, an active search for an underlying CTD is imperative, as this could result in timely initiation of appropriate limb-saving therapy. Corticosteroids alone with rapid tapering may be an appropriate option to consider in the initial management of digital gangrene in CTD. Key Points • Mixed connective tissue disorder is an important cause of digital gangrene in rheumatology practice in western India. • In patients presenting with digital gangrene, an active search for an underlying connective tissue disorder is imperative, as this could result in timely initiation of appropriate therapy and can prove limb saving. • Corticosteroids alone with rapid tapering may be an appropriate option to consider in the initial management of digital gangrene in connective tissue disorders.
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Affiliation(s)
- Neeraja Vijayan
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India
| | - Parag Vijayvergia
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India
| | - Gopal Krishna Bohra
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India
| | - Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Basni Industrial Estate, Jodhpur, 342005, India.
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Kumar A, Gopalakrishnan M, Kuri HR, Bajpayee A, Kothari N, Garg MK. Case Report: Delayed Diffuse Alveolar Hemorrhage in Echis sochureki Envenoming, Jodhpur, India. Am J Trop Med Hyg 2022; 106:967-969. [PMID: 35100564 PMCID: PMC8922478 DOI: 10.4269/ajtmh.21-1187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/28/2021] [Indexed: 11/07/2022] Open
Abstract
Snakebite envenoming is a common occupational hazard in the tropics. Venom-induced consumption coagulopathy and acute kidney injury are the most frequently encountered complications of viper bites. Diffuse alveolar hemorrhage (DAH) is an unusual presentation reported rarely in the literature. Our case report highlights the uncommon presentation of delayed pulmonary hemorrhage after snakebite envenoming. A 40-year-old healthy man presented to our emergency department after 6 hours of Echis sochureki (a saw-scaled viper subspecies) bite. He had abnormal coagulation parameters and thrombocytopenia with no signs of acute kidney injury. Transfusion protocols were initiated because of active bleeding and a rapid decrease in hemoglobin levels over next few days. Around day 10, his coagulation profile and hemoglobin were corrected, but he developed hemoptysis with rapidly progressive respiratory distress. Computed tomography of the chest was suggestive of DAH and the patient was started on plasma exchange with pulse methylprednisolone. After the initial worsening, he had rapid symptomatic improvement and radiological resolution. The patient had persistent hypofibrinogenemia, which resolved, and was discharged and remained healthy at the 60-day follow-up. This case highlights a presentation with an initial phase of venom-induced consumption coagulopathy followed by delayed DAH in saw-scaled viper envenoming that was treated successfully with immunosuppressants and plasma exchange.
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Affiliation(s)
- Akhilesh Kumar
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India;,Address correspondence to Maya Gopalakrishnan, Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Basni Industrial Estate, Jodhpur, Rajasthan, India. E-mail:
| | - Harshavardhan R. Kuri
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | - Archana Bajpayee
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Nikhil Kothari
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
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Gopalakrishnan M, Saurabh S, Sagar P, Bammigatti C, Dutta TK. A simple mortality risk prediction score for viper envenoming in India (VENOMS): A model development and validation study. PLoS Negl Trop Dis 2022; 16:e0010183. [PMID: 35192642 PMCID: PMC8896694 DOI: 10.1371/journal.pntd.0010183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 03/04/2022] [Accepted: 01/20/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Snakebite is a neglected problem with a high mortality in India. There are no simple clinical prognostic tools which can predict mortality in viper envenomings. We aimed to develop and validate a mortality-risk prediction score for patients of viper envenoming from Southern India. METHODS We used clinical predictors from a prospective cohort of 248 patients with syndromic diagnosis of viper envenoming and had a positive 20-minute whole blood clotting test (WBCT 20) from a tertiary-care hospital in Puducherry, India. We applied multivariable logistic regression with backward elimination approach. External validation of this score was done among 140 patients from the same centre and its performance was assessed with concordance statistic and calibration plots. FINDINGS The final model termed VENOMS from the term "Viper ENvenOming Mortality Score included 7 admission clinical parameters (recorded in the first 48 hours after bite): presence of overt bleeding manifestations, presence of capillary leak syndrome, haemoglobin <10 g/dL, bite to antivenom administration time > 6.5 h, systolic blood pressure < 100 mm Hg, urine output <20 mL/h in 24 h and female gender. The lowest possible VENOMS score of 0 predicted an in-hospital mortality risk of 0.06% while highest score of 12 predicted a mortality of 99.1%. The model had a concordance statistic of 0·86 (95% CI 0·79-0·94) in the validation cohort. Calibration plots indicated good agreement of predicted and observed outcomes. CONCLUSIONS The VENOMS score is a good predictor of the mortality in viper envenoming in southern India where Russell's viper envenoming burden is high. The score may have potential applications in triaging patients and guiding management after further validation.
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Affiliation(s)
- Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences Jodhpur, Rajasthan, India
| | - Suman Saurabh
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pramod Sagar
- Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Chanaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Medical Education and Research, Puducherry, India
| | - Tarun Kumar Dutta
- Department of Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Vishnu V, Garg D, Dhamija R, Choudhary A, Shree R, Kumar S, Samal P, Pathak A, Vijaya P, Sireesha Y, Nair S, Sharma S, Desai S, Sinha H, Agarwal A, Upadhyay A, Padma Srivastava MV, Bhatia R, Pandit A, Singh R, Reyaz A, Yogeesh PM, Salunkhe M, Lal V, Modi M, Singh G, Singla M, Panda S, Gopalakrishnan M, Puri I, Sharma S, Kumar B, Kushwaha P, Chovatiya H, Ferreira T, Bhoi S, Bhartiya M, Kaul S, Patil A, Mathukumalli N, Nagappa M, Sharma PP, Basheer A, Ramachandran D, Balaram N, Sebastian J. Impact of the COVID-19 pandemic on the frequency, clinical spectrum and outcomes of pediatric guillain-Barré syndrome in India: A multicentric ambispective cohort study. Ann Indian Acad Neurol 2022; 25:60-67. [PMID: 35342256 PMCID: PMC8954314 DOI: 10.4103/aian.aian_392_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/25/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: To study impact of COVID-19 pandemic on frequency, clinical/electrophysiological profile and treatment outcomes in pediatric Guillain-Barré syndrome (GBS). Background: GBS is the most frequent cause of pediatric acute flaccid paralysis. The effect of the COVID-19 pandemic on pediatric GBS is unclear in the literature. Methods: We conducted an ambispective, multicentric, cohort study involving 12 of 27 centres in GBS Consortium, during two periods: pre-COVID-19 (March-August 2019) and during COVID-19 (March-August 2020). Children ≤12 years who satisfied National Institute of Neurological Diseases and Stroke criteria for GBS/variants were enrolled. Details pertaining to clinical/laboratory parameters, treatment and outcomes (modified Rankin Scale (mRS) at discharge, GBS Disability score at discharge and 3 months) were analysed. Results: We enrolled 33 children in 2019 and 10 in 2020. Children in 2020 were older (median 10.4 [interquartile range 6.75–11.25] years versus 5 (2.5–8.4) years; P = 0.022) and had more sensory symptoms (50% versus 18.2%; P = 0.043). The 2020 group had relatively favourable mRS at discharge (median 1 (1–3.5) versus 3 (2–4); P = 0.042) and GBS disability score at 3 months (median 0 (0–0.75) versus 2 (0–3); P = 0.009) compared to 2019. Multivariate analysis revealed bowel involvement (P = 0.000) and ventilatory support (P = 0.001) as independent predictors of disability. No child in 2020 had preceding/concurrent SARS-CoV2 infection. Conclusions: The COVID-19 pandemic led to a marked decline in pediatric GBS presenting to hospitals. Antecedent illnesses, clinical and electrophysiological profile of GBS remained largely unchanged from the pre-pandemic era.
