Publications by authors named "Ashish Bhalla"

193 Publications

Pulmonary Function, Mental and Physical Health in Recovered COVID-19 Patients Requiring Invasive Versus Non-invasive Oxygen Therapy: A Prospective Follow-Up Study Post-ICU Discharge.

Cureus 2021 Sep 6;13(9):e17756. Epub 2021 Sep 6.

Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND.

Background Survivors of COVID-19 pneumonia may have residual lung injury and poor physical and mental health even after discharge. We hypothesized that COVID-19 severe acute respiratory distress syndrome (ARDS) patients needing mechanical ventilation may be at a greater risk of deterioration in pulmonary function, mental health, and quality of life (QOL). This study analyses the differences in pulmonary function, mental health, and QOL after recovery, in patients having received non-invasive oxygen therapy versus invasive mechanical ventilation during ICU stay. Methods Patients aged >18 years, who had completed 3 months post ICU discharge, with moderate to severe COVID-19 ARDS, were consecutively enrolled from May 1 to July 31, 2021. Patients were allocated into Group A - having required high flow nasal cannula (HFNC)/non-invasive ventilation (NIV) and Group B - having received invasive mechanical ventilation. Pulmonary function tests, 6-minute walk test (6-MWT), and health-related quality of life were compared. Results Of the 145 eligible patients, 31 were lost to follow-up and 21 died. Seventy-four patients were allocated into Groups A (57 patients) and B (17 patients). In Group A, abnormal forced expiratory volume in first second (FEV), forced vital capacity (FVC), forced expiratory flow in mid-half of FVC (FEF), and peak expiratory flow rate (PEFR) values were obtained in 27 (47.37%), 43 (75.44%), 11 (19.3%), and 25 (43.86%) patients, and in Group B, in 13 (76.47%), 17 (100%), 1 (5.88%), and 8 (47%) patients, respectively. No patient had abnormal FEV/FVC. All Group B patients had a restrictive pattern in spirometry as compared to 77% in Group A. Group B had a lower arterial partial pressure of oxygen (PaO) (p=0.0019), % predicted FVC (p<0.0001), % predicted FEV (p=0.001), and 6-MWT distance (p<0.001). The physical component score in the short-form survey 12 questionnaire was higher in group A, p<0.001, whereas the mental component score was comparable. Conclusions Patients requiring invasive mechanical ventilation (MV) have a greater risk of impaired pulmonary function and reduced QOL post-ICU discharge. This warrants a greater need for following these patients for better rehabilitation.
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http://dx.doi.org/10.7759/cureus.17756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8493858PMC
September 2021

Acute febrile illness with choreoathetosis: a rare presentation of brucellosis.

Postgrad Med J 2021 Sep 8. Epub 2021 Sep 8.

Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1136/postgradmedj-2021-140351DOI Listing
September 2021

Fatigue, perceived stigma, self-reported cognitive deficits and psychological morbidity in patients recovered from COVID-19 infection.

Asian J Psychiatr 2021 Oct 21;64:102815. Epub 2021 Aug 21.

Department of Anaesthesia & Critical Care, Post Graduate Institute of Medical, Education and Research, Chandigarh, 160012, India.

Background: Few studies have highlighted multiple psychosocial and physical outcomes in patients with COVID-19 infection after recovery. However, the data from developing countries is limited.

Aim: To evaluate psychological morbidity, post-traumatic stress disorder (PTSD), fatigue, and perceived stigma among patients with COVID-19 after recovery from the acute phase of COVID-19 infection.

Methods: In a cross-sectional online survey, 206 adult patients (age>18 years), recovered from COVID-19 infection completed the Patient Health Questionnaire-4 (PHQ-4), the Impact of Events Scale-Revised (IES-R), Fatigue Severity Scale (FSS), 4 items self-designed questionnaire evaluating cognitive deficits and self-designed questionnaire to evaluate perceived stigma. Additionally, they completed the information about demographic and clinical information.

Results: The prevalence of anxiety, depressive symptoms, and PTSD in the study sample was 24.8 %, 23.8 %, and 30 % respectively. About three-fifths of the participants (61.2 %) had at least one fatigue symptom as per the FSS with the mean FSS score being 32.10 ± 15.28. About one-fourth of the participants (23.7 %) reported "feeling confused and always feeling mentally foggy", and 38 % of patients reported experiencing at least one cognitive problem. The level of felt stigma related to self was seen in 31.1 %, 20 % reported stigma related to family, and 50 % reported stigma in relation to neighbors and society. Those reporting higher PTSD scores had higher anxiety and depressive scores, reported more fatigue and stigma, and had a higher level of cognitive deficits. A higher fatigue score was also associated with higher anxiety, depression, and cognitive deficits.

