Radiological review of rhinocerebral mucormycosis cases during the COVID-19 Pandemic: A single-center experience

Mucormycosis is caused by the fungi belonging to the order Mucorales and class Zygomycetes. The incidence of mucormycosis has increased with the onset of the severe acute respiratory syndrome coronavirus 2 infections leading to the coronavirus disease 2019 (COVID-19) pandemic. This rise is attributed to the use of immunosuppressive medication to treat COVID-19 infections. Authors have retrospectively collected data of our cases of mucormycosis diagnosed from April 2020 to April 2021 at our institute. A total of 20 patients with rhinocerebral mucormycosis were studied. Most of the study subjects were male patients (90%) and were of the age group 41-50 years. Most patients in the review had comorbidities (85%) with diabetes being the most common comorbidity. Para nasal sinuses were involved in all the cases. Involvement of the neck spaces was present in 60% of the cases. Involvement of the central nervous system was present in 80% of the cases. Orbital involvement was present in 90% of the cases. The authors reviewed the various imaging findings of mucormycosis on computed tomography and magnetic resonance imaging in this article.     

A review of the impact of the COVID-19 pandemic on pre-registration medical radiation science education

ObjectiveThe COVID-19 pandemic has changed traditional ways to provide pre-registration medical radiation science (MRS) (medical imaging and radiation therapy) education. This literature review explores the published pre-registration MRS education curriculum adaptations implemented in response to the pandemic and effects of the adaptations on stakeholders.Key findingsEleven articles were identified through a systematic literature search. The included articles covered the pre-registration MRS curriculum adaptations implemented in response to the pandemic in 12 countries of five continents. Through changing content delivery and assessment modes from face-to-face to online, non-practical classes and academic assessments could continue without significant interruptions. However, cancellation/postponement of practical classes and clinical placements was common during COVID-19 lockdown. Simulated learning was used by some institutions to replace some practical classes and placements. Among the stakeholders of MRS education (students, academics and clinical educators), the students were most affected. The main impacts were negative psychological effects and learning experiences. For the academics, they had common concerns about online learning quality and assessment integrity.ConclusionThis review of the early publications in the first year of the pandemic provides an illustration of the MRS curriculum adaptations implemented in five continents covering both English and non-English speaking countries and their effects on the stakeholders as yet. It is expected that more articles on this area will be published over time and hence allowing a more comprehensive review in the future.Implications for practiceThe included articles show provision of wellbeing support, good planning of online content delivery based on sound pedagogical approaches, implementation of computer-based simulation tools suitable for home-based learning environment and use of authentic online assessments would address the impacts on the students and academics.     

Forensic medicine in Nepal: Past,present, and future

The practice of autopsy for medico-legal purposes in Nepal was started during the 1960s when jail doctors used to perform the autopsy. However, the medico-legal service in clinical forensic settings is less than three decades old. In Nepal, a police inquest is done for all the unnatural deaths who then subjects the body for medico-legal autopsy at the nearest government hospital. Except for a few hospitals where forensic medicine experts are available, the medico-legal work in Nepal is done by medical officers most of who have no forensic qualification. For a country with a population of nearly 30 million, there are less than 50 forensic medicine experts who are currently practicing. There are 21 medical colleges in Nepal each having a forensic medicine department engaged in teaching forensic medicine as a separate subject in the undergraduate medical curriculum. Currently, postgraduate courses are also offered in the country. However, there is a lack of uniformity in the curriculum set by different universities for both postgraduate and undergraduate education. Due to the lack of forensic medicine faculty members in some medical colleges, the undergraduate students of medicine have to undertake the exam being taught by some guest lectures and without witnessing a single medico-legal autopsy. To standardize the medico-legal services and forensic medicine education, the Medico-Legal Society of Nepal was established with an aim to conduct regular seminars, conferences, and CMEs and also various training programs for the non-forensic medicine experts who deal with medico-legal cases. This paper aims to provide a brief history of medico-legal practice in Nepal, the current situation, and future plans to improve the medico-legal service of the country.     

Common medical ethics dilemmas: Few reflections from a Saudi perspective

Medical ethics plays a crucial role in physicians’ daily practice, as it reflects on themselves, their institution, and, most importantly, the outcome of the treatment they provide to their patients. Common medical ethics dilemmas faced in Saudi Arabia include: end-of-life care, patient rights, which comprise autonomy, informed consent, and confidentiality, reproductive ethics, and equity of resources. The identification of flaws within the healthcare system and the implementation of clear guidelines are important to overcome the risk of malpractice and flawed judgment, and ensure the delivery of the best possible care to patients.     

Influence of treatment and response status on infection risk in multiple myeloma

The clinical course of 60 patients with multiple myeloma was examined for risk factors associated with infection. The overall incidence of infection was 1.46 per patient-year. The greatest risk period for the occurrence of infection was the first two months after the start of initial chemotherapy. The incidence of infection during this period was 4.68 infections per patient-year compared with 1.04 infections per patient-year for subsequent months. Serum creatinine levels of 2 mg/dl or more (p < 0.03) and decreased polyclonal serum immunoglobulins (p < 0.01) predicted increased risk of early infections. Patients infected during the first two months of initial chemotherapy had the same rate of infection during the subsequent clinical course as did patients free of infection during the early treatment period. Thus, the early risk period does not represent only the attrition of susceptible patients. Patients who achieved an objective response had a decrease in infection risk during the time of the response (0.44 infections per patient-year). While response to chemotherapy prolongs life in multiple myeloma, the initiation of chemotherapy is associated with a definable risk period for infections.     