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Kumar S, Midha NK, Ahari K, Kumar D, Gopalakrishnan M, Kumar B, Bohra GK, Garg P, Sureka B, Garg MK. Role of Pigtail Catheter Drainage Versus Percutaneous Needle Aspiration in the Management of Liver Abscess: A Retrospective Analysis. Cureus 2021; 13:e20528. [PMID: 35070562 PMCID: PMC8767523 DOI: 10.7759/cureus.20528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction A liver abscess is an important health concern in tropical countries. Effective management of liver abscesses includes appropriate antibiotics and drainage of the abscess cavity. Percutaneous abscess drainage by pigtail catheterization is now gaining popularity. We analyzed the role of pigtail catheter drainage over percutaneous aspiration in the treatment of liver abscesses. Methods and material This was a retrospective analytical study conducted in a tertiary care center in western India. Patients of age ≥ 18 years admitted with the diagnosis of liver abscess were included in this study. To find the effectiveness of different treatment modalities, data were analyzed in three groups: Group A (Conservative treatment), Group B (Percutaneous needle aspiration), and Group C (Pigtail catheter drainage). Results A total of 64 patients with a liver abscess were analyzed. There was male predominance (93.75%). Mean abscess volume in Group C (307.9 ± 212.8 ml) was significantly higher when compared to Group A (130.8 ± 72.9 ml, p = 0.03) and Group B (177.2 ± 129.5; p = 0.024). The duration of hospital stay and residual abscess volume at the time of discharge did not show a statistically significant difference between treatment groups. Pigtail catheterization of abscesses with volume >150 ml shortened the hospital stay, whereas it prolonged the hospital stay in patients with abscess volume <150 ml. Conclusion Percutaneous pigtail catheterization would be an operative decision for the management of liver abscess. We concluded that the use of pigtail catheterization of patients with abscess volume > 150 ml improved the clinical outcome.
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Yadav P, Vohra C, Gopalakrishnan M, Garg MK. Integrating health planning and primary care infrastructure for COVID-19 and tuberculosis care in India: Challenges and opportunities. Int J Health Plann Manage 2021; 37:632-642. [PMID: 34820907 PMCID: PMC9015569 DOI: 10.1002/hpm.3393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/08/2021] [Accepted: 11/15/2021] [Indexed: 11/21/2022] Open
Abstract
Tuberculosis (TB) is the leading cause of death from a single infectious agent worldwide. The COVID‐19 pandemic has overburdened healthcare services around the world especially in resource constrained settings. It has shaken already unstable foundation of TB control programs in India and other high burden states. A 25% decline is expected in TB detection while estimates suggest 13% increase in TB deaths due to the impact of the pandemic. However, the significant intersections between the two diseases perhaps offer potential opportunities for consolidating the efforts to tackle both. The widespread implementation and acceptance of universal masking and social distancing in India has helped limit transmission of both diseases. Integrating the capacity building strategies for the two diseases, optimizing the existing the surveillance and monitoring systems which have been achieved over the years will result in a single vertically integrated national program addressing both, rather than multiple parallel program which utilize the already sparse primary care manpower and infrastructure. In this article, we explore the impact of the COVID‐19 pandemic on tuberculosis in India and offer suggestions on how effective health planning can efficiently integrate infrastructure and manpower at primary level to provide care for both COVID‐19 and tuberculosis. Tuberculosis deaths are on the rise for the first time in more than a decade due to the COVID‐19 pandemic. There is an urgent need to evolve an integrated service delivery addressing both diseases. This article highlights the challenges that COVID‐19 has posed for TB care in India. We propose a unified inclusive primary care delivery model which integrates care for both TB and COVID‐19 at the level of surveillance, diagnosis, management, and preventive care. The challenges in implementing this model and possible solutions are discussed.
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Affiliation(s)
- Prakrati Yadav
- Department of MedicineAll India Institute of Medical SciencesJodhpurIndia
| | - Chirag Vohra
- Department of MedicineAll India Institute of Medical SciencesJodhpurIndia
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18
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Affiliation(s)
- Soumyadeep Bhaumik
- Injury Division, The George Institute for Global Health, New Delhi, India; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Priti Meena
- Department of Nephrology, All India Institute of Medical Sciences, Bhubaneswar 751019, Odisha, India.
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19
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Vijayvergia P, Vijayan N, Midha NK, Kumar D, Gopalakrishnan M, Tiwari S, Garg MK. Methicillin-Sensitive Staphylococcus aureus Pyogenic Iliopsoas Abscesses: A Case Series from Jodhpur, India. Infect Disord Drug Targets 2021; 21:e270421187570. [PMID: 33155919 DOI: 10.2174/1871526520999201103192948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/09/2020] [Accepted: 09/25/2020] [Indexed: 11/22/2022]
Abstract
Early recognition of iliopsoas abscess is important for limiting morbidity and mortality. Mycobacterium tuberculosis remains an important cause of iliopsoas abscess in developing countries and most patients are initiated on empirical anti-tubercular therapy. In this context, methicillin- sensitive Staphylococcus aureus (MSSA) as a cause of iliopsoas abscess is rare in India. Four cases were diagnosed with pyogenic iliopsoas abscesses caused by MSSA. Half of the patients had a typical clinical triad of fever, difficulty in walking and backache. Primary iliopsoas abscesses were present in three patients. All patients were managed with percutaneous drainage and antibiotics with a favourable outcome. MSSA as a cause of primary iliopsoas abscesses is rare in India. Early diagnosis of microbial aetiology also minimizes the non-judicial use of antibiotics and anti-tubercular therapy.
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Affiliation(s)
- Parag Vijayvergia
- Department of Medicine, All India Institutes of Medical Sciences, Jodhpur, Rajasthan, India
| | - Neeraja Vijayan
- Department of Medicine, All India Institutes of Medical Sciences, Jodhpur, Rajasthan, India
| | - Naresh Kumar Midha
- Department of Medicine, All India Institutes of Medical Sciences, Jodhpur, Rajasthan, India
| | - Deepak Kumar
- Department of Medicine, All India Institutes of Medical Sciences, Jodhpur, Rajasthan, India
| | - Maya Gopalakrishnan
- Department of Medicine, All India Institutes of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarbesh Tiwari
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Mahendra Kumar Garg
- Department of Medicine, All India Institutes of Medical Sciences, Jodhpur, Rajasthan, India
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20
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Rassiah P, Esiashvili N, Olch AJ, Hua CH, Ulin K, Molineu A, Marcus K, Gopalakrishnan M, Pillai S, Kovalchuk N, Liu A, Niyazov G, Peñagarícano JA, Cheung F, Olson AC, Wu CC, Malhotra H, MacEwan IJ, Faught J, Breneman JC, Followill DS, FitzGerald TJ, Kalapurakal JA. Practice patterns of pediatric total body irradiation techniques: A Children's Oncology Group survey. Int J Radiat Oncol Biol Phys 2021; 111:1155-1164. [PMID: 34352289 DOI: 10.1016/j.ijrobp.2021.07.1715] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/30/2021] [Accepted: 07/28/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE The aim of this study was to examine current practice patterns in pediatric total body irradiation (TBI) techniques among xxx member institutions. METHODS AND MATERIALS Between Nov 2019 and Feb 2020 a questionnaire, containing 52 questions related to the technical aspects of TBI was sent to medical physicists at 152 xxx institutions. The questions were designed to obtain technical information on commonly used TBI treatment techniques. Another set of 9 questions related to the clinical management of patients undergoing TBI was sent to 152 xxx member radiation oncologists at the same institutions. RESULTS Twelve institutions were excluded because TBI was not performed in their institutions. A total of 88 physicists from 88 institutions (63% response rate) and 96 radiation oncologists from 96 institutions responded (69% response rate). The AP/PA technique was the most common (49 institutions - 56%); 44 institutions (50%) used the lateral technique and 14 institutions (16%) used volumetric modulated arc therapy (VMAT)/Tomotherapy. Mid-plane dose rates of 6-15 cGy/min were most commonly used. The most common specification for lung dose was the mid lung dose for both AP/PA (71%) and lateral (63%) techniques. All physician responders agreed with the need to refine current TBI techniques and 79% supported the investigation of new TBI techniques to further lower the lung dose. CONCLUSION There is no consistency in the practice patterns, methods for dose measurement and reporting of TBI doses among xxx institutions. The lack of a standardization precludes meaningful correlation between TBI doses and clinical outcomes including disease control and normal tissue toxicity. The xxx radiation oncology discipline is currently undertaking several steps to standardize the practice and dose reporting of pediatric TBI using detailed questionnaires and phantom-based credentialing for all xxx centers.