Conclusions: Our study reveals that a significant proportion of patients after recovery from COVID-19 experience psychological morbidities, fatigue, cognitive problems, and stigma. Efforts should be made to take care of these issues in routine post-COVID follow-up care.
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http://dx.doi.org/10.1016/j.ajp.2021.102815DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8379818PMC
October 2021

The clinical association between Periodontitis and COVID-19.

Clin Oral Investig 2021 Aug 27. Epub 2021 Aug 27.

Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Objectives: The study aimed to clinically assess the association between periodontitis and COVID-19-related outcomes.

Material And Methods: Data pertaining to patient demographics, medical history, blood parameters, periodontal clinical examination and aMMP-8 point-of-care diagnostics (both site-level and patient-level) was recorded for eighty-two COVID-19-positive patients. COVID-19-related outcomes such as COVID-19 pneumonia, death/survival, types of hospital admission and need of assisted ventilation were also assessed.

Results: Males were predominantly afflicted with COVID-19, with advanced age exhibiting a greater association with the presence of periodontitis. Higher severity of periodontitis led to 7.45 odds of requiring assisted ventilation, 36.52 odds of hospital admission, 14.58 odds of being deceased and 4.42 odds of COVID-19-related pneumonia. The aMMP-8 mouthrinse kit was slightly more sensitive but less specific than aMMP-8 site-specific tests.

Conclusions: Based on the findings of the present study, periodontitis seems to be related to poorer COVID-19-related outcomes. However, within the constraints of this work, a direct causality may not be established. Periodontitis, by means of skewing the systemic condition for a number of comorbidities, may eventually influence COVID-19 outcomes in an indirect manner.

Clinical Relevance: The study is the first to clinically, and by means of a validated point-of-care diagnostic methodology, assess the association between periodontal health and COVID-19-related outcomes. Assessment of the periodontal status of individuals can aid in the identification of risk groups during the pandemic along with reinforcing the need to maintain oral hygiene and seeking periodontal care.
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http://dx.doi.org/10.1007/s00784-021-04111-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8390180PMC
August 2021

Evaluation of a First Responders Course in Rural North India.

J Surg Res 2021 Aug 23;268:485-490. Epub 2021 Aug 23.

Department of Surgery, Northwestern University, Chicago, Illinois; Sadanah Foundation, Chicago, Illinois.

Background: Most mortality in trauma occurs in prehospital settings when the golden hour is spent accessing healthcare facilities rather than resuscitating and stabilizing. Assessments performed in the rural community of Nanakpur, India demonstrated a significant paucity of, and limited access to healthcare facilities. To address deficiencies in prehospital care, the All-India Institute of Medical Sciences (AIIMS) constructed the Basic Emergency Care Course (BECC). This study evaluated the BECCs efficacy in Nanakpur.

Methods: The first responder courses took place in 2017 in Nanakpur. Local community health workers, known as Accredited Social Health Activists (ASHAs) were recruited as participants. Participants completed both a pre- and post-course evaluation to assess baseline knowledge and improvement. Participants then took a one-year post-course assessment to evaluate retention.

Results: The course included 204 individuals, and over half (109/204) were ASHAs. Pre- and post-course test results were available for 70 participants and demonstrated a significant improvement in knowledge (P < 0.0001). The one-year knowledge retention assessment was completed by 48.6% (n = 53/109) of the original ASHAs. Comparisons between both the pre- and post-course assessment tests with the 12-mo retention assessment revealed a significant decay in knowledge (P < 0.0001).

Conclusions: This study demonstrates the feasibility of utilizing BECC to train ASHAs in Nanakpur as first responders. Participants demonstrated a significant improvement in knowledge immediately after the course. After one year, there was a significant loss in knowledge, highlighting the need for refresher courses. These data suggest potential for the use of BECC for training ASHAs countrywide to strengthen India's prehospital care system.
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http://dx.doi.org/10.1016/j.jss.2021.07.023DOI Listing
August 2021

Clinical spectrum and outcomes of geriatric tuberculosis emergencies in North India.

Turk J Emerg Med 2021 Jul-Sep;21(3):91-97. Epub 2021 Jul 7.

Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Chandigarh, India.

Objectives: Despite the acute and life-threatening repercussions that tuberculosis (TB) may have on the burgeoning older population in endemic countries like India, the spectrum of geriatric TB emergencies is not adequately understood.

Methods: We performed a prospective observational study at the emergency department of an academic hospital in north India between January 2019 and June 2020, investigating the clinical and laboratory features and outcomes of active TB in older patients aged 60 years and above.

