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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 17 | Issue 3
Page Nos. 133-236

Online since Wednesday, September 16, 2020

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EDITORIAL  

Editorial p. 133
Rajendra N Srivastava
DOI:10.4103/am.am_100_20  
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GUEST EDITORIAL Top

What has the COVID-19 pandemic taught us? p. 134
Raju Vaishya
DOI:10.4103/am.am_75_20  
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OVERVIEW Top

Impact of the COVID-19 pandemic on India p. 136
Raju Vaishya, Abhishek Vaish, YS Suresh Babu
DOI:10.4103/am.am_106_20  
The COVID-19 pandemic has posed a devastating effect on humankind across the world. Its rapid spread is the result of it being a highly contagious viral pathogen. Its spread in India is universal, and nearly 3 million people have been affected, to date. Fortunately, the reported direct death rates have been around 2%, and recovery rates being >70% are promising indicators. The multiple lockdowns by the Government of India have helped in gearing up the health-care sector and significantly improving the availability of personal protection gears and medicine, availability of beds, and training of the health-care workers to deal with this dreaded disease.
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REVIEW ARTICLES: LABORATORY DIAGNOSIS Top

Laboratory diagnosis of COVID-19 infection p. 139
MS Ratnamani
DOI:10.4103/am.am_105_20  
Rapid diagnostic tests are required for the early diagnosis of COVID-19 infection. Rapid antigen detection tests are card-based, and the reports are available within 30 min. Sample type is nasopharyngeal swab. Rapid antigen tests help in triaging the patients, early identification, isolation, and contact tracing. Antigen test has high specificity and moderate sensitivity. Symptomatic patients and those with high pretest probability, but are antigen test negative, need to go for real-time polymerase chain reaction testing. Rapid antigen tests aid in the early decision-making and reduce the burden on molecular diagnostics. Serological tests for COVID-19 involve the detection of antibodies in blood. Immunoglobulin G (IgG) antibodies to SARS CoV-2 indicates past infection or past exposure. It should not be used for the diagnostic purpose. IgG, IgM, and total antibodies detection is available on different platforms. IgG antibody testing is useful for seroprevalence, plasma donation, and as epidemiological tool. ICMR has given advisory and algorithm for both antigen and antibody testing.
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REVIEW ARTICLES: MANAGEMENT Top

Practical approach to manage patients with moderate and severe COVID infection p. 144
Sanjay P Khare
DOI:10.4103/am.am_108_20  
COVID-19 infection has hit humanity with a ferocious velocity that's left 7.8 billion humans across 195 countries in seven continents absolutely stunned. Never have we seen life brought to such an absolute standstill by a biological agent. The WHO declared the COVID-19 outbreak a global health emergency and subsequently a global pandemic. The hospitals and intensive care units have been packed to capacity. Most of the modalities of treatment are intuitive and based on a short experience of 6 months (three in our country). This article presents a practical approach to the management of patients with moderate and severe infection COVID-19. The patients in these two groups are separated on the basis of clinical and laboratory parameters. Adequate management of moderately severe patients may prevent the progression of the disease. The role of various specific agents used in the treatment is briefly discussed.
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Management of COVID infection p. 149
Manjit Singh Kanwar
DOI:10.4103/am.am_51_20  
Corona Virus has jolted the world. The government and the medical community world wide has not only been stretched but stressed a lot during this pandemic. The numbers and mortality figures are ever increasing. The lock down have served their purpose and it is a stage of hospitals undertaking the paramount care of the suffering and psychologically stressed COVID -19 patients. Caring for those and trying to save their lives who could in turn transmit disease to you has never been an easy task. Yet our bravehearts the Doctors, Nurses and Paramedics stood valiant on the line of Duty to serve humanity. The description in this article will take you on a virtual tour on a journey we ask physicians and our patients mutually undertake through the diseases process. We go through periods of uncertainty and at times anxiety with not only the patients but their families too. However we remain optimistic and impart the same optimism into them because we know that except in an occasional patient, we will win the race. How we manage mild cases at home to hospitalise patient on the floor is a relatively simpler issue for treating COVID patients. Challenges appear when patients require increasing oxygen flow to maintain minimum acceptable SO2 of 90%. Trying out experimental therapies and their correct timing is very important. We constantly update ourselves among a crack team of highly experienced critical care physicians to decide all investigations and treatments. Some patients require ventilatory support. The COVID patients have been found to behave a little different way on ventilators compares to other our sick respiratory failure patients unless they how gone into full blown ARDS. Those challenges are also explained here.
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REVIEW ARTICLES: SYSTEMIC INVOLVEMENT IN COVID DISEASE Top