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Affiliation(s)
- P Rassiah
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT.
| | - N Esiashvili
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - A J Olch
- Department of Radiation Oncology, University of Southern California and Children's Hospital of Los Angeles, Los Angeles, CA
| | - C H Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - K Ulin
- Imaging and Radiation Oncology Core, Rhode Island QA Center, University of Massachusetts Medical School, Lincoln, RI
| | - A Molineu
- Imaging and Radiation Oncology Core, Houston QA Center, MD Anderson Cancer Center, Houston, TX
| | - K Marcus
- Department of Radiation Oncology, Harvard Medical School, Boston, MA
| | - M Gopalakrishnan
- Department of Radiation Oncology, Northwestern University, Chicago, IL
| | - S Pillai
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR
| | - N Kovalchuk
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - A Liu
- Department of Radiation Oncology, City of Hope, Los Angeles, CA
| | - G Niyazov
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - J A Peñagarícano
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - F Cheung
- Medical Physics division, Princess Margaret Cancer Center, Toronto, Canada
| | - A C Olson
- Department of Radiation Oncology, Children's Hospital of Pittsburgh, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine Pittsburgh, PA
| | - C C Wu
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY
| | - H Malhotra
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - I J MacEwan
- Department of Radiation Medicine and Applied Sciences, UC San Diego, La Jolla, CA
| | - J Faught
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - J C Breneman
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH
| | - D S Followill
- Imaging and Radiation Oncology Core, Houston QA Center, MD Anderson Cancer Center, Houston, TX
| | - T J FitzGerald
- Department of Radiation Oncology, University of Massachusetts, Worcester, MA
| | - J A Kalapurakal
- Department of Radiation Oncology, Northwestern University, Chicago, IL
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21
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Tripathi S, Bhati R, Gopalakrishnan M, Bohra GK, Tiwari S, Panda S, Sahay RR, Yadav PD, Nag VL, Garg MK. Clinical profile and outcome of patients with Crimean Congo haemorrhagic fever: a hospital based observational study from Rajasthan, India. Trans R Soc Trop Med Hyg 2021; 114:643-649. [PMID: 32286662 DOI: 10.1093/trstmh/traa014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/05/2020] [Accepted: 02/07/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Crimean Congo haemorrhagic fever (CCHF) is an emerging zoonotic infection with high mortality. Nosocomial spread is described secondary to body fluid contact. METHODS Patients meeting the case definition for viral haemorrhagic fever (VHF) from August to November 2019 were tested for CCHF after ruling out dengue, malaria, scrub typhus and leptospirosis in a tertiary teaching hospital in western Rajasthan, India. Diagnosis was confirmed using both quantitative reverse transcription polymerase chain reaction and immunoglobulin M/immunoglobulin G enzyme-linked immunosorbent assay for all patients. All hospital contacts were line listed and tested and symptomatic high-risk contacts received ribavirin post-exposure prophylaxis. Cohorting, personal protective equipment use and hand washing were employed to prevent nosocomial spread. RESULTS Four patients tested positive for CCHF. We encountered uncommon initial presentations involving motor weakness and supraventricular tachycardia. Elevated serum lactate dehydrogenase and creatinine kinase were useful in clinical diagnosis. Only one patient survived despite ribavirin therapy. There was zero nosocomial transmission. A partial segment of nucleocapsid of amplified CCHF virus was 99.62% identical to the Afghanistan and Oman strains. CONCLUSIONS The distribution of CCHF appears to be expanding, with CCHF emerging as endemic in Rajasthan, India. In this setting of high mortality, hand washing and PPE use prevented nosocomial transmission.
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Affiliation(s)
- Swapnil Tripathi
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Basni Industrial estate, Jodhpur, 342005, India
| | - Rajendra Bhati
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Basni Industrial estate, Jodhpur, 342005, India
| | - Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Basni Industrial estate, Jodhpur, 342005, India
| | - Gopal Krishna Bohra
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Basni Industrial estate, Jodhpur, 342005, India
| | - Sarika Tiwari
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, Basni Industrial estate, Jodhpur, 342005, India
| | - Samhita Panda
- Department of Neurology, All India Institute of Medical Sciences, Jodhpur, Basni Industrial estate, Jodhpur, 342005, India
| | - Rima R Sahay
- Indian Council of Medical Research, National Institute of Virology, 20/ A, Dr. Ambedkar Road, Pune, 411001, India
| | - Pragya D Yadav
- Indian Council of Medical Research, National Institute of Virology, 20/ A, Dr. Ambedkar Road, Pune, 411001, India
| | - Vijaya Lakshmi Nag
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, Basni Industrial estate, Jodhpur, 342005, India
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Basni Industrial estate, Jodhpur, 342005, India
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Kumar B, Mittal M, Gopalakrishnan M, Garg MK, Misra S. Effect of plasma glucose at admission on COVID-19 mortality: experience from a tertiary hospital. Endocr Connect 2021; 10:589-598. [PMID: 33971617 PMCID: PMC8240722 DOI: 10.1530/ec-21-0086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/06/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Plasma glucose has been correlated with in-hospital mortality among many diseases including infections. We aimed to study the plasma glucose at the admission of hospitalized patients with COVID-19 at a tertiary care referral hospital at Jodhpur, India and its relation with mortality. DESIGN A hospital-based clinical study of plasma glucose of COVID-19 patients conducted from May 15 to June 30, 2020 after ethical approval. MEASUREMENTS Random blood samples at admission were collected for plasma glucose, interleukin-6 (IL6) and high sensitivity C-reactive protein (hsCRP) after written informed consent was obtained. Plasma glucose was analyzed by the automated analyzer, IL6 by chemiluminescent immunoassay and hsCRP by immune-turbidimetric assay. RESULTS A total of 386 patients were studied (female 39.6%); 11.1% had severe disease and 4.1% expired. There were 67 (17.4%) patients with known diabetes mellitus (DM). Patients with a history of DM had three times higher mortality (6/67, 9%) than those without DM (10/309, 3.1%). Patients with moderate and severe disease according to ICMR and WHO grading had higher plasma glucose than those with asymptomatic or mild disease (P < 0.0001). Plasma glucose levels at admission were significantly higher in non-survivors when compared to those who survived (297 ± 117 vs 131 ± 73; P < 0.0001). COVID-19 patients showed increased mortality with incremental plasma glucose levels. The hazard ratio for mortality was 1.128 (95% CI 0.86-14.860), 1.883 (95% CI 0.209-16.970), and 4.005 (95% CI 0.503-32.677) in random plasma glucose group of >100-200, >200-300 and >300 mg/dL, respectively, compared to those with random plasma glucose of <100 mg/dL at admission. Plasma glucose was strongly correlated with hsCRP (P < 0.001) and IL6 (P < 0.0001). CONCLUSIONS Plasma glucose at admission in hospitalized COVID-19 patients is a strong predictor of mortality.
