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   Table of Contents - Current issue
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October-December 2022
Volume 19 | Issue 4
Page Nos. 197-283

Online since Friday, December 2, 2022

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GUEST EDITORIAL  

Laboratory medicine: Towards technology-driven patient-centric care p. 197
Mamta Soni
DOI:10.4103/am.am_156_22  
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ORIGINAL ARTICLES Top

Role of prognostic markers as a predictor of mortality and short-term prognosis in COVID-19 p. 199
Ajith Kumar Jayachandran, Vincy Nelson, F Thaiba, Mohammad Easa Shajahan
DOI:10.4103/am.am_68_22  
Introduction: As the world is slowly out of its second wave wrecked by the Delta strain, the world population is now struck once again with a new strain of COVID-19. As the outbreak is spreading, prognostic markers such as C-reactive protein (CRP), D-dimer, and ferritin levels can help the physician in predicting clinical outcomes at an early stage. Materials and Methods: Our study made an analysis of patients presented to the emergency medicine department with positive COVID antigen or reverse transcriptase–polymerase chain reaction (RT-PCR) results. Patient demographic data, clinical profile, and values of D-dimer, CRP, and serum ferritin were obtained. All the patients were subjected to standard treatment according to COVID protocol. Results: Our study population was comprised of 312 patients. Among them, 162 (51.9%) were male, and 150 (48.1%) were female. Our study found that among 45 patients, who had expired, 38 (84.4%) patients had elevated D-dimer values, 45 (100%) patients had elevated CRP values, and 41 (91.1%) patients had elevated ferritin values. P =001, which is statistically significant. Conclusion: Our study found that values of prognostic markers such as D-dimer, CRP, and serum ferritin at the time of presentation can be used as a predictor of mortality and risk stratification and predict the probable need for prolonged hospital and intensive care unit stay. These values also correlate well with the disease severity of the patients. They can also be used to predict the probable need for respiratory support during the course of a stay in the hospital.
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Evaluation of novel 23-gauge winged blood collection set for venipuncture: Impact on patient pain perception p. 204
Mamta Soni
DOI:10.4103/am.am_112_22  
Introduction: Venipuncture is a starting point of most diagnostic processes and a common source of pain and anxiety in many patients. The study aimed to evaluate and report the pain perception upon needle insertion during phlebotomy using the novel UltraTouch™ Push Button Blood Collection Set (UTPBBCS) with a five-bevel tip and assess the recommendation from the patients to use UTPBBCS for future blood collections. Materials and Methods: The blood samples were collected with UTPBBCS (23 g) from 100 adult patients who reported at the outpatient department phlebotomy room for routine blood tests. The pain level was distributed into five scores. Consent and feedback were collected from all the patients. Results: In the current study, 89% of individuals reported “No Pain” (score 1), and 11% reported a score of 2. 100% of the study population reported less pain during the blood collection process with UTPBBCS. All the individuals who had undergone blood collection with an UltraTouch needle recommended this device for future blood collections. Conclusion: The results of this observational study provided insights on the use of technology such as the penta bevel needle and ultra-thin wall cannula, which reduced the pain during phlebotomy and improved patient experience. This can lead to a practice change in phlebotomy, especially for trypanophobia patients and patients with difficult venous access (thin and fragile veins) such as pediatric, geriatric, dialysis, and oncology patients. By reducing the number of phlebotomy attempts, pain, and hematoma, the patient's satisfaction score is improved, and they feel safe to come back to the hospital when seeking a health-care facility.
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Liver and renal function profile of mucormycosis cases receiving amphotericin B - A retrospective study p. 208
Bhoomi Bavadiya, Jugal Hiren Bhatt, Shubhangi Vishwas Deshpande, Kedar Gautambhai Mehta, Rikin Raj
DOI:10.4103/am.am_86_22  
Background: Mucormycosis is a serious infection that needs to be treated with prescription antifungal medicine, usually amphotericin B. In the study, we have analyzed the side effects of amphotericin B because studies have revealed that the drug has toxic effects both on the liver and the kidneys. Methodology: This is a retrospective study and was conducted using a record of mucormycotic patients who were admitted at GMERS Gotri Medical College and Hospital, Vadodara. We included the patients who were admitted to the hospital from June 1, 2021, to August 31, 2021. Three reports each of liver and renal function tests (LFT and RFT) were collected. These reports were entered into the excel sheet and a result was framed. Results: A total of 64 patients were reviewed with the infection of mucormycosis. Increase in bilirubin levels and serum glutamic pyruvic transaminase (significant rise) levels and decrease in albumin levels and albumin/globulin ratio were observed in LFT 2 and LFT 3 after initiating amphotericin B therapy. Similarly, a rise in serum urea and creatinine levels was observed in RFT 2 and RFT 3. The number of patients with altered serum sodium and potassium levels did not vary much in the three consecutive RFT reports. Conclusion: Amphotericin B drug does have adverse effects on the liver and kidneys. The three consecutive RFT and LFT reports revealed liver and kidney dysfunction due to damage induced by the drug. These led to altered levels of the factors included in the respective LFT and RFT reports.