Acute renal complications of COVID-19 : Impact of pathophysiology on management p. 153
Jayant Kumar Hota
DOI:10.4103/am.am_52_20  
The ongoing pandemic of coronavirus disease-2019 (COVID-19) due to a novel coronavirus named severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) by the World Health Organization has already wreaked havoc all over the world. About 5%–10% of all the patients of COVID-19 have severe diseases including acute respiratory distress syndrome, septic shock, disseminated intravascular coagulation, and multi-organ failure in different population. Acute renal complications are not unusual and can range from mild proteinuria to advanced acute kidney injury requiring some form of renal replacement therapy. Many studies have shown that renal dysfunction is associated with very high mortality. Understanding the underlying pathophysiologic mechanisms may help the treating physicians to recognize the renal complications early and to prevent and manage the complications adequately.
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Neurological manifestations of COVID-19 (severe acute respiratory syndrome coronavirus 2) p. 157
Vinit Suri, Kunal Suri, Swapnil Jain, Kanika Suri
DOI:10.4103/am.am_63_20  
Coronaviruses including the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are known to affect primarily the respiratory system with additional manifestations on the enteric, hepatic, and cardiac systems as well. Neurological manifestations are increasingly being reported from all over the world though only as case reports and short case series. Neurological manifestations are not uncommon and may be seen in up to a third of patients with COVID-19 infection and may range from minor symptoms of headache, dizziness, anosmia, and ageusia to severe neurological illnesses including encephalitis, acute necrotizing hemorrhagic encephalitis, stroke, myelitis, and Guillain–Barre syndrome. Neurological symptoms may occasionally be the presenting or sole manifestation of COVID-19 infection, and a high index of suspicion is required while dealing with such cases during the COVID-19 pandemic. A Medline search was made till June 20, 2020 using the keywords SARS-CoV-2, COVID-19, and Neurological Manifestations for the review.
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COVID-19 and endocrinopathies p. 161
Subhash Kumar Wangnoo, Radhika Jindal, Mohammad Asim Siddiqui
DOI:10.4103/am.am_59_20  
In general, it is rare for an endocrine physician to be at the fore-front of any pandemic, as most of the acutely ill patients are managed by first responders and emergency physicians. With increasing evidence that patients having endocrine and metabolic disorders, especially uncontrolled, are the ones expected to have poorer outcomes during the ongoing coronavirus disease 2019 (COVID-19) pandemic, it has brought the endocrine physician to the fore-front of management. Several publications have reported the endocrine and metabolic conditions that may be considered risk factors for acquiring the new coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) infection, but the direct evidence whether SARS-CoV-2 may directly lead to endocrinopathies causing disorders that make the prognosis of affected patients worse, are lacking. Most of the endocrine disorders, but their etiopathogenesis or treatment thereof alter the way the body's immune defense mechanisms are triggered. Furthermore, in specific scenarios, ongoing treatment may have to be discontinued/modified. There is still paucity of data to alter the already available “best practices or clinical recommendations” statements. In the absence of any specific recommendations, it is the left to the judgment of the treating endocrine physician to adapt the available recommendations/guidelines on the basis of the clinical judgment.
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Pediatric inflammatory multisystem syndrome-temporally associated with SARS-CoV-2 p. 166
Tania Oberoi, Nameet Jerath
DOI:10.4103/am.am_73_20  
Covid-19 is generally a mild disease in children. Coinciding with the peak of the pandemic many children have been reported with a severe disease syndrome comprising fevers, shock with hyper-inflammation, and multiorgan dysfunction, now named pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2-(CoV-2). Although initially thought to be a spurt in cases of Kawasaki Disease (KD) the clinical manifestations differ from KD in being more common in older children with more severe derangements of inflammatory markers and cardiac dysfunction. Gastrointestinal symptoms are prominent. This is likely a postinfection hyper-inflammatory response as almost 90% test positive for antibodies against CoV-2 with significantly raised inflammatory markers and cytokine levels. Most children require cardiovascular and respiratory support and vasoactive therapy in intensive care units. Extracorporeal support is occasionally needed. Intravenous immunoglobulin, aspirin, and steroids are the cornerstones of therapy, though some refractory cases require immune-modulating agents. With adequate treatment, most have shown a favorable outcome.
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Challenges in providing surgical care during and after COVID-19 pandemic p. 170
Saseendar Shanmugasundaram, Abhishek Vaish, Raju Vaishya
DOI:10.4103/am.am_69_20  
COVID-19 has changed the way clinical practice and orthopedic care services existed. The pandemic has affected almost all types of health-care delivery, more importantly the surgical care of patients. Although there have been a flurry of opinions and scientific reports on health-care delivery during and after the COVID-19 pandemic, no established consensus exists on the guidelines to the surgical care of patients. We summarize the available evidence on the principles and guidelines to be followed in the care of the surgical patient. Care starts with precautions of infection prevention and care in the outpatient department, which includes sufficient protection of the medical staff, planning to avoid crowding, and smart usage of resources and workforce. Surgery should be contemplated only when absolutely indicated. Surgical care of the patient should encompass not only the prevention of morbidity associated with operating on COVID-19 patients but also the prevention of transmission of infection to other health-care staff and non-COVID-19 patients. Precautions should be taken at multiple levels and include but are not limited to proper preoperative, anesthetic, and surgical considerations and a coordinated functioning of the COVID-dedicated Operating Room (COR). The health-care personnel should be trained on the dos and don'ts in every step in the execution of a surgical procedure on a COVID-19 patient. Senior health-care staff need to overlook the adherence of the health-care personnel to these guidelines. Sanitization of the OR and disposal of infected material carry prime importance after the procedure. In all, it is necessary to accept the new normal resulting from the COVID-19 pandemic to better accept and execute protective measures.