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Affiliation(s)
- Bharat Kumar
- All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Madhukar Mittal
- All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
- Correspondence should be addressed to M Mittal:
| | | | - Mahendra K Garg
- All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sanjeev Misra
- All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Sivapriya S, Priyanka S, Gopalakrishnan M, Manikandan H, Selvanayagam S. Ethyl 2-cyano-2-{( Z)-2-[2,2-dicyano-1-(4-methylphenyl)ethyl]cyclohexylidene}acetate. IUCrData 2021; 6:x210500. [PMID: 36338267 PMCID: PMC9462338 DOI: 10.1107/s2414314621005009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/11/2021] [Indexed: 11/11/2022] Open
Abstract
In the crystal of the title cyclohexylidene derivative, molecules associate via C—H⋯N hydrogen bonds, forming a three-dimensional network. In the title compound, C22H23N3O2, the cyclohexane ring adopts a chair conformation. The methylphenyl ring is oriented at an angle of 36.2 (1)° with respect to the best plane of cyclohexane moiety. In the crystal, molecules associate via C—H⋯N hydrogen bonds, forming a three-dimensional network.![]()
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Meena DS, Kumar B, Gopalakrishnan M, Kachhwaha A, Kumar S, Sureka B, Gupta S, Bohra GK, Garg MK. Pseudo-pseudo Meigs' syndrome (PPMS) in chronic lupus peritonitis: a case report with review of literature. Mod Rheumatol Case Rep 2021; 5:300-305. [PMID: 33970813 DOI: 10.1080/24725625.2021.1916160] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Gastrointestinal involvement in systemic lupus erythematosus (SLE) usually occurs in the form of mesenteric vasculitis, protein-losing enteropathy, intestinal pseudo-obstruction, and pancreatitis. We describe a 23-year-old female, a known case of SLE presented with significant ascites and pleural effusion. Further evaluation showed elevated CA-125 levels without evidence of malignancy. The patient was treated with corticosteroids, hydroxychloroquine, and azathioprine resulting in the resolution of ascites in 2 weeks. The triad of ascites, pleural effusion, and increased CA-125 is known as pseudo-pseudo Meigs' syndrome, which is rarely reported in the literature. Clinicians should be aware of this entity while evaluating an SLE patient with low serum-ascites albumin gradient (SAAG) ascites.
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Affiliation(s)
- Durga Shankar Meena
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Bharat Kumar
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Maya Gopalakrishnan
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Arjun Kachhwaha
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Saurabh Kumar
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Binit Sureka
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Shruti Gupta
- Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur, India
| | - Gopal Krishana Bohra
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Mahendra Kumar Garg
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, India
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Gopalakrishnan M, Yadav P, Mathur R, Midha N, Garg MK. Venom-Induced Consumption Coagulopathy Unresponsive to Antivenom After Echis carinatus sochureki Envenoming. Wilderness Environ Med 2021; 32:221-225. [PMID: 33781663 DOI: 10.1016/j.wem.2021.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/18/2020] [Accepted: 01/04/2021] [Indexed: 10/21/2022]
Abstract
Snakebite envenoming is a serious and life-threatening but neglected problem in the tropics. The focus in the Indian subcontinent is usually on the Indian cobra (Naja naja), common krait (Bungarus caeruleus), Russell's viper (Daboia russelii), and Indian saw-scaled viper (Echis carinatus). The Indian polyvalent antivenom contains hyperimmunized horse antibodies against only these 4 species. However, regional intraspecific variations are important in viper envenomings, leading to marked differences in clinical presentation and response to the available polyvalent antivenom. Echis carinatus sochureki, a subspecies of Echis carinatus, has been linked to serious morbidity in the Thar Desert regions of Rajasthan, although consistent reports are lacking. We report a patient with prolonged venom-induced consumption coagulopathy owing to Echis carinatus sochureki envenoming who did not respond to Indian polyvalent antivenom in Jodhpur, India. Features of local and hemotoxic envenoming resolved after a week with supportive care. Echis sochureki venom has been shown to be different from Echis carinatus in terms of composition and in vitro neutralization by antivenom. Clinicians in the tropical desert regions must suspect Echis sochureki envenoming in the setting of nonresponsiveness to Indian polyvalent antivenom. This will help optimize antivenom use in these patients, preventing potentially life-threatening antivenom associated reactions. Because the usefulness of Indian polyvalent antivenom appears to be limited in this setting, there is an urgent need to advocate for region-specific antivenom or monovalent antivenom for this area.
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Affiliation(s)
- Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India.
| | - Prakrati Yadav
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Rohit Mathur
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Naresh Midha
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Mahendra Kumar Garg
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
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Gopalakrishnan M, Garg MK. The power of subjectivity in competency-based assessment. J Postgrad Med 2021; 67:57-58. [PMID: 33533743 PMCID: PMC8098865 DOI: 10.4103/jpgm.jpgm_1251_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- M Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - M K Garg
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Niwas R, S AS, Garg MK, Nag VL, Bhatia PK, Dutt N, Chauhan N, Charan J, Asfahan S, Sharma P, Bhardwaj P, Banerjee M, Garg P, Sureka B, Bohra GK, Gopalakrishnan M, Misra S. Clinical outcome, viral response and safety profile of chloroquine in COVID-19 patients - initial experience. Adv Respir Med 2021; 88:515-519. [PMID: 33393643 DOI: 10.5603/arm.a2020.0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/29/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Chloroquine and its analogues are currently being investigated for the treatment and post exposure prophylaxis of COVID-19 due to its antiviral activity and immunomodulatory activity. MATERIAL AND METHODS Confirmed symptomatic cases of COVID-19 were included in the study. Patients were supposed to receive chloroquine (CQ) 500 mg twice daily for 7 days. Due to a change in institutional protocol, initial patients received chloroquine and subsequent patients who did not receive chloroquine served as negative controls. Clinical effectiveness was determined in terms of timing of symptom resolution and conversion rate of reverse transcriptase polymerase chain reaction (RT-PCR) on day 14 and day 15 of admission. RESULTS Twelve COVID-19 patients formed the treatment arm and 17 patients were included in the control arm. The duration of symptoms among the CQ treated group (6.3 ± 2.7 days) was significantly (p-value = 0.009) lower than that of the control group (8.9 ± 2.2 days). There was no significant difference in the rate of RT-PCR negativity in both groups. 2 patients out of 12 developed diarrhea in the CQ therapy arm. CONCLUSION The duration of symptoms among the treated group (with chloroquine) was significantly lower than that of the control group. RT-PCR conversion was not significantly different between the 2 groups.