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Alteration in bone metabolism and bone mineral density with chronic antiepileptic drug therapy p. 213
Damera Achyuth Kumar, Lubna Zafar, Hamid Ashraf, Ahmad Ghayas Ansari
DOI:10.4103/am.am_71_22  
Objective: The prolonged usage of antiepileptic medicines has been linked to a reduction in bone mineral density (BMD), resulting in the risk of fracture. However, most evidence has been from western countries, predominantly in institutionalized patients. Furthermore, only a single antiepileptic drug (AED) has been evaluated. This study explores the impact of AEDs on bone health in ambulatory patients from North India. Methodology: A hospital-based observational study on sixty adult patients with epilepsy. All patients were already on AED (valproic acid [VPA], levetiracetam, and phenytoin) either as monotherapy or polytherapy. The serum levels of calcium, phosphorus, alkaline phosphatase, albumin, 25 (OH) Vitamin D, and intact parathyroid hormone were estimated. BMD was assessed at the lumbar spine and femur using a dual-energy X-ray absorptiometry scan. Results: The mean age of patients was 32.75 ± 5.9 years. 56.7% of subjects were female, and 43.3% were male. 40% of patients were taking VPA. Both cytochrome P450 inducing and noninducing AED resulted in a decline in T-score at the lumbar spine (P < 0.01). The BMD declined significantly as the duration of AED intake was prolonged (P < 0.001). Conclusions: In some patients, the intake of AEDs is prolonged, even lifelong. People living with epilepsy are predisposed to falls, and the adverse effects of AED on bone metabolism over time compound the risk of fractures. Thus, the physician needs to monitor all patients on AED for bone health and advise early intervention.
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A cross-sectional study to assess the correlation of cardiovascular endurance levels across the gender among sedentary adults of 18–25 years p. 219
Aftab Begum, T Lakshmi, Syed Sadat Ali, BA Praveen Kumar
DOI:10.4103/am.am_52_22  
Background: Cardiorespiratory proficiency is an important estimate of healthiness. Participation in endurance activities by both genders has increased in recent times but a shift in lifestyle due to industrialization and mechanization has increased the rate of noncommunicable diseases. Objectives: The objective of this study was to assess the correlation of cardiovascular endurance levels across the gender among sedentary adults. Materials and Methods: A cross-sectional study was initiated among 400 subjects, of which 188 were male and 212 were female participants. Both the study groups were assessed for cardiovascular endurance using anthropometry, pulse rate, respiratory rate, blood pressure, and oxygen saturation at rest, followed by immediate, 1, 2, 3, and 5 min after exercise. They were asked to perform the Harvard step test and fitness index, and all these variables were compared across the gender. Results: There was a significant change in anthropometric indices across the gender. The cardiovascular endurance variables including pulse rate and respiratory rate did not show any significant change except immediately after exercise. The oxygen saturation was significantly affected all the time across the gender. All the participants could perform the Harvard step test and fitness index without any significant change except the duration of the fitness. Conclusion: Physical activity has significant health benefits in all physiological systems. Cardiorespiratory and cardiovascular suitability can be increased in sedentary individuals through trained endurance exercises leading to healthier individuals in the future and improve general health and social well-being, reducing the burden of disease, and improving their quality life years.
