Clinical profile and outcome of myasthenic crisis in a tertiary care hospital: A prospective study

Background:

The present understanding of the clinical course, complications, and outcome of myasthenic crisis (MC) is based chiefly on observational studies and retrospective case series.

Aim:

To study the baseline demographic and clinical variables, risk factors, complications, outcome, and mortality in patients of MC.

Materials and Methods:

All patients of myasthenia gravis (MG) who presented with myasthenic crisis between July 2009 and December 2010 were included.

Results:

Ten patients of MC were included in this study. The median age of the patients was 40.5 years (range 14-71 years). Seven were females and three were males. Nine had generalized MG and one patient had oculobulbar involvement only. Median duration of disease was 3 years (range 1 month to17 years). Two patients had thymoma. Two patients had history of thymectomy in the past. Infection was the most common triggering factor accounting for five cases (50%) followed by inadequate treatment/drug withdrawal in three (30%) and steroid initiation and hypokalemia in the remaining two patients (20%). Median duration of MC was 12 days (range 3-28 days). Mortality was in 3 out of 10 (30%) during MC. Management in the intensive care unit (ICU) and treatment with plasma exchange/intravenous immunoglobulins were associated with good outcome.

Conclusions:

Ventilator support and management in intensive care unit are the most important components in the management of MC. The high mortality rate seen in present study may be more reflective of the actual ground reality in resource constrained developing countries, however, larger prospective studies are needed to confirm these findings.     

The Impact of “COVID-19” and “Webinar Pandemic” on Plastic Surgery Practice in Teaching Institutes and Resident Training—A Multicentric Perspective

Introduction  The study was carried out to quantify the changes induced by the pandemic in plastic surgery practice and training and to study the impact of the webinars on plastic surgery education from a residents’ perspective. Methods  In this multicentric study, the number and type of surgeries, cause of injuries, and their regional variation during the coronavirus disease 2019 (COVID-19) period (February–September 2020) were compared with pre–COVID-19 time. An online survey on the impact of webinars was conducted for plastic surgery trainees across the country. Results  There was a significant reduction in total number of surgeries ( p = 0.003). The procedures for hand ( p = 0.156), faciomaxillary injuries ( p = 0.25), and replantations ( p = 0.46) were comparable; there was a significant reduction in combined orthopedic-plastic-surgical procedures ( p = 0.009) during the pandemic. There was a significant reduction in road accidents ( p = 0.007) and suicidal injuries ( p = 0.002) and increase in assault ( p = 0.03) and domestic accidents ( p = 0.01) during the COVID-19 period. A usefulness score of >8 was given for the webinars by 68.7% residents. There was no significant difference in perception of utility when correlated with the academic program at their institutes ( p = 0.109); 92% opined webinars should continue in post-COVID times. Conclusion  There was a drastic reduction in number of elective and emergency procedures during the COVID-19 time, negatively affecting resident training program. Majority of residents felt that webinars could prove a useful adjunct to training in formal training program in post-COVID-19 scenario.     

Circulatory and hepatic failure at admission predicts mortality of severe scrub typhus patients: A prospective cohort study

Objective: To study the spectrum and outcome of severe scrub typhus in adult patients and to predict the hospital mortality by organ failure on admission.Methods: This was a prospective observational cohort study conducted between July 2017 and October 2020 at the medical emergency centre of PGIMER, Chandigarh, India. One hundred and twenty-six patients aged ≥13 years were diagnosed with scrub typhus. Severe disease was defined as the presence of organ failure based on the Sequential Organ Failure Assessment(SOFA) score on admission.Results: About two-thirds of the patients were from geographic regions outside the endemic sub-Himalayan belt. Fever(99.21%) and dyspnea(79.36%) were the most frequent complaints. Respiratory failure(81.75%) was the most common organ failure, followed by hepatic(52.38%), coagulative(47.62%), circulatory(33.33%), renal(21.43%), and cerebral dysfunction(13.49%). The median(Q1, Q3) SOFA score was 8(6, 9), and 48.41% of the patients had a quick-SOFA score ≥2. Organ supports with invasive ventilation(40.48%), vasopressors(36.51%), and renal replacement therapy(7.14%) were frequently required. The in-hospital mortality was 11.90% and was independently predicted by circulatory and hepatic failures on multivariate logistic regression(OR 11.12, 95% CI 1.73-71.31 and OR 8.49, 95% CI 1.18-61.41, respectively).Conclusions: Most patients had pulmonary dysfunction; circulatory or hepatic failure on admission strongly predicts death.     