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Affiliation(s)
- Ram Niwas
- Department of Pulmonary Medicine, All India Institute of Medical Sciences Jodhpur, India.
| | - Aneesa Shahul S
- Department of Pulmonary Medicine, All India Institute of Medical Sciences Jodhpur, India
| | - M K Garg
- Department of General Medicine, All India Institute of Medical Sciences Jodhpur, India
| | - Vijaya Lakshmi Nag
- Department of Microbiology, All India Institute of Medical Sciences Jodhpur, India
| | - Pradeep Kumar Bhatia
- Department of Anaesthesiology & Critical Care, All India Institute of Medical Sciences Jodhpur, India
| | - Naveen Dutt
- Department of Pulmonary Medicine, All India Institute of Medical Sciences Jodhpur, India
| | - Nishant Chauhan
- Department of Pulmonary Medicine, All India Institute of Medical Sciences Jodhpur, India
| | - Jaykaran Charan
- Department of Pharmacology, All India Institute of Medical Sciences Jodhpur, India
| | - Shahir Asfahan
- Department of Pulmonary Medicine, All India Institute of Medical Sciences Jodhpur, India
| | - Praveen Sharma
- Department of Biochemistry, All India Institute of Medical Sciences Jodhpur, India
| | - Pankaj Bhardwaj
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences Jodhpur, India
| | - Mithu Banerjee
- Department of Biochemistry, All India Institute of Medical Sciences Jodhpur, India
| | - Pawan Garg
- Department of Diagnostic & Interventional Radiology, All India Institute of Medical Sciences Jodhpur, India
| | - Binit Sureka
- Department of Diagnostic & Interventional Radiology, All India Institute of Medical Sciences Jodhpur, India
| | - Gopal Krishna Bohra
- Department of General Medicine, All India Institute of Medical Sciences Jodhpur, India
| | - Maya Gopalakrishnan
- Department of General Medicine, All India Institute of Medical Sciences Jodhpur, India
| | - Sanjeev Misra
- Department of Surgical Oncology, All India Institute of Medical Sciences Jodhpur, India
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Kumar B, Gopalakrishnan M, Garg MK, Purohit P, Banerjee M, Sharma P, Khichar S, Kothari N, Bhatia P, Nag VL, Misra S. Endocrine Dysfunction among Patients with COVID-19: A Single-center Experience from a Tertiary Hospital in India. Indian J Endocrinol Metab 2021; 25:14-19. [PMID: 34386388 PMCID: PMC8323627 DOI: 10.4103/ijem.ijem_577_20] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 02/15/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE COVID-19 has emerged as a multi-system disease with the potential for endocrine dysfunction. We aimed to study the hormonal profile of hospitalized patients with COVID-19 at a tertiary care referral hospital at Jodhpur, India. DESIGN A hospital-based clinical study of endocrine profile of COVID-19 patients conducted from 15th May to 30th June 2020 after ethical approval. MEASUREMENTS Fasting blood samples for free thyroxine (T4), free tri-iodothyronine (T3), thyroid stimulating Hormone (TSH), serum prolactin; basal and 1 h post-intramuscular adrenocorticotropic hormone (ACTH) stimulated cortisol, interleukin-6 (IL-6), and high sensitivity C-reactive protein (hsCRP) were collected within 24 h of admission after written informed consent. All hormones and IL-6 were analyzed by chemiluminescent immunoassay. hsCRP was measured by immune-turbidimetric assay. RESULTS Of 235 patients studied, 14% had severe disease and 5.5% died. Adrenal insufficiency was present in 14%, most of whom had mild disease. A robust adrenal response was observed in those with severe disease. Basal and post-ACTH serum cortisol were significantly increased in severe disease or those who died compared to those who were mild or asymptomatic. Basal and post-ACTH serum cortisol showed a significant positive correlation with hsCRP but not with IL-6. Low T3 and low T4 syndrome were documented in 25% and 5%, respectively. Serum TSH and FT3 levels declined significantly from asymptomatic to severe category. Hyperprolactinemia was found in 21 patients. hsCRP showed a rising trend with disease severity while IL-6 did not. CONCLUSIONS Endocrine dysfunction in the form of adrenal insufficiency, low T3, and low TSH syndrome and hyperprolactinemia were common COVID-19 hospitalized patients.
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Affiliation(s)
- Bharat Kumar
- Department of Medicine and Endocrinology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Maya Gopalakrishnan
- Department of Medicine and Endocrinology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mahendra Kumar Garg
- Department of Medicine and Endocrinology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Purvi Purohit
- Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mithu Banerjee
- Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Praveen Sharma
- Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Satyendra Khichar
- Department of Medicine and Endocrinology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Nikhil Kothari
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pradeep Bhatia
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vijay Lakshmi Nag
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sanjeev Misra
- Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Midha N, Ahari K, Gopalakrishnan M, Garg M, Bohra G. Risk factors and treatment outcome in the patients of amoebic liver abscess: A prospective study from Rajasthan, India. Int J Infect Dis 2020. [DOI: 10.1016/j.ijid.2020.09.1100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Asfahan S, Gopalakrishnan M, Dutt N, Niwas R, Chawla G, Agarwal M, Garg MK. Using a simple open-source automated machine learning algorithm to forecast COVID-19 spread: A modelling study. Adv Respir Med 2020; 88:400-405. [PMID: 33169811 DOI: 10.5603/arm.a2020.0156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Machine learning algorithms have been used to develop prediction models in various infectious and non-infectious settings including interpretation of images in predicting the outcome of diseases. We demonstrate the application of one such simple automated machine learning algorithm to a dataset obtained about COVID-19 spread in South Korea to better understand the disease dynamics. MATERIAL AND METHODS Data from 20th January 2020 (when the first case of COVID-19 was detected in South Korea) to 4th March 2020 was accessed from Korea's centre for disease control (KCDC). A future time-series of specified length (taken as 7 days in our study) starting from 5th March 2020 to 11th March 2020 was generated and fed to the model to generate predictions with upper and lower trend bounds of 95% confidence intervals. The model was assessed for its ability to reliably forecast using mean absolute percentage error (MAPE) as the metric. RESULTS As on 4th March 2020, 145,541 patients were tested for COVID-19 (in 45 days) in South Korea of which 5166 patients tested positive. The predicted values approximated well with the actual numbers. The difference between predicted and observed values ranged from 4.08% to 12.77% . On average, our predictions differed from actual values by 7.42% (MAPE) over the same period. CONCLUSION Open source and automated machine learning tools like Prophet can be applied and are effective in the context of COVID-19 for forecasting spread in naïve communities. It may help countries to efficiently allocate healthcare resources to contain this pandemic.
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Affiliation(s)
- Shahir Asfahan
- All India Institute of Medical Sciences, Rajasthan, Jodhpur, India
| | | | - Naveen Dutt
- All India Institute of Medical Sciences, Rajasthan, Jodhpur, India
| | - Ram Niwas
- All India Institute of Medical Sciences, Rajasthan, Jodhpur, India
| | - Gopal Chawla
- All India Institute of Medical Sciences, Rajasthan, Jodhpur, India.
| | - Mehul Agarwal
- All India Institute of Medical Sciences, Rajasthan, Jodhpur, India
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Bhattacharya S, Krishnamurthy A, Gopalakrishnan M, Kalra S, Kantroo V, Aggarwal S, Surana V. Endocrine and Metabolic Manifestations of Snakebite Envenoming. Am J Trop Med Hyg 2020; 103:1388-1396. [PMID: 32602439 DOI: 10.4269/ajtmh.20-0161] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Snakebite envenoming is a neglected, public health problem in tropical and subtropical regions. Local tissue necrosis, neurotoxic, and hemo-vasculotoxic effects are well-recognized features, whereas the endocrine and metabolic derangements are not as well known. In addition to contributing to morbidity, some of these manifestations can be potentially life-threatening if not recognized early. The most prominent endocrine manifestation is hypopituitarism (HP), which can manifest acutely or remain asymptomatic and present years later. Unexplained recurrent hypoglycemia and refractory hypotension are early clinical clues to suspect corticotroph axis involvement in acute settings. Chronic pituitary failure may present, like Sheehan's syndrome, several years after the bite. The occurrence of acute kidney injury, capillary leak syndrome, and disseminated intravascular coagulation are predictors of HP. Adrenal hemorrhages are documented in autopsy series; however, primary adrenal insufficiency is very rare and confounded by the presence of HP. Hyponatremia, hypokalemia or hyperkalemia, and dysglycemia can occur, but the mechanisms involved are only partially understood. Awareness, a high index of suspicion, correct interpretation of hormonal parameters, and timely treatment of these abnormalities can be lifesaving.