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Gastrointestinal cancer surgery during COVID times p. 174
Devi Singh Dhankhar, Rigved Gupta, Supreet Kumar, Deepak Govil
DOI:10.4103/am.am_79_20  
COVID pandemic has taken the whole world off guard, and it has lasting serious implications on every aspect of human life. Surgical services for our elective cases are suffering. There are a lot of issues related to gastrointestinal (GI) cancer patients in these COVID times. It is difficult to decide whether to operate on these patients taking the risk or delay the surgery with attendant risk of cancer progression or use some alternative protocols. Here, we aim to offer guidance for the prioritization of surgical services to further minimize the effect of the COVID-19 pandemic across various overburdened surgical units and to preserve the surgical workforce with special emphasis on GI malignancy patients.
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Urology practice in COVID-19 era, Indian perspective p. 180
Rajesh Taneja
DOI:10.4103/am.am_67_20  
COVID-19 has hit the world as an unforeseeable calamity leading to unprecedented difficulties faced by the medical fraternity on the whole. A review of published literature pertaining to global experiences in the field of urology, in the backdrop of this disease has been carried out. The common problems faced by urologists world over have been difficulty in the stratification and advising surgical intervention, while conforming to the principles of medical ethics. This has been compounded by rationing of resources, diversion of trained workforce, and increased financial burden on hospitals and patients alike. There has been a reduction in the outpatient department (OPD) attendance, OPD procedures, and major surgical procedures in the past 3 months. Benign diseases have been deferred much more than malignant conditions. A guide for stratification of urological illness according to deferability has been proposed. The psychological burden of the patients, who have been categorized low in priority after the diagnosis has been made, may be immeasurable. Working with personal protective gear along with lead apron has been pointed out as physical stress, which may affect the surgeons' performance. The training of residents has been a collateral damage, which may have far reaching implications. The consequences of this may manifest in some years to come. Telemedicine may be the new normal in the coming times.
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Minimally access laparoscopic and robotic surgery during the COVID-19 era p. 185
Arun Prasad, Abhishek Tiwari, Nimo Osman
DOI:10.4103/am.am_76_20  
COVID-19, the novel coronavirus, has affected all aspects of life including the way we do surgery. While patients are being tested with real-time reverse trancriptase-polymerase chain reaction before admission for elective surgeries, there are a good number of false-negative tests. This has led to the concept of a minimum standard precautions in all the negative cases too. In our unit at Indraprastha Apollo Hospitals, New Delhi, we have done 84 minimally access laparoscopic and robotic surgeries during the lockdown. This included benign and malignant diseases. No staff in the operation theater (OT) was infected during any of these surgeries. Wearing personal protective equipment and use of smoke evacuation system in a pressure-adjusted OT is the key to safety.
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Safe neuroanesthesia practice during COVID-19 pandemic – How different from routine? p. 190
Nidhi Gupta, KJ Choudhury
DOI:10.4103/am.am_74_20  
Currently, we are in the midst of a global pandemic caused by SARS-CoV-2 viral infection, termed Coronovirus disease or COVID-19. Despite the enormous working constraints imposed by this highly contagious virus and limited healthcare infrastructure, the neurosurgeons and neuroanaesthetists worldwide continue to provide their emergency services to neurocritically ill patients who need immediate intervention. Appropriate treatment modifications are mandatory to minimize nosocomial spread of SARS-CoV-2 while providing emergency care to the suspected or confirmed cases with COVID-19. In this review, we shall discuss the salient points about the various COVID-19 specific modifications involved in neuroanaesthesia practice, pertinent to the ongoing pandemic.
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Contraception and MTP in COVID times p. 194
Kawita Bapat, Sonal Palod
DOI:10.4103/am.am_58_20  
In this pandemic of COVID-19, women's health is disproportionately affected due to reduced access to contraceptive and safe abortion services. It has led to increased incidence of unsafe abortions, unwanted pregnancy, and quack practices. With the help of government services and policymakers, all these services should be made easily approachable to women. Basic guidelines of COVID precaution should be clearly explained to women and adolescent girls, safe contraception methods and their access should be known to patients. Telemedicine can play a huge role in covering all these aspects of women's health. Psychological counseling by doctors and health service providers reduces fear and anxiety regarding their health issues. Contraception can reduce the need for termination of pregnancy, resulting in the reduced risk of women and girls facing unsafe abortions. Recently, the United Nations Fund for Population Activities (UNFPA) data reveal that if lockdown continues for another 6 months, 47 million women in low- and middle-income countries may not be able to access contraception and that 7 million unintended pregnancies are expected to occur globally. Hence, contraception and medical termination of pregnancy services also have to be taken as prime importance among all the other gynec services to avoid upcoming population explosion.
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REVIEW ARTICLES: NURSING CARE Top