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A study on the health status of adolescent school students in North Kerala during the COVID-19 pandemic lockdown p. 225
G Shrinath, KT Muhammed Basheer, Vasant Bhanusali, KS Premlal
DOI:10.4103/am.am_60_22  
Introduction: During the initial phase of COVID-19 pandemic crisis, the schools and educational institutions were closed countrywide. Hence, more than 90% of students admitted to educational institutions worldwide are affected as 188 countries have implemented COVID restrictions. Hence, this study focuses on the health status of adolescent students during the shutdown of educational institutions during the COVID-19 pandemic. Aim and Objective: This study assesses mental health, dental health, eye health, physical activity, immunization, and nutrition in adolescents during the COVID-19 pandemic among adolescent boys and girls. Materials and Methods: The current cross-sectional study was done among school-going adolescent children. One hundred and eighty students from different syllabus systems and urban and rural parts of north Kerala participated. The data collected were entered into an excel sheet and analyzed using the SPSS software. Results: 59.4% of students have gained weight due to sedentary behaviour. Students spend more time in front (95%) of a digital screen, leading to computer vision syndrome. Loss of social interactions adversely affected students' mental health by 37.8%. Thirty percentage of physically active students were involved in indoor physical activities such as Zumba and aerobics. In addition, 77% of students have not taken their routine immunization. Conclusion: The newer learning methods have impacted the students' knowledge. There is no uniformity in the form of teaching. Multiple factors have played a role in improving the lockdown situation, including the families, schools, local authorities, government, digital media, and newspapers.
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A study on safety and clinical efficacy of COVID-19 vaccines among adults in South India: A cross-sectional study p. 230
Huluvadi Shivalingaiah Anwith, Deena Mariyam, M Madhusudan, Ramegowda Chethana, Hulugappa Lakshmi
DOI:10.4103/am.am_92_22  
Introduction: COVID-19 virus caused a pandemic in 2020. Since vaccine was the only modality to combat the pandemic, the development of vaccine was fast tracked and made available within 1 year of detecting the virus. Objective: The objective of this study was to assess the safety and clinical efficacy of the COVID-19 vaccines. Materials and Methods: This was a cross-sectional study conducted between June 2021 and September 2021 in Bengaluru using digital data capture. Data pertaining to sociodemographic profile, details of the vaccine administered, adverse events developing within 7 days of vaccine administration, and breakthrough infection were collected. Descriptive statistics such as frequencies, percentages, and mean and standard deviation were used. Inferential statistics such as the Chi-square test were used to test association. Results: The study involved 103 study participants. Totally 100 (97.08) participants had taken Covishield and 3 (2.92) had taken Covaxin. Only 3 (2.9%) study participants had breakthrough infections and all these three participants had taken Covishield. Ninety-four (91.26%) of study participants had taken at least one dose of COVID-19 vaccine. A total of 62 (60.19%) participants had one or the other adverse reaction following vaccination. Only 3 (2.9%) study participants had breakthrough infections and all these three participants had taken Covishield. Conclusion: The given COVID-19 vaccines are safe and clinically efficacious with no statistically significant difference between the COVID-19 vaccine type and adverse reaction or with the incidence of breakthrough infection.
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Association between screen time and psychosocial and behavioral well-being of preschoolers during the COVID-19 lockdown in Tamil Nadu p. 234
Anuradha Gunasekaran, Viswanathan Rangaswamy Gounder Karupannagounder, Muraleetharan Gopal, Panneerselvam Periasamy, Suganthi Vajiravelu, Sasikala Gunasekaran
DOI:10.4103/am.am_101_22  
Introduction: COVID-19 pandemic-caused burden among the pediatric age group was less in terms of severity and mortality; indirect impacts of the pandemic on the mental health of children are huge and largely unnoticed. The main objective of this exploratory study was to analyze the association between screen time exposures among preschool children aged 3–6 years during the lockdown period in Tamil Nadu, India. Materials and Methods: An exploratory and anonymous population-based e-survey through social networks, including social media platforms (Facebook, LinkedIn, and WhatsApp) and researchers' acquaintances (email), using a snowball sampling strategy was conducted among parents of preschool children (aged 3–6 years) residing in different states of Tamil Nadu. Data were collected using Google Forms, and statistical, analysis was conducted. Results: Among 427 study participants, the mean age of screen introduction was 19.88 ± 11.73 months, and the mean age of independent operation of screen devices was 3.29 ± 1.16 years. Demanding extra attention (25.53%), temper tantrums (21.31%), increased aggressiveness (19.90%), more fussy (18.74%), altered night sleep (18.5%), and clinging (18.27%) were the frequently reported behavioral changes apart from increased screen time (60.88%) and decreased physical activity (28.80%) during the lockdown period. Conclusion: Excessive screen time beyond the recommended 1 h/day was seen in 94.1% of children, and screen exposure was inversely correlated with the duration of outdoor play. Among the behavioral changes, temper tantrums and fussiness were found to be significantly associated with increased recreational screen time.