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Affiliation(s)
| | | | - Maya Gopalakrishnan
- Department of General Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
| | - Viny Kantroo
- Department of Respiratory Critical Care and Sleep Medicine, Apollo Hospitals, New Delhi, India
| | - Sameer Aggarwal
- Department of Endocrinology, Apex Plus Superspeciality Hospital, Rohtak, India
| | - Vineet Surana
- Department of Endocrinology, Manipal Hospital, New Delhi, India
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Meena DS, Kumar D, Gopalakrishnan M, Bohra GK, Midha N, Vijayvargiya P, Tiwari S. Purulent pericarditis in a patient with community-acquired methicillin-resistant Staphylococcus aureus: a case report with mini-review. Germs 2020; 10:249-253. [PMID: 33134204 DOI: 10.18683/germs.2020.1212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/26/2020] [Accepted: 06/06/2020] [Indexed: 11/08/2022]
Abstract
Introduction The etiopathogenesis of purulent pericarditis has changed significantly in modern antibiotic era with the emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in the last few decades. Pericarditis due to MRSA is rarely reported in the literature without risk factors like immunosuppression, thoracic surgery, chest trauma or pre-existing pericardial diseases. Case report We describe an 18-year-old male who presented with 5 days history of fever, chest pain and shortness of breath. Echocardiogram and thorax CT showed significant pericardial effusion. The patient underwent pericardiocentesis, MRSA was isolated from blood and pericardial fluid. The patient improved with intravenous antibiotics (linezolid). Follow-up echocardiography at 3 months was unremarkable, without any residual fluid or features of constrictive pericarditis. Discussion In the absence of known risk factors, MRSA is an extremely rare cause of pericarditis in modern antibiotics era. The possibility of MRSA pericarditis should be sought in every case of pericarditis to achieve prompt diagnosis and treatment. Conclusions Our case highlights the role of aggressive pericardiocentesis and appropriate antibiotic therapy in purulent pericarditis.
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Affiliation(s)
- Durga Shankar Meena
- MD, Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Deepak Kumar
- MD, Assistant Professor, Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Maya Gopalakrishnan
- MD, Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Gopal Krishana Bohra
- MD, Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Naresh Midha
- MD, Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Parag Vijayvargiya
- MD, Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Sarbesh Tiwari
- DM, Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
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Rassiah P, Esiashvili N, Olch A, Hua C, Ulin K, Molineu A, Marcus K, Gopalakrishnan M, Pillai S, Kovalchuk N, Liu A, Niyazov G, Penagaricano J, Cheung F, Olson A, Wu C, Malhotra H, MacEwan I, Faught J, Breneman J, Followill D, FitzGerald T, Kalapurakal J. Practice Patterns of Pediatric Total Body Irradiation (TBI) Techniques: A Children’s Oncology Group Survey. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Khichar S, Gopalakrishnan M, Bohra GK, Garg MK, Misra S. ‘Greet with NAMASTE, bye-bye handshake’: a behavioural change campaign for infection prevention in the Emergency Department from Jodhpur, India. Arch Emerg Med 2020; 37:571. [DOI: 10.1136/emermed-2020-210121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2020] [Indexed: 11/04/2022]
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Panda S, Sharma S, Bajpai N, Gopalakrishnan M, Kombade SP, Nag VL. A Rare Fatal Cause of Acute Areflexic Quadriparesis in the Tropics. Neurol India 2020; 68:1196-1200. [PMID: 33109875 DOI: 10.4103/0028-3886.299153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Crimean-Congo hemorrhagic fever is a sporadic zoonotic viral illness recently becoming endemic in regions in the western parts of India. It usually presents as a viral hemorrhagic fever with severe liver and kidney failure. CASE REPORT An 18-year-old male from the western part of Rajasthan presented with rapidly progressing areflexic weakness of limbs a week after brief fever. He deteriorated rapidly with drowsiness, fulminant liver failure, and acute kidney injury with high creatine kinase. He also developed thrombocytopenia and hemorrhage from various sites. Workup for viral hemorrhagic fever revealed IgM positivity for Crimean-Congo hemorrhagic fever. The patient kept worsening and died of multiorgan failure and diffuse alveolar bleeding after 14 days. CONCLUSIONS This report highlights the need to expand the differential diagnoses in the commonly encountered presentation of acute quadriparesis to include the possibility of tick-borne diseases like Crimean-Congo hemorrhagic fever in the setting of bleeding diathesis and acute hepatorenal syndrome.
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Affiliation(s)
- Samhita Panda
- Department of Neurology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sanjiv Sharma
- Department of Neurology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Nitin Bajpai
- Department of Nephrology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Maya Gopalakrishnan
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sarika P Kombade
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vijaya Lakshmi Nag
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Garg MK, Gopalakrishnan M, Yadav P, Misra S. Endocrine Involvement in COVID-19: Mechanisms, Clinical Features, and Implications for Care. Indian J Endocrinol Metab 2020; 24:381-386. [PMID: 33489841 PMCID: PMC7810055 DOI: 10.4103/ijem.ijem_440_20] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/06/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023] Open
Abstract
Coronavirus 2019 (COVID -19) has rapidly emerged as a global pandemic with multi-system involvement. Involvement of the endocrine system is expected in COVID-19 as the interplay between severe acute respiratory syndrome corona virus-2 (SARS CoV-2) and the endocrine system occurs at multiple levels. The widespread presence of ACE-2 receptors on various tissues suggests scope for direct viral infection. The interactions via the activation of inflammatory mediators and indirect immune-mediated damage are also postulated. Evidence so far suggests that COVID-19 can cause functional hypopituitarism by direct and indirect effects on the hypothalamo-pituitary axis resulting in inappropriate adrenal response to stress. Several reports highlight possible immune-mediated damage to thyroid glands resulting in subacute thyroiditis. COVID-19 is implicated in precipitating hyperglycemia in known diabetics and uncovering insulin resistance in those previously undiagnosed. COVID-19 has also been shown to trigger Type 1 Diabetes with ketosis. Various mechanisms including direct virus-induced beta cell apoptosis and immune-mediated beta-cell damage have been demonstrated. The presence of virus in semen has unclear clinical significance at present. In this mini-review summarize the endocrine manifestations reported so far in COVID-19 disease and explore mechanisms to decipher how SARS CoV-2 may affect various endocrine organs.
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Affiliation(s)
- Mahendra K. Garg
- Professor, Department of Medicine and Endocrinology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Maya Gopalakrishnan
- Assistant Professor, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Prakrati Yadav
- Resident Doctor, Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sanjeev Misra
- Director and Chief Executive Officer, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Yadav P, Kumar A, Mathur R, Garg P, Gopalakrishnan M, Garg M. Tubelight Adrenals in Diabetic Ketoacidosis. Clin Pract Cases Emerg Med 2020; 4:482-484. [PMID: 32926723 PMCID: PMC7434289 DOI: 10.5811/cpcem.2020.6.47617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/01/2020] [Indexed: 12/04/2022] Open
Abstract
Case Presentation We report a patient with the triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis associated with computed tomography hypoperfusion complex and adrenal hyperdensity on abdominal imaging – an association not previously reported in diabetic ketoacidosis. Discussion Presence of computed tomography hypoperfusion complex with hyperdense ‘Tubelight adrenals’ in a patient with diabetic ketoacidosis is associated with poor prognosis and thus serves to guide clinicians towards early and aggressive management.
