Kerala Medical Journal <p>Kerala Medical Journal is the academic journal published by Indian Medical Association – Kerala State Branch.</p> PublishMed Journals en-US Kerala Medical Journal 0301-4827 <p>When publishing with Kerala Medicial Journal (KMJ), authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal. Work includes the material submitted for publication and any other related material submitted to KMJ. In the event that KMJ does not publish said work, the author(s) will be so notified and all rights assigned hereunder will revert to the author(s).</p> <p>The assignment of rights to KMJ includes but is not expressly limited to rights to edit, publish, reproduce, distribute copies, include in indexes or search databases in print, electronic, or other media, whether or not in use at the time of execution of this agreement.</p> <p>Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.</p> <p>The author(s) hereby represents and warrants that they are sole author(s) of the work, that all authors have participated in and agree with the content and conclusions of the work, that the work is original, and does not infringe upon any copyright, propriety, or personal right of any third party, and that no part of it nor any work based on substantially similar data has been submitted to another publication.</p> Precision Medicine: Personalising Healthcare <p>Precision medicine, also known as personalized or genomic medicine currently holds high regard in medical practice. The Precision Medicine Initiative defines precision medicine as the medical approach to disease treatment and prevention by taking into account individual variations in genes, environment, and lifestyle for each person. Developing targeted medical therapies and interventions based on these individual factors will lead to improving the efficiency of the medicines while reducing their side effects. Thus, precision medicine seeks “the right treatment for the right patient at the right time.”</p> Kavitha Ravi ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 1 2 10.52314/kmj.2024.v17i1.622 Knowledge, Attitude and Practice on Dental Issues in Persons with Epilepsy <p>Background and Objective: Epilepsy is a common neurological disorder with significant disabilities. Persons with epilepsy is considered to have poor dental hygiene. It is due to multifactorial causations. Studies regarding the attitude of neurologists and dentists and knowledge of patients is limited.<br>Methods: This is a questionnaire based cross sectional study of patients diagnosed with Epilepsy treated in Sree Chitra Tirunal Institute of Medical Sciences and Technology. Attitude and practice of neurologists and dentists towards the dental health issues in persons with epilepsy were studied via online questionnaire.<br>Results: A total of 111 dentists, 106 neurologists and 82 patients were enrolled in the study. Out of the 106 neurologists, 73 (68.9%) opined that person with epilepsy has increased risk of dental health issues, while 22.6% opined same risk compared to normal population. The opinion of neurologists regarding fitness for dental procedures: 57.1 % gives fitness only in controlled epilepsy while 33.3 % opined that they give fitness for all cases regardless of control of epilepsy. 40.6% opined that refractory epilepsy has a link to periodontal diseases. Among dentists, 17.6 % dentists refer to alternate higher centre, if patient had seizures in past. 80.9 % ask for history of seizures, in their dental patient in consulting room, while 19.1 % does not ask. 46.8% of dentists ask for history of antiseizure medications when they see an oral pathology, while 13.8% does not ask for such history, and 39.4% ask only if he has history of seizures. Most dentists (34.9%) opined that anxiety as the most common issue faced during the procedure of persons with epilepsy. 24. 8% opined gum bleeding. Out of 82 persons with epilepsy, 78 believes in keeping the mouth clean is essential while 4 were unaware. 24 people experience nervousness while on dental chair, and 10 people fear being there and 46 have no such difficulties. 