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An encounter with potentially reemerging chikungunya infection during 2016-2017 p. 241
Nidhi Singla, Monica Gupta, Gursimran Kaur Mohi
DOI:10.4103/am.am_98_22  
Background: Chikungunya (CHIK) virus infection is an arthropod-borne “reemerging” zoonotic disease. Our geographical region reported almost negligible cases during 20112015; however, in the latter part of 2016 and early 2017, Chandigarh experienced a major outbreak of CHIK infection. The present retrospective observational study was undertaken to examine the seroprevalence and clinical profile of all the adult patients suspected of CHIK presenting to our hospital from 2016 to 2017. Materials and Methods: All consecutive patients with clinical suspicion of CHIK infection were included in the study. Serum samples were collected from all the adult patients and tested for IgM antibodies by enzyme-linked immunosorbent assay using commercially available kits. Results: Out of 1087 clinically suspected adult patients, 351 (32.29%) were found to be positive for CHIK IgM antibodies. Males 208 (59.2%) outnumbered the females 143 (40.7%). Family clustering was common. All patients presented with fever, severe joint pains (95.7%), and joint stiffness and swelling (69.8%). Two patients presented with encephalitis. Conclusion: CHIK is a reemerging debilitating arthritic disease of global health concern with a capacity for immeasurable morbidity. In the absence of a licensed vaccine or chemoprophylaxis, active surveillance and vector control are the key factors in limiting the disease outbreak and transmission.
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Changes in the audiometric patterns in presbycusis with ongoing medical upgradation p. 245
Sugandha Sharma, Girja Thakur, Arvinpreet Kour, Ajaydeep Singh
DOI:10.4103/am.am_80_22  
Background: Presbycusis or age-related hearing loss. Nowadays, age-related hearing impairment is recognized as a disorder with environmental and genetic factors, use of ototoxic medication, hypertension with increasing age, i.e., longevity of life the burden of presbycusis is increasing. Aims: This study aims to identify patterns based on audiometric data collected from a sample with a clinical indication of presbycusis and to quantify hearing loss at the time of presentation. Materials and Methods: One hundred and forty-five participants were studied, and tuning fork tests, pure-tone audiometry, and speech audiometry were performed. Conclusion: It concluded that hearing loss increased with increasing age and speech discrimination scores decreased with increasing age. The hearing loss associated with presbycusis seen in the elderly was essentially symmetrical. The most common audiogram configuration seen in the study of presbycusis was the Flat type, followed by the high-frequency gently sloping and high-frequency steeply sloping types.
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SARS-CoV-2 Infection after Effects: Multi-Organ Damage through Oxygen Radicals p. 251
Debatosh Datta, Rajveer Singh, Ravichandiran Velayutham, Arka Bhattacharya, Ujjwayini Ray, Sarbani Dasgupta, Soma Dutta, Aditi Saha, Debabrata Roy, Srinika Ghosh, Somasundaram Arumugam, Pallab Datta, NK Ganguly
DOI:10.4103/am.am_122_22  
Introduction: SARS-CoV-2 respiratory infection leads to two-layered pathology in time (a) immediate pathology and recovery or fatal ending and (b) long periods of remission followed by unexplained clinical expressions involving one or more systems with various clinical presentations, even leading to loss of lives. Among the common causative factors affecting nearly all organs and systems, oxygen radicals and oxygen-derived species (ROS) should rank conclusively on top. Objective: This clinical report, part of a community screening of unexplained clinical outcomes in post-COVID presentation, carries findings focusing on ROS production and possible ROS-induced damages. Materials and Methods: Flow cytometry was used to quantify the samples' total ROS, superoxide production, and apoptosis quantification. Results: Observations indicate unexplained nearly uniform enhanced ROS production in all these long COVID subjects, although clinical presentations varied from no complaints to the requirement of advanced interventions. Conclusion: Causative factors leading to raised oxygen-derived toxic intermediaries (ROS) in initiating these variable long COVID presentations are ill-understood yet possibly merit mass screenings and possible intense anti-oxidative therapy given that such antioxidant therapy through oral medications led to rapid lowering of ROS production and improvement of clinical presentations.