Nursing contribution to cope COVID -19 infection with courage and compassion p. 197
Usha Banerjee, Navaneetha Rathina, Ramesh Sarin
DOI:10.4103/am.am_82_20  
The advent of COVID-19 pandemic has suddenly changed the world and influenced the nursing profession as well. Nurses were among the first group of “COVID duty frontline warriors.” We briefly report the organization of services for the management of COVID affected or suspected patients at Indraprastha Apollo Hospital. The experiences of some of the nurses are described, highlighting their various problems when caring for these patients.
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REVIEW ARTICLES: COVID VACCINE Top

SARS CoV2 vaccine-present scenario p. 200
Ashok Dutta
DOI:10.4103/am.am_77_20  
SARS CoV2 virus is responsible for the pandemic of COVID-19 disease and has devastated the entire world. The COVID-19 disease has been responsible for huge number of morbidity and mortality in the world including India. Since there is no specific drug to cure this disease, research and development is going on to find a safe and effective vaccine to prevent the disease. According to the World Health Organization, there are 24 candidate vaccines which are in advance stages of development and 142 are in preclinical stages. There are various platforms in which this novel coronavirus vaccines are underdevelopment, for example, nonreplicating viral vector, RNA, DNA, inactivated, and subunit. In normal situation, it takes minimum 10-year time to develop a new vaccine from conception to first use in the market. In case of SARS CoV2 vaccine, all out efforts are made by all institutions and vaccine manufacturing companies with the help of respective regulatory authorities to reduce the time frame. In all probabilities, few vaccines would be developed in record time and expected to be in the market by the beginning of 2021. In India, there are six candidate vaccines which are in development and all are in various stages. There are several challenges during development and later once it becomes available for human use. This review is an attempt to briefly cover the present stages of development of various vaccines and the challenges that are likely to be encountered.
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REVIEW ARTICLES: TELEMEDICINE Top