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Affiliation(s)
- Prakrati Yadav
- All India Institute of Medical Sciences, Department of internal Medicine, Jodhpur, India
| | - Akhilesh Kumar
- All India Institute of Medical Sciences, Department of internal Medicine, Jodhpur, India
| | - Rohit Mathur
- All India Institute of Medical Sciences, Department of internal Medicine, Jodhpur, India
| | - Pawan Garg
- All India Institute of Medical Sciences, Department of internal Medicine, Jodhpur, India
| | - Maya Gopalakrishnan
- All India Institute of Medical Sciences, Department of internal Medicine, Jodhpur, India
| | - Mahendra Garg
- All India Institute of Medical Sciences, Department of internal Medicine, Jodhpur, India
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Meena M, Kumar S, Gopalakrishnan M, Bohra GK, Garg MK. Diagnosis and Management of Cryptogenic Occupational Tetanus: A Case Report from Rajasthan, India. Indian J Occup Environ Med 2020; 24:36-38. [PMID: 32435114 PMCID: PMC7227738 DOI: 10.4103/ijoem.ijoem_74_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/29/2019] [Accepted: 01/25/2020] [Indexed: 11/08/2022] Open
Abstract
The reported cases of non-neonatal tetanus have doubled from 2015 to 2017 in India, while neonatal tetanus has declined by half during this period. Most of these non- neonatal tetanus are acquired by occupational exposure especially in high risk populations such as agricultural workers, industrial workers and health care workers secondary to increased spore exposure or risk for minor injuries. We report a case of occupational tetanus in a steel worker and discuss the importance of recognising tetanus as an occupational hazard and address issues related to its early diagnosis and management. The report also highlights the need for policymakers and health practitioners in India to evolve a robust understanding of the needs and vulnerabilities of high risk occupational groups in order to apply specific and effective interventions to prevent occupational tetanus.
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Affiliation(s)
- Mahadev Meena
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Saurabh Kumar
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Maya Gopalakrishnan
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Gopal Krishna Bohra
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Mahendra Kumar Garg
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
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Zhao X, Shen J, Ivaturi V, Gopalakrishnan M, Feng Y, Schmidt BJ, Statkevich P, Goodman V, Gobburu J, Bello A, Roy A, Agrawal S. Model-based evaluation of the efficacy and safety of nivolumab once every 4 weeks across multiple tumor types. Ann Oncol 2019; 31:302-309. [PMID: 31959348 DOI: 10.1016/j.annonc.2019.10.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 10/18/2019] [Accepted: 10/24/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Nivolumab 480 mg every 4 weeks (Q4W) is approved in the European Union, United States, and several other markets across multiple tumor types. Its approval was supported by quantitative efficacy/safety analyses bridging to 3 mg/kg every 2 weeks (Q2W). PATIENTS AND METHODS The benefit-risk profile of nivolumab 480 mg Q4W relative to 3 mg/kg Q2W was evaluated using population pharmacokinetic modeling and exposure-response (E-R) analyses for safety and efficacy. Pharmacokinetic exposures were predicted for 3203 patients with melanoma, non-small-cell lung cancer (NSCLC), renal cell carcinoma (RCC), squamous cell carcinoma of the head and neck, urothelial carcinoma, or classical Hodgkin lymphoma. Quantitative models analyzed E-R to predict 480-mg Q4W safety across all indications and efficacy for melanoma, NSCLC, and RCC. Intratumoral receptor occupancy (RO) was predicted for parameters representing different tumor types. RESULTS Time-averaged concentrations for 480 mg Q4W versus 3 mg/kg Q2W were higher during the first 28 days (26.8%) and similar at steady state (5.2%). The maximum concentration (Cmax) after the first dose was higher (110.4%), and the trough concentration at day 28 was lower (-22.1%) with 480 mg Q4W versus 3 mg/kg Q2W. The Cmax achieved with 480 mg Q4W was lower than the previously established safe dose of 10 mg/kg Q2W. The probability of adverse events for key safety end points was similar for 480 mg Q4W and 3 mg/kg Q2W. The predicted overall survival and objective response rates with 480 mg Q4W were comparable to 3 mg/kg Q2W. The predicted high intratumoral RO provided additional evidence to support 480 mg Q4W across tumor types. CONCLUSIONS The benefit-risk profile for nivolumab 480 mg Q4W was predicted to be similar to that of 3 mg/kg Q2W across tumor types while providing a convenient and flexible option for patients and their caregivers.
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Affiliation(s)
- X Zhao
- Clinical Pharmacology & Pharmacometrics, Bristol-Myers Squibb, Princeton, USA
| | - J Shen
- Clinical Pharmacology & Pharmacometrics, Bristol-Myers Squibb, Princeton, USA
| | - V Ivaturi
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, USA
| | - M Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, USA
| | - Y Feng
- Clinical Pharmacology & Pharmacometrics, Bristol-Myers Squibb, Princeton, USA
| | - B J Schmidt
- Clinical Pharmacology & Pharmacometrics, Bristol-Myers Squibb, Princeton, USA
| | - P Statkevich
- Clinical Pharmacology & Pharmacometrics, Bristol-Myers Squibb, Princeton, USA
| | - V Goodman
- Oncology Clinical Development, Bristol-Myers Squibb, Princeton, USA
| | - J Gobburu
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, USA
| | - A Bello
- Clinical Pharmacology & Pharmacometrics, Bristol-Myers Squibb, Princeton, USA
| | - A Roy
- Clinical Pharmacology & Pharmacometrics, Bristol-Myers Squibb, Princeton, USA
| | - S Agrawal
- Oncology Clinical Development, Bristol-Myers Squibb, Princeton, USA.
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Samaddar A, Sharma A, Kumar Ph A, Srivastava S, Shrimali T, Gopalakrishnan M, Bohra GK. Disseminated histoplasmosis in immunocompetent patients from an arid zone in Western India: A case series. Med Mycol Case Rep 2019; 25:49-52. [PMID: 31453079 PMCID: PMC6702145 DOI: 10.1016/j.mmcr.2019.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 07/06/2019] [Accepted: 07/31/2019] [Indexed: 11/26/2022] Open
Abstract
Histoplasmosis is a systemic fungal disease caused by dimorphic fungus Histoplasma capsulatum and is more common in immunocompromised patients. We report two cases of disseminated histoplasmosis in immunocompetent individuals from a non-endemic zone in Western India. Rapid diagnostic tests like urinary antigen detection and molecular assays comprise the need of the hour as early initiation of antifungal therapy can be life-saving. Clinicians need to be aware of this entity to prevent misdiagnosis and initiate prompt effective management.