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REVIEW ARTICLE Top

Metaverse and healthcare: A clinician's perspective Highly accessed article p. 256
Krishnan Ganapathy
DOI:10.4103/am.am_103_22  
Introduction: Metaverse is the augmented virtual world formed by convergence of virtual and physical space. Users interact within this created world, meeting each other virtually, immersing themselves in performing virtual activities, which subsequently could lead to real experiences. Conventionally, the healthcare “industry” is conservative in deploying future ready technology. Aims and Objectives: This overview discusses the untapped potential of metaverse applications in healthcare from a clinician's perspective. Bereft of technical jargon, the article points out the advantages, disadvantages, limitations, and challenges in actual deployment of the metaverse in clinical practice in the real world. The exponential transformation occurring in this area is highlighted. The highly technical literature is simplified for easier comprehension. Findings: Clinical applications, use of the metaverse in training, education, and augmenting telehealth consultations, in an immersive milieu, is discussed. Direct “in-person” interaction with digital products and solutions will be a new experience for a healthcare provider and the beneficiary. The role of digital twins is illustrated. Consultation process and various clinical applications in the metaverse are outlined. Technology-enabled futuristic training and education is discussed. Conclusion: Demonstrating significant improvement in healthcare outcomes using the metaverse will be difficult to prove. This alone will ultimately lead to the development of a business model, insurance reimbursement and behavioral modification necessary for accepting and using, a hitherto unused method in patient care.
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CASE REPORTS Top

Spuriously low thyroid-stimulating hormone? A laboratory phenomenon p. 262
S Danalakshmi, Mamta Soni
DOI:10.4103/am.am_81_22  
Thyroid gland is an endocrine gland with vital functions regulating metabolism, growth, and development. The tests used to assess the functions of the thyroid gland include thyroid-stimulating hormone (TSH), free thyroxine, and free tri-iodothyronine. TSH is routinely measured in the clinical laboratory with automated immunoassays to diagnose and monitor thyroid disorders. We present a case wherein the discrepancy between the clinical symptoms and the biochemical test results raised the possibility of methodological interference in laboratory testing, finally leading to a detection of a rare genetic mutation in the patient. This case reiterates that clinical correlation of laboratory results and effective communication between the clinician and the laboratory are imperative for a correct diagnosis and therapeutic interventions.
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Diagnosis of AL amyloidosis on bone marrow aspirate smears - A Case Report p. 264
Supraja Sundaram, Mamta Soni, Prabu Pandurangan, Soukat Ali
DOI:10.4103/am.am_50_22  
Introduction: An amyloidosis is a group of diseases associated with the deposition of abnormal protein fibrils in the tissues. Primary amyloidosis (AL) type is the most common form of systemic amyloidosis encountered in clinical settings resulting from the deposition of abnormal light chains associated with underlying plasma cell dyscrasia. Amyloid deposits are rarely seen in bone marrow aspirate smears. Methods: Amyloidosis occurs as a result of the deposition of autologous proteins, which, when viewed under a light microscope, appear as eosinophilic, acellular, amorphous deposits. Results: We presented a case of AL amyloidosis presenting with cardiac manifestations and detected to have amyloid deposits in bone marrow aspirates. Conclusion: To the best of our knowledge, reporting amyloid deposition in bone marrow aspirate smears is very rare and unusual, with sparse mention of its occurrence in literature. Careful examination of bone marrow aspirate for this striking finding leads us to a quicker diagnosis of amyloidosis for a prompt determination of therapeutic protocol, improving the outcomes for the patients.
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Factor XI deficiency case reports on congenital and acquired Hemophilia C - A case report p. 267
Mamta Soni, Srikanth Muralikrishnan, Supraja Sundaram
DOI:10.4103/am.am_108_22  
Introduction: Factor XI deficiency or hemophilia C is a very rare coagulation factor deficiency, with a global incidence of 1 in 1 million. Although it is an under-recognized entity, it can cause significant bleeding, resulting in life-threatening complications. Materials and Methods: Coagulation parameters were analyzed using a Sysmex CS-2400 coagulation analyzer. Factor XI levels were detected using Factor XI deficient plasma from Siemens. Activated Partial Thromboplastin Time (APTT) testing was performed using Actin FSL from Siemens. Results: Here, we report the two cases of Factor XI deficiency, one genetic and the other a very rare acquired deficiency due to sepsis, detected during the workup of an isolated APTT prolongation. Conclusion: Factor XI deficiency is a rare bleeding disorder that presents as prolonged isolated APTT. Careful clinical evaluation and complete coagulation workup are necessary for the efficient management of patients, which can prevent life-threatening events.