Comparative assessment of dentition status among poliomyelitis children in Udaipur,India

To determine and compare the dental caries experience and treatment needs of children with Poliomyelitis at Udaipur, India. Total sample comprised of 344 children with Poliomyelitis (upper limb disability: 33.4%; lower limb disability: 33.7%; both upper and lower limb disability: 32.8%) in the age group of 12–15 years. Clinical examination included recording Dentition Status and Treatment Needs. Chi‐square test, Analysis of variance (ANOVA), multiple logistic and stepwise linear regressions were used for statistical analysis. The mean decayed, missing, filled teeth (DMFT) score (4.47 ± 3.09) was found to be highest among children with Poliomyelitis having both upper and lower limb impairment (p < .05). Stepwise and logistic regression analysis showed that the best predictors for dental caries were disability, socioeconomic status and snacks in between meals. A significant relationship of dental caries with limb involved in impairment draws immediate attention for a planned approach in improving the oral health.     

Internal fixation of shaft humerus fractures by dynamic compression plate or interlocking intramedullary nail: a prospective,randomised study

Compare the results of internal fixation of shaft of humerus fractures using dynamic compression plating (DCP) or antegrade interlocking intramedullary nail (IMN). Fifty patients with diaphyseal fracture of the shaft of the humerus and fulfilling the inclusion criterion were randomly assigned to one of the two groups. Twenty-five patients were managed with closed antegrade interlocking intramedullary nail, and 25 underwent open reduction and internal fixation using dynamic compression plating. The mean age of patients with IMN fixation was 37.28 years (SD 12.26) and 37.72 years (SD 12.70) for those who underwent plating. Road traffic accident was the most common mode of injury in both groups. There was a statistically significant difference between the two groups with respect to duration of hospital stay, operative time and blood loss. There was no significant difference between the two groups in terms of union or complications. The functional assessment at the end of 1 year between the two groups did not show any significant difference in outcome. Antegrade interlocking IMN and DCP fixation are comparable when managing diaphyseal shaft of humerus fractures with respect to union rates and complications. Although shoulder related complications are more in the IMN group, however, it is associated with shorter hospital stay, lesser operative time and less blood loss. This makes interlocking IMN an effective option in managing these fractures.     

Prominent dysautonomia in a patient with POEMS syndrome

POEMS syndrome is a rare, multisystem disorder characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and/or skin changes. Here we present an unusual case of a patient with POEMS syndrome who exhibited a prominent autonomic neuropathy.     

Sporadic pharyngitis-associated acute poststreptococcal nephritis. A four-year prospective clinical study of the acute episode

Between December 1980 and November 1984, the acute episode was studied prospectively in 187 children under 14 years presenting with acute poststreptococcal glomerulonephritis. The mean annual incidence was 19.5/10(5) children. The disease was mainly pharyngitis-associated and occurred throughout the year but peaked in the winter. The mean age was 5.4 years, and 71 percent of children were under the age of 8 years. Gross hematuria was the presenting feature in 93.6% of cases and was usually associated with edema. Hypertension was present in 45 percent, circulatory congestion in 27 percent, and heavy proteinuria in 22 percent of cases. The C3 level was low in 97 percent of the patients tested and returned to normal within 6-8 weeks. There were no deaths. Only one patient needed peritoneal dialysis. All except one patient were asymptomatic with normal creatinine within 8 weeks. The authors adopted a very optimistic attitude in the counseling of children with the disease and of their families.