Palliative dilation of esophageal carcinoma

The authors' experience with palliative dilation of 46 consecutive patients evaluated for squamous cell carcinoma of the esophagus was retrospectively reviewed. Thirty-nine of 46 patients (85%) underwent dilation in order to palliate symptoms, enable endoscopy and biopsy, or prepare for placement of an esophageal prosthesis. Thirty-two of the 46 patients (70%) were treated with radiation therapy and seven (15%) underwent placement of an esophageal prosthesis. Thirty-five of the 39 patients dilated (90%) noted improvement in swallowing, allowing resumption of a soft or regular diet. Complications were noted in three of the 39 patients dilated (8%). The authors conclude that peroral dilation is a safe, effective, and probably underutilized method of palliation in patients with squamous cell esophageal carcinoma.     

Reassessment of vasodilator therapy in angina: Effects of oral isosorbide dinitrate and hydralazine on exercise tolerance in patients receiving propranolol

Nitrates, predominantly venodilators, are commonly used in the treatment of angina pectoris, whereas hydralazine, a potent systemic and coronary arterial vasodllator, is usually contraindicated. Hydralazine might be useful in therapy of angina H tachycardia could be prevented by beta adrenergic blockade. Consequently, treadmill exercise tolerance was determined in 20 patients with chronic stable angina during treatment with oral propranolol, 60 mg four times daily (control), propranolol plus 20 mg of oral isosorbide dinitrate, propranolol plus 100 mg of oral hydralazine, and all three drugs combined. The mean heart rate at rest in patients recelving propranolol was 54.0 ± 1.7 beats/min (mean ± standerd error of the mean). It increased 6.8 beats/min with the additlon of hydralazine (p < 0.005) and 7.2 beats/min with Isosorbide dlnitrate and hydralazine comblned (p < 0.005), but was unchanged with Isosorbide dinitrarate alone. Systoilc blood pressure decreased 13.5 mm Hg with Isosorbide dinitrate (p < 0.05) and 28.3 mm Hg with Isosorbide dinitrate and hydralazine combined (p < 0.005), but did not change significantly with hydralazine alone (average decrease 4.1 mm Hg). The mean duration of exercise increased by 24.1 seconds with Isosorbide dinitrate (p < 0.05), and almost twice that (42.4 seconds longer than the control value) with Isosorbide dinitrate and hydralazine (p < 0.005). With hydralazine alone, exercise duration was decreased by 24.7 seconds (p < 0.05). Rate-pressure product at symptom-tolerated maximal exercise was unchanged with Isosorbide dinitrarate or hydralazine alone, but lower than the control value with the two agents combined. It Is concluded that Isosorbide dinitrate Improves exercise tolerance in patients with angina who are being treated with propranolol, but hydralazine remains detrlmental despite the use of the beta blocking agent. However, when Isosorbide dinitrate is combined with hydralazine, the detrimental effects of hydralazine on exercise tolerance are reversed.     

Massive coronary arterial aneurysm.

The pathologic and echocardiographic findings of a massive right coronary arterial aneurysm in a 62 year old man are presented. The thrombosed aneurysm simulated a cardiac tumor, destroying one pulmonary valve cusp. It also caused marked pulmonary stenosis with elongation and narrowing of the outflow tract of the right ventricle and fixation of half of one cusp of the tricuspid valve.     

Coronary artery bypass surgery for left main coronary artery disease.

The course of 146 consecutive patients with significant occlusive disease of the left main coronary artery who underwent coronary artery bypass surgery during a 4 year period is reviewed. Preoperatively, 11 patients were in New York Heart Association functional class II, 57 in class III and 78 in class IV. Seventy patients had progressive angina and 12 unstable angina. There were two operative deaths (surgical mortality rate 1.4 percent). Seven patients (4.8 percent) had a perioperative acute myocardial infarction. Complete follow-up has been achieved in the surgical survivors over an average period of 18.1 months; 77 percent of the surviving patients are completely asymptomatic and 19 percent are in functional class II. Four patients (2.8 percent) had a nonfatal late postoperative myocardial infarction and five (3.5 percent) died during the late postoperative period (3.3 percent annual mortality rate during a 2 to 47 month follow-up period). Postoperative cardiac catheterization studies performed in 35 patients an average of 12.1 months postoperatively revealed 78 percent of 80 grafts and patency of at least 1 graft in 93 percent of patients. Results of 42 (89 percent) of 47 near maximal treadmill stress tests were abnormal preoperatively compared with results of 14 (26 percent) of 54 postoperatively; in 74 percent of patients having both a preoperative and postoperative stress test, abnormal preoperative test results converted to normal after surgery. This study suggests that direct myocardial revascularization may offer an effective means of improving both the quality and duration of life in a patient with significant occlusive disease of the left main coronary artery.     

P wave changes on exercise in patients with isolated mitral stenosis

Patients with mitral stenosis usually showed a marked increase in the P negativity following exercise. The P terminal force in Lead V₁ in 20 cases with isolated mitral stenosis was ?0.090 mm. sec. before exercise, which changed to ?0.177 mm. sec. following the single Master two-step test.Normal adults never showed such changes on exercise. The phenomenon was considered to be due to the posterior rotation of the P wave vector in the horizontal plane, which was induced by the enlargement of the left atrial wall on exercise.