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Mesenteric inflammatory veno-occlusive disease of the colon: An under-recognized entity - A Case Report p. 270
Saloni Naresh Shah, Priyansh Bhayani, Sarojini Ashok Parameswaran, Ashok Parameswaran
DOI:10.4103/am.am_85_22  
Isolated nonthrombotic venulitis of the colon with concomitant ischemic injury, also known as mesenteric inflammatory veno-occlusive disease (MIVOD), is a rare inflammatory vascular disorder of unknown etiology. First described in 1994, there are only about 34 cases in the literature. We report a 25-year-old woman who presented with loose stools and abdominal pain of 3-week duration. Investigations revealed eosinophilia. Endoscopy showed erosion and ulcers of the gastrointestinal tract, with mucosal biopsies showing features of ischemic injury. Computed tomography showed an edematous and thickened colonic wall with impending perforation, hence, a subtotal colectomy was performed. The patient, however, had a cardiac arrest and expired despite adequate measures. The resection specimen was consistent with a diagnosis of MIVOD. As the clinical and radiological features of MIVOD are nonspecific and overlap with inflammatory bowel disease or mesenteric ischemic disorders, histopathological examination of the resection specimen is the mainstay for its diagnosis. We believe this is the only other case in the literature of MIVOD with eosinophil predominance.
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Norethisterone-induced subacute on chronic cerebral venous sinus thrombosis with secondary intracranial hypertension in a young woman: A case report p. 273
Garikapati Kavitha, Vijayan Sharmila
DOI:10.4103/am.am_105_22  
Background: Cerebral venous sinus thrombosis is associated with several etiologies and may present with various symptoms. Oral contraceptives are one of the potential risk factors for cerebral venous sinus thrombosis (CVST) apart from infection and genetically acquired prothrombotic states. Abnormal uterine bleeding (AUB) is one of the common clinical conditions in gynecology practice, for which hormonal therapy is prescribed. Progestogens are relatively safe compared to combined estrogen and progesterone hormonal pills and hence a preferred therapy for AUB management. Case Report: We report a subacute on chronic CVST with secondary intracranial hypertension, probably induced by norethisterone intake in a young woman for AUB management. Diagnosis: CVST is diagnosed by contrast-enhanced computed tomography, magnetic resonance imaging, or MR venography. Treatment: CVST is treated with heparin and switched to warfarin anticoagulant therapy. Conclusion: Physicians need to have a high index of suspicion of CVST and treat the condition to prevent significant morbidity and mortality.
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Non-islet cell tumor-related hypoglycemia in a case of metastatic gastrointestinal stromal tumor: A rare paraneoplastic syndrome: A case report p. 276
Nalini Kanta Ghosh, Ashok Kumar, Vijay Kumar Sharma, Vikrant Verma
DOI:10.4103/am.am_67_22  
Introduction: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Clinical presentations depend upon the site of involvement. It can lead to obstruction, bleeding, perforation, or symptoms due to mass effects. Tumor-induced hypoglycemia (nonislet cell tumor-related hypoglycemia [NICTH]) is a rare manifestation of GIST. Case Report: We herewith present the case of a 46-year-old female who presented with multiple abdominal lumps and recurrent episodes of syncope due to NICTH. On investigations, she was diagnosed to have unresectable GIST on biopsy. Her hypoglycemic episodes could be explained by rare paraneoplastic syndrome due to the raised levels of insulin-like growth factor-2. After treatment with imatinib (800 mg once daily), her hypoglycemic episodes subsided, which supported the diagnosis. Conclusion: NICTH is a rare paraneoplastic manifestation of GIST; targeted therapy can avert neuroglycopenic symptoms.
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CLINICAL IMAGES Top

Ultrasound diagnosis of the perinatal form of autosomal recessive polycystic kidney disease at 29 weeks of gestation p. 280
Ravikanth Reddy
DOI:10.4103/am.am_47_22  
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LETTERS TO THE EDITOR Top

Human immunodeficiency virus-associated nephropathy with hypothyroidism p. 282
Novonil Deb, Poulami Roy
DOI:10.4103/am.am_78_22  
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