27 people takes preventive measures if they notice a dental caries to prevent further decay, 18 will wait and watch, 34 will consult dentist at the earliest, while 1 person will ask neurologist opinion for the same<br>Conclusion: The neurologists should give importance in enquiring the dental health problems and should advise for routine dental health check-ups for persons with epilepsy. In addition, dentists should be educated in doing emergency measures during a seizure episode and should not defer patients from doing dental procedures due to history of seizures.</p> Jithin George Jayakumari Nandana Thania Elizabeth Pidiyancheril Thania Elizabeth Pidiyancheril Lakshmi Priya Ramshekhar N Menon Ashalatha Radhakrishnan ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 3 12 10.52314/kmj.2024.v17i1.623 Pregnancy Outcome in First and Second Trimester Covid Infection <p>Background: Covid 19 is entering its third year now. Most studies have concentrated on third trimester. We have attempted to study outcome in pregnancies afflicted with covid in first and second trimester.<br>AIM: To study outcome of pregnancies with covid in first and second trimester<br>Methods: We reviewed pregnancy outcome retrospectively in 153 pregnant women with covid in first and second trimester admitted in our institution between March 2020 - January 2022.<br>Results: 39.86% were between 26-30 years, 32.02% between 20-25 years. 49.01% were &lt; 14 weeks of gestation, 40.52% &gt; 14 and &lt; 26 weeks of gestation, 10.45% were 26 - 28 weeks. Intrauterine growth restriction [ IUGR] was seen in 13.07% patients, gestational diabetes mellitus [GDM] in 7.8%, hypertensive disorders of pregnancy [PIH] in 4.5% patients. 7.1% patients developed foetal distress. There were 42 miscarriages (27.45%), 42 normal deliveries (27.45%), 11 preterm deliveries [PTL (7.1%), 54 caesarean sections [CS]{30 emergency}. Asymptomatic patients had 80.95% of total abortions. Those with fever and upper respiratory tract infection (URT)] and severe acute respiratory illness [SARI] contributed 36.66% each of total emergency CS. 36.66% of total cases of PTL were contributed by SARI while 36.36% were in asymptomatic group. In asymptomatic patients 57.62 % had miscarriages,13.55% required emergency caesarean and 6.7% PTL.<br>In group with fever and URTI, 12% abortions, 22.91% emergency CS 6% PTL. There was one miscarriage in group with fever and diarrhoea. Those &lt; 14 weeks, 38.66% miscarriages, contributing to 69.04% of total abortions. 10.66% emergency caesarean [two&lt; 34 weeks]. 5.3% PTL [one &lt; 34 weeks]. In patients &gt; 14 -&lt; 26 weeks,20.96% miscarriages, 8% PTL (one&lt; 34 weeks), 19.35% emergency CS [two&lt; 32 weeks]; one maternal, 2 intrauterine and one neonatal death. In patients 26-28 weeks, 62.5% required emergency caesarean [three&lt; 32 weeks]. There was one maternal death, 2 patients PTL &lt;34 weeks.<br>The maternal and neonatal death occurred in patients with SARI.<br>Conclusion: Our study shows increased abortions in early trimester irrespective of severity. The emergency caesarean and PTL rates increased in late second trimester and severe disease.</p> Sabnam S Nambiar S Ajith VP Reshmi ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 13 18 10.52314/kmj.2024.v17i1.624 Viral Pandemics Throughout History and What We Have Learnt from Them <p>In the course of global history, infectious disease outbreaks have occurred intermittently, causing long-lasting effects on human societies which then subsequently went on to change the very course of history. These outbreaks, whether they be globalized or ubiquitous have lent us the power to alter socioeconomic, political, religious, and cultural aspects of human civilization. Pandemics have shaped modern medicine through the creation of systematic frameworks for epidemiological study, and prevention of disease through pharmaceutical (drugs, mass vaccination) and non-pharmaceutical interventions (quarantine, handwashing and hygiene techniques). Thus, we are constantly striving to overcome the threat of emerging as well as reemerging infectious disease outbreaks. In the last 40 years, we have faced most notably, the Spanish Flu (from 1918 to 1919), HIV-AIDS (from 1981 to present), SARS-CoV (from 2002 to 2003), Swine Flu (from 2009 to 2010) and most recently, COVID-19 (from 2019 to present). Most viral pandemics were caused by zoonoses transmitted through practices of breeding, hunting and global trading leading to increased human-animal contact. By understanding the pathophysiology and pathways of transmission of pathogens to humans, we can discover newer and better methods to controlling and even preventing infections. 