Telemedicine and COVID-19 p. 205
K Ganapathy
DOI:10.4103/am.am_84_20  
The COVID-19 pandemic has within months turned the world upside down. SRS-COV-2 is making us look at how health-care services are being delivered, and how this needs to radically change. Every country is reporting an exponential increase in Telemedicine utilization, as fallout of the enormous stress on health-care systems globally. The notification of the Telemedicine Practice Guidelines by the Government of India has also contributed to the rapid adoption of Remote Health Care. This review focuses on deployment of Telehealth in the pandemic milieu, illustrating how a crisis is turning into an opportunity to provide remote health care. Necessity for “contactless” health care and physical distancing has led to acceptance of Telehealth by all stakeholders, from lingering in the periphery for two decades to center stage.
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Tele-intensive care unit networks: A viable means for augmenting critical care capacity in India for the COVID pandemic and beyond p. 209
Sai Praveen Haranath, Jai Ganesh Udayasankaran
DOI:10.4103/am.am_104_20  
The COVID-19 pandemic has enormously stressed global healthcare systems compelling new approaches to care, especially by leveraging telehealth. In India, the timely release of the Telemedicine Practice Guidelines by the Government has enabled health providers to deliver essential medical evaluation, diagnosis, and triage remotely. Patients with COVID-19 present with a range of symptoms, and some need intensive care. The management of critically ill patients is resource-intensive and requires partnership between humans and machines. Monitoring vital physiology is key to effective critical care. In many countries, including India, the distribution of intensivists is skewed and tends to be predominantly based in urban tertiary care hospitals. Hospitals without on-site intensivists may benefit from tele-intensive care unit (ICU) services wherein electronic systems connect ICU patient data with intensivists at remote locations as part of a collaborative network. The tele-intensivists provide real-time data and audiovisual monitoring, diagnostic, and intervention services and work together with bedside teams bridging the critical care gap. This article is a practical guide for the logistics of telemedicine-based critical care in India for patients with COVID-19 and other conditions. In addition, this paper also suggests methods to expedite care. Information is provided for immediate use by physicians who have not practiced telemedicine in the ICU. As the number of patients affected increases around India rapid deployment of tele-ICU services will be essential to save lives. Caregiver stress can be minimized by remote care providers who can assist at any time.
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COVID-19 and the role of telemedicine in delivering health care p. 217
Karthikeyan P Iyengar, Vijay Kumar Jain
DOI:10.4103/am.am_62_20  
As the COVID-19 pandemic spread across the world, there has been an urgent need to devise and identify new models of delivering care to the needy individuals to avoid “face-to-face” consultation between clinician and patient, thus reducing the risk of disease transmission. The medical community had to re-think and reconfigure a way it could deliver continuity of care to its patients during the pandemic. Information technologies such as telemedicine have traditionally been used in patient care supported by various digital platforms. However, telemedicine's development, application, and revolution have accelerated during the COVID-19 pandemic and are bound to play a significant part in the future delivery of health care when the pandemic stabilizes.
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REVIEW ARTICLES: TECHNOLOGY Top