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Affiliation(s)
- Arghadip Samaddar
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Anuradha Sharma
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Akhilesh Kumar Ph
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Saumya Srivastava
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Twishi Shrimali
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Maya Gopalakrishnan
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Gopal Krishna Bohra
- Department of General Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
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Meenakshisundaram S, Gopalakrishnan M, Nagarajan S, Sarathi N, Sumathi P. Kinetics and mechanism of the oxidation of alkenes by chromium(VI) in the presence of complexing agents. Journal of Chemical Research 2019. [DOI: 10.3184/0308234054497173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The catalytic activities of 2,2′-bipyridyl (bipy) and oxalic acid (Oxa) in the HCrO4– oxidation of some substituted trans-cinnamic acids have been investigated in acidic solutions. The Cr(VI)–bipy and Cr(VI)–Oxa complexes are believed to be the probable reactive electrophiles in this redox process. The kinetic data reveal that electron-releasing groups enhance the reactivity to a significant extent while the electron-withdrawing ones reduce the rate marginally. It appears that the mechanism of bipy/Oxa catalysed chromium(VI) oxidation of unsaturated systems to the corresponding cleavage products involves an electrophilic attack of the reactive complex at the C–C double bond. The formation of a ternary complex as an intermediate is envisaged to describe the redox process. In this paper, we also report on the kinetic form of the oxidation of trans-stilbene to methyl 3-hydroxy-2,3-diphenylpropanoate. The mechanistic pathway has been determined based on the kinetic behaviour and the product assignment.
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Affiliation(s)
| | - M. Gopalakrishnan
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, India
| | - S. Nagarajan
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, India
| | - N. Sarathi
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, India
| | - P. Sumathi
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, India
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Gopalakrishnan M, Kumar PS, Thanusu J, Prabhu C, Kanagarajan V. Conversion of Piperidine-4-ones into [1,4]-diazepan-5-ones under Microwave Irradiation Using a Silica Gel Supported NaHSO4 Catalyst. Journal of Chemical Research 2019. [DOI: 10.3184/030823407x198276] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A rapid conversion of some 2,6-diarylpiperidin-4-ones into 2,7-diaryl-[1,4]-diazepan-5-ones in high yields has been developed involving treatment with hydroxylamine hydrochloride under microwave irradiation in the presence of a silica gel supported NaHSO4 catalyst.
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Affiliation(s)
- M. Gopalakrishnan
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, Tamil Nadu, India
| | - P. Suresh Kumar
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, Tamil Nadu, India
| | - J. Thanusu
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, Tamil Nadu, India
| | - C. Prabhu
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, Tamil Nadu, India
| | - V. Kanagarajan
- Department of Chemistry, Annamalai University, Annamalainagar – 608 002, Tamil Nadu, India
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Gopalakrishnan M, Vinod KV, Dutta TK, Shaha KK, Sridhar MG, Saurabh S. Exploring circulatory shock and mortality in viper envenomation: a prospective observational study from India. QJM 2018; 111:799-806. [PMID: 30107433 DOI: 10.1093/qjmed/hcy175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Viper envenomation contributes to nearly 50% of snake-bite deaths in India, chiefly due to circulatory shock. The mechanisms leading to circulatory shock include bleeding, capillary leak syndrome (CLS) and myocardial depression. Pituitary-adrenal axis involvement in circulatory shock, though described, has not been fully elucidated. AIM To identify predictors of circulatory shock and mortality in viper envenomation and explore the role of pituitary-adrenal axis in circulatory shock. DESIGN Prospective hospital-based observational study. METHODS Once a syndromic diagnosis of viper envenomation was made, relevant clinical and laboratory data were collected. Serum cortisol was estimated in those with circulatory shock. Post-mortem examination of pituitary, kidneys and adrenals was performed. Adjusted odds-ratios were calculated for respective risk-factors for shock and mortality using multivariable logistic regression with backward elimination strategy. RESULTS Of 248 patients of viper envenomation treated at our hospital, circulatory shock was present in 19% and in-hospital mortality was 23%. CLS, circulatory shock, bleeding and requirement of > 20 vials of antivenom predicted mortality. Ischaemic and haemorrhagic necrosis of pituitary or adrenals was present in 51% of post-mortem specimens. Disseminated intravascular coagulation (DIC) and CLS were strong predictors of pituitary haemorrhage. CONCLUSION Predictors of mortality - bleeding, CLS and requirement of high antivenom doses are warning signs which can alert clinicians to patients who may have poor outcomes. Our study points to a definite role of pituitary-adrenal axis in circulatory shock supports the hypothesis that pituitary involvement in viper envenomation closely resembles Sheehan syndrome. The mechanism of pituitary involvement appears to be a result of increased susceptibility of the swollen gland secondary to CLS and micro thrombi deposition in DIC.
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Affiliation(s)
- M Gopalakrishnan
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - K V Vinod
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - T K Dutta
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - K K Shaha
- Department of Forensic Medicine and Toxicology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - M G Sridhar
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
| | - S Saurabh
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantari Nagar, Puducherry, India
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Gopalakrishnan M, Saurabh S, Dutta TK. Clinical profile of viper envenomations in Kerala, India: some unanswered questions. Int J Gen Med 2018; 11:391-392. [PMID: 30323646 PMCID: PMC6175540 DOI: 10.2147/ijgm.s177509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Maya Gopalakrishnan
- Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India,
| | - Suman Saurabh
- Neglected Tropical Diseases- WHO India, Muzaffarpur, India
| | - Tarun Kumar Dutta
- Department of Internal Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Zhao X, Shen J, Gopalakrishnan M, Feng Y, Schmidt B, Statkevich P, Kelleher T, Rashford M, Ivaturi V, Gobburu J, Agrawal S, Bello A, Roy A. Model-based assessment of benefit-risk profile of nivolumab (NIVO) flat dosing schedules (Q2W and Q4W) across multiple tumor types. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy288.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sivamaran V, Balasubramanian V, Gopalakrishnan M, Viswabaskaran V, Gouravrao A. Optimizing Chemical Vapor Deposition Parameters to Attain Minimum Diameter Carbon Nano Tubes by Response Surface Methodology. ACTA ACUST UNITED AC 2018. [DOI: 10.1166/jamr.2018.1377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ravikirti, Gopalakrishnan M. Objective Structured Clinical Examinations (OSCEs) as an Assessment Tool in Undergraduate Medical Education. J Natl Med Assoc 2018; 110:553-555. [PMID: 30129500 DOI: 10.1016/j.jnma.2018.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/02/2017] [Accepted: 02/08/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Ravikirti
- All India Institute of Medical Sciences, Patna, India.
| | - Maya Gopalakrishnan
- Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
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Gopalakrishnan M, Vijayan Sobha V, Shamanna S. Macrophage activation syndrome complicating adult-onset still's disease: A diagnostic challenge. Int J Adv Med Health Res 2018. [DOI: 10.4103/ijamr.ijamr_19_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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49
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Ananda Srinivasan C, Saravanan CG, Gopalakrishnan M. Emission reduction on ethanol–gasoline blend using cerium oxide nanoparticles as fuel additive. Particulate Science and Technology 2017. [DOI: 10.1080/02726351.2017.1287791] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- C. Ananda Srinivasan
- Department of Mechanical Engineering, Faculty of Engineering and Technology, Annamalai University, Annamalainagar, Chidambaram, Tamil Nadu, India
| | - C. G. Saravanan
- Department of Mechanical Engineering, Faculty of Engineering and Technology, Annamalai University, Annamalainagar, Chidambaram, Tamil Nadu, India
| | - M. Gopalakrishnan
- Department of Chemistry, Annamalai University, Annamalainagar, Chidambaram, Tamil Nadu, India
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Kalapurakal J, Gopalakrishnan M, Jung J, Peterson S, Leisenring W, Laurie F, Rigsby C, Lee C, Fitzgerald T, Lee C. Accuracy of a Computational Human Phantom Model for Retrospective 3-Dimensional Target-Organ Dosimetry for Late Effects Study of Patients on National Wilms Tumor Study Protocols. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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