40 years back when the plague struck, public health preparedness and interventional measures such as quarantining, isolation, and strict border control were critical in containing the spread of outbreaks and maintaining the structural infrastructure of human society. These non-pharmaceutical containment methods are still found to be effective in controlling the COVID-19 pandemic to this day. Newer technologies for quick diagnosis with disease severity markers and contact tracing as well as mass production and distribution of vaccines are required for effective response. Medical historians opine that studying earlier pandemics and our response to them may help further our insight into infectious diseases in the 21st century. Amongst the advancements made in the healthcare sector, public health response seems to be mostly unchanged.</p> Rachana S Menon Swarupa Chakole ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 19 25 10.52314/kmj.2024.v17i1.625 Multidimensional Evolution in Transfusion Medicine <p>Transfusion Medicine is a rapidly developing clinical entity. Since no artificial substitute is available for major elements in blood, a safe transfusion chain is quite essential. Efficient blood donor recruitment is most important in transfusion services. Blood component separation and technologies like apheresis have helped in utilizing available resources to their maximum potential. Transfusion Transmitted Disease testing and immunohematological investigations have evolved continually to maintain the highest quality. The methodology for testing for TTDs has shifted to better versions of Enzyme-Linked Immunosorbent Assay (ELISA) to Chemiluminescence immunoassay (CLIA), and additionally Nucleic Acid Amplification Testing (NAT). Automation and more sensitive platforms for immunohematological testing have helped in attaining precision and decreasing workload. Nowadays, clinical transfusion practice is having well-established policies, guidelines, audits, training etc. This has helped in maintaining the quality of services from vein to vein. Therapeutic apheresis is the mainstay of treatment for many diseases. Research is ongoing for the development of RBC and platelet substitutes. Regenerative medicine is rapidly evolving to its best potential. Hematopoietic stem cell transplantation (HSCT) is the most frequently used cell therapy and is used to treat a variety of blood cancers and hematologic conditions. Apart from bone marrow and peripheral blood, the umbilical cord has been recognized as an alternate source of stem cells. Slowly, tissue banking is gaining its importance. Intrauterine transfusion is a novel modality that saves the fetus from anaemia or thrombocytopenia and its complications. Platelet-rich plasma (PRP) injections are gaining popularity for a variety of conditions, from sports injuries to hair loss. Likewise, Autologous platelet gel has many applications in sports medicine, dermatology, surgery etc. These rapid advances along with good governance promise better transfusion practice and patient care in upcoming years.</p> Sajith Vilambil ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 26 31 10.52314/kmj.2024.v17i1.626 Advancements and Current Trends in Next-Generation Sequencing (NGS) Technology <p>NGS represents a ground-breaking technology facilitating swift, high-throughput sequencing of DNA or RNA molecules. NGS techniques empower the simultaneous parallel sequencing of millions to billions of DNA or RNA fragments, a capability unmatched by traditional Sanger sequencing, which is constrained by scalability and speed. The versatility of NGS platforms has expanded the scope of genomics research, enabling investigations into rare genetic diseases, cancer genomics, microbiome analysis, infectious diseases, and population genetics. Furthermore, NGS has paved the way for the advancement of targeted therapies, precision medicine strategies, and enhanced diagnostic methods.