Biosensors applications in fighting COVID-19 pandemic p. 221
Shashi Bahl, Mohd Javaid, Ashok Kumar Bagha, Ravi Pratap Singh, Abid Haleem, Raju Vaishya, Rajiv Suman
DOI:10.4103/am.am_56_20  
Biosensors can measure nonpolar molecules, which is not possible by other conventional devices. These sensors provide high specificity and fast response time. During COVID-19, this technology has helped to identify the symptoms of the viral infection. It measures the respiration rate, heart rate, temperature, and any movement in the real time for COVID-19 patients. During any changes in the symptoms of the patient, this technology rapidly contacts and advice to the health-care service provider. It helps to monitor infected patients without any risk of contamination easily. We have identified seven significant applications of the biosensors for the COVID-19 pandemic. Tests of the COVID-19 virus can be carried out effectively by employing these biosensors more appropriately and productively. This technology has completely changed and revolted the health-care world to perform its intended functions in an ongoing situation. In the future, biosensors can offer better treatment of the patients in an epidemic and pandemic, more productively and effectively.
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CASE REPORTS Top

Anesthetic management of a cesarean section in COVID-positive pregnant patient p. 224
Ashish Malik, Balaji Pallapotu
DOI:10.4103/am.am_61_20  
The novel coronavirus disease 2019 first emerged in Wuhan, China, and is now an emerging pandemic globally. This has strained health-care services leading to restrategizing anesthesia care and management of patients. We describe the anesthetic management of a 30-year-old COVID positive, multigravida, with term pregnancy taken up for elective cesarean section under the subarachnoid block in a dedicated operating room earmarked for COVID cases. For such a case, challenges in the modification of standard procedures to minimize exposure of the health-care professionals are delineated.
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COVID-Positive preterm neonate for emergency laparotomy: Anesthesia and management issues. p. 226
Chetan Mehra, Unaiza Khan, Sujit Kumar Chowdhary
DOI:10.4103/am.am_70_20  
Thirty weeks low-birth-weight preterm COVID-positive baby with anorectal malformation underwent emergency laparotomy in view of perforative peritonitis. Baby was assessed by a virtual telecommunication. Safety precautions were carried out for health-care workers during patient transit, aerosol-generating procedures, surgery, and postoperative care in COVID intensive care unit. Scarcity of evidence base for preterm neonates at that time made us design and efficiently conduct our own safety protocol. Interdepartmental team work was the key.
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A case of endogenous endophthalmitis in COVID- 19 pandemic p. 229
Sonam Verma, Jaydeep A Walinjkar
DOI:10.4103/am.am_71_20  
The home isolation from lockdown has limited the exchange of microflora in community. It benefits in limiting 2019 nCOV but collateral depletion in memory-based immunity has its own devastating consequences. It triggers subclinical infections, by reactivation of dormant pathogens or evolution of normal microflora into multidrug-resistant strains, which may escalate to endogenous infections. With the following case report, as a consequence of such unfortunate circumstances, we emphasize upon timely management of endophthalmitis, an ocular emergency, on promptly ruling out inflammatory etiologies, with modifications in protocol and due precautions as per the current COVID situation. The case demonstrates rapid response to acute endophthalmitis in a tertiary eye hospital with 24 h emergency services in a megacity amidst lockdown. The condition masqueraded as uveitis initially hence appropriate treatment got delayed by a week. Immediate aqueous sample collection for microbiological investigation and medical treatment with intravitreal injection antibiotics and steroid followed by intensive therapy with topical steroids and fortified drops aided in local delivery of drugs in better concentration than commercially available vials. Further surgical intervention, provided vitreous sample for microbial testing, debulked infection from vitreous. Growth of Enterobacter hormaechi was observed in vitreous sample, uncommon in endogenous endophthalmitis. Blood sample revealed drug-resistant Staphylococcus hominis. The patient regained vision successfully from mere perception of light to 6/60 within a few weeks. Such endogenous infections are highly alarming and necessitate urgent replacement of antibiotic abuse, over the counter treatments, approaching quacks, and fear of going to hospital with meticulous management by concerned specialists under updated protocols.
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LETTER TO EDITOR Top

Innovative “19 H of COVID-19” Management Protocol at a dedicated COVID-19 Hospital in Madhya Pradesh p. 233
Saurabh G Agarwal, Ajay Goenka, Krishnagopal Singh, Gyaneshwar Mishra, Rajkumar Patil
DOI:10.4103/am.am_86_20  
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Combating COVID-19 pandemic: The role of indian railways p. 235
Lalit Chandra Trivedi
DOI:10.4103/am.am_57_20  
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