</p> Hari Shankar R Krishnachandran MS Sinto ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 32 34 10.52314/kmj.2024.v17i1.627 Spontaneous Ovarian Hyperstimulation Syndrome in Failed Early Pregnancy: A Rarity <p>Spontaneous ovarian hyperstimulation syndrome (s-OHSS) is a rare occurrence, particularly in the absence of assisted reproductive technology. This case report discusses a rare occurrence of spontaneous ovarian hyperstimulation syndrome (s-OHSS) in the context of a failed early pregnancy, emphasizing radiological findings and diagnostic implications. Clinicians and radiologists need to be aware of this rare entity, even when there is no history of ovulation induction. The report outlines the patient’s clinical presentation, imaging studies, differential diagnoses, and relevant literature supporting this unusual manifestation of s-OHSS.1–9</p> Vivek Khandelwal Anupama Reddy Vikas Chauhan Ravi Raj ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 35 37 10.52314/kmj.2024.v17i1.628 A Rare Case of Large Nasopharyngeal Teratoma <p>Congenital nasopharyngeal teratoma is a rare, germ cell tumour in newborns seen in the nose or throat. These can be life-threatening if they obstruct the airway or cause bleeding or infection. Treatment often involves surgery and may include chemotherapy or radiation therapy. Congenital germ cell tumours are uncommon, with the most common location being the sacrococcygeal region (incidence 1 in 4000). Head and neck teratomas (incidence 1 in 20000 - 40000) make up less than 10% of reported cases and nasopharyngeal teratomas are particularly rare. Preoperative CT scans and MRIs are helpful to rule out intracranial extension of the tumour. While most teratomas are benign, this case presents nasopharyngeal teratoma associated with severe birth asphyxia and bleeding with neonatal death.</p> M.M Ramadas M.M Ramadas K.Hari Hara Das M.K Shaniba Raihana K P Dilshath ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 38 40 10.52314/kmj.2024.v17i1.629 Peutz Jegher’s Syndrome - Double Intussusception in a Teenage Patient in a Single Setting - A Rare Case Report <p>Peutz jegher’s syndrome is a rare autosomal dominant disorder with hamartomatous polyps and mucocutaneous melanin pigmentation. This case report shows a case of a teenage Indian boy presented with intestinal obstruction due to double intussusception in a single setting due to the PJS polyps. This is the first case of double intussusception in a teenage patient with PJS in a single setting reported in India and fifth case in the world. A 14-year-old teenage boy presented to a surgical emergency with complaints of abdominal pain, bloody stools, and vomiting with characteristic ink black macules over buccal mucosa. On abdominal examination, sausage-shaped mass was palpable and he was provisionally diagnosed with Peutz-Jeghers Syndrome. Ultrasound abdomen findings favoured the diagnosis of intussusception at two sites. He underwent Emergency Laparotomy with resection &amp; anastomosis of involved segments of the ileum and jejunum. Intraoperative findings showed Jejunojejunal intussusception 50 cm distal to DJ junction with 25 cm of gangrenous jejunum and ileoileal intussusception 30 cm proximal to ileocaecal junction which was histopathologically found to be hamartomatous polyps. The postoperative period was uneventful. He is under surveillance. Periodic surveillance is helpful in patients with PJS.</p> N.V Devipriya R.C Sreekumar ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 41 44 10.52314/kmj.2024.v17i1.630 Disseminated Bacillus Calmette-Guerin (BCG) Infection in Severe Combined Immunodeficiency (SCID) Patients <p>Disseminated Bacille Calmette-Guerin (BCG) infection is a rare and life-threatening complication of BCG vaccination. It is mainly seen in cases of severe immune deficiency. We report two cases of disseminated BCG infection in genetically proven cases of Severe Combined Immunodeficiency (SCID) from our institution. The first case is that of a one-year-old child who presented with fever, cough, yellowish discoloration of eyes, multiple skin nodules all over the body, and ulcer over the BCG vaccination site. Biopsy from the skin nodules showed multiple granulomas with plenty of Acid-fast bacilli; hence, anti-tubercular treatment was started for the child. The second case is that of a five-month-old child who presented with a lower respiratory tract infection, multiple episodes of loose stools, vomiting, poor feeding, poor activity, and a deranged Liver Function Test. Gastric aspirate Gene expert study was done and Mycobacterium tuberculosis was detected. Hence the patient was started on anti-tubercular treatment. Subsequent liver biopsy revealed a focus of granuloma. Genetic study was done in both cases and SCID was proved. Because of the rarity, we are presenting the cases.</p> Rose Maria Jose V.S Priya N Laila Raji GS Bindhu S  Bindhu VH Sankar ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 45 48 10.52314/kmj.2024.v17i1.632 Anesthetic Management of Retrosternal Thyroid A Case Report <p>Airway management during thyroidectomy for retrosternal goitre is most often a challenge. It can contribute to adverse events intraoperatively and postoperatively.¹ Here we describe the anesthetic management of a patient with long standing retrosternal goitre. The patient also had compression of trachea and total thyroidectomy was advised. Patient underwent awake nasal fiber optic intubation under topical anesthesia and sedation. The entire thyroid tissue including the retrosternal thyroid was removed through the neck. This case report suggests that Awake fiberoptic intubation (FOI) under topical anesthesia can be considered in patients with retrosternal goitre. Difficult airway should always be anticipated. The success of awake intubation depends on good communication along with psychological and pharmacological preparation of the patient. The primary principle should be a patient tailored approach keeping in mind the comorbidities and clinical status of the patient.</p> Hima Rajan Anju Mariam Jacob ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 49 51 10.52314/kmj.2024.v17i1.633 Sigmoid ‘GIST’ Masquerading as Intestinal Obstruction <p>Gastrointestinal stromal tumours (GIST) are one of the most prevalent mesenchymal tumours of the digestive tract despite constituting less than 1% of all gastrointestinal cancers. GISTs usually occur in the stomach followed by the small intestine and rarely in the colon and esophagus. Furthermore, colorectal GIST is usually in the rectum, so sigmoid GIST is rather uncommon. Abdominal pain, GI bleeding, anaemia, and weight loss are the common presentations of the affected patients.<br>Large bowel obstruction is defined as bowel obstruction distal to the ileocaecal valve, commonly caused by an underlying carcinoma or less commonly diverticular disease Acute obstructions present with rapid onset of pain, distension, and abdominal tenderness. <br>Here is a case of a 58-year-old gentleman who presented with acute large intestinal obstruction with no significant previous history and underwent emergency laparotomy with resection of sigmoid colon with a tumor, which on histopathology was diagnosed to be a high-grade GIST.</p> Satish G Prabhu Sruthi R Pillai ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 52 54 10.52314/kmj.2024.v17i1.634 HIPEC - An Effective Treatment Option for Abdominal Cancers <p>Hyperthermic Intraperitoneal chemotherapy is a novel treatment for Peritoneal Surface Malignancies. It involves both surgery and chemotherapy together. The treatment success depends on the correct selection of patients. The procedure is still undergoing standardization.</p> Jojo V Joseph ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 55 56 10.52314/kmj.2024.v17i1.637 The Changing Role of the Pathologist in the Era of Precision Medicine: A Brief Review <p>Precision oncology, an upcoming field of Oncology, aims to target the specific genetic alterations in tumour cells, thereby avoiding the harmful effects of chemotherapy on normal cells, and improving quality of life. The role of the pathologists is changing, from being pure diagnosticians to ensuring good quality tissue and ensuring adequate tissue which is crucial for all necessary tests to guide tailored therapy in an individual case</p> Neena Mampilly ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 57 58 10.52314/kmj.2024.v17i1.635 “No Bystanders” Policy in ICUs. Time to Rethink <p>This is an article about my wish to highlight the deficiencies in our ICUs and what we as doctors can do about it.<br>My husband who is a retired professor of history, was recently admitted in a surgical ICU following a bowel resection. He narrates his experience.</p> Annie Kuriyan Thadicaren ##submission.copyrightStatement## 2024-04-15 2024-04-15 17 1 59 60 10.52314/kmj.2024.v17i1.636