Results: Out of 71 geriatric TB emergencies, central nervous system disease predominated ( = 41, 57.7%), followed by pulmonary ( = 16, 22.5%), pleural TB ( = 8, 11.3%), and multisite involvement ( = 6, 8.4%). Nearly 71.8% were male, and 77.4% belonged to low socioeconomic status (lower-middle or lower class). Usual predisposing factors were tobacco smoking (38.0%), chronic alcohol use (27.0%), and diabetes mellitus (23.9%). Atypical features were more frequent with extrapulmonary TB. Only 28.2% were microbiologically confirmed cases, and rifampicin resistance was seen in only one case. The mortality rate was considerably high (24.0%), highest with pulmonary TB (37.0%).

Conclusion: Older patients with TB emergencies have atypical presentations, diagnostic difficulties, and high mortality.
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http://dx.doi.org/10.4103/2452-2473.320800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8330606PMC
July 2021

Containment of varicella outbreak in intensive care unit of a tertiary level hospital.

J Anaesthesiol Clin Pharmacol 2021 Apr-Jun;37(2):279-283. Epub 2021 Jul 15.

Department of Anaesthesia, PGIMER, Chandigarh, India.

Background: Varicella-Zoster virus (VZV) infection in healthcare organizations, especially in intensive care units (ICU), having admitted immunocompromised patients, is of serious concern as well as poses threat to healthcare workers working in such critical areas. The present report defines the transmission and infection control measures initiated to curtail VZV infection spread in the trauma ICU of a tertiary care hospital of North India.

Outbreak Report: At the infection outset, there were 12 patients admitted in ICU and 54 healthcare workers were posted to manage these critical patients. After confirmation of VZV infection, all susceptible patients as well as healthcare workers were quarantined and fresh intake of patients was restricted. Out of the total healthcare workers, 14 (25.92%) were found susceptible (as per protective VZV IgG titers) and were vaccinated. Of the 12 patients admitted in the ICU, six patients were discharged and sent home directly, four patients expired due to their critical disease state, one patient left against medical advice, and one patient remained admitted in ICU till the incubation period was over. Epidemiologically, line listing for index case reporting was done. The efficacy of control measures was re-evaluated to strengthen existing infection control practices and general measures viz. strict hand washing, adherence to aseptic protocols and intensification of environmental cleaning.

Conclusions: Established varicella surveillance measures ensure VZV outbreaks are identified in a timely manner and control measures implemented to prevent further transmission. Also, vaccination policy among HCWs is the utmost requirement despite having huge financial implications.
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http://dx.doi.org/10.4103/joacp.JOACP_542_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289633PMC
July 2021

Tropical Infections in Returning Travelers.

Indian J Crit Care Med 2021 May;25(Suppl 2):S175-S183

Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

In the modern era, the relative ease and faster speed of travel have made the world a global village. An increasing number of people are traveling to distant and sometimes exotic locations for vacation/leisure or at times for business purposes. Along with the experiences of far-fetched lands, sometimes they bring bugs/organisms that are not native to their motherland. This makes the diagnosis and management of illnesses in a traveler challenging. In this review, we have tried to outline a management protocol for travelers returning with fever, with specific emphasis on trypanosomiasis and schistosomiasis. Suri V, Bhalla A. Tropical Infections in Returning Travelers. Indian J Crit Care Med 2021;25(Suppl 2):S175-S183.
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http://dx.doi.org/10.5005/jp-journals-10071-23873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8327792PMC
May 2021

Rapid antigen detection kit for the diagnosis of SARS-CoV-2 - are we missing asymptomatic patients?

Indian J Med Microbiol 2021 Jul 19. Epub 2021 Jul 19.

Department of Virology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India. Electronic address:

Purpose: To determine the utility, diagnostic accuracy, sensitivity, specificity, and negative predictive value of the laboratory based Covid-19 antigen detection test (Coris Bio- Concept, Gembloux, Belgium) for the diagnosis of SARS-CoV-2 in a tertiary care hospital among symptomatic and asymptomatic patients.

Methods: The nasopharyngeal swab samples were collected from the symptomatic patients and their contacts. The diagnostic accuracy of this antigen kit was determined in comparison to SARS-CoV-2 real-time reverse transcriptase (RT-PCR).

Results: A total of 825 patients fulfilling the inclusion criteria were included in the study; RT-PCR and antigen detection was performed simultaneously for 484 samples to determine the sensitivity and specificity of the test. The overall specificity and sensitivity was 99.32% and 71.96% respectively. Also, 3.7% of the asymptomatic patients who were negative by RAT were detected positive by RT-PCR.

Conclusion: This rapid antigen test (RAT) was sensitive in the symptomatic patients presenting during the initial phase of the illness. Since, majority of the SARS-CoV-2 patients are asymptomatic and considering the huge population, the testing strategy formulated by Indian Council of Medical Research (ICMR) at the national level was cost effective. Thus, Ag-RDTs could play a pivotal role in early diagnosis, policy making and surveillance of the SARS-CoV-2.
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http://dx.doi.org/10.1016/j.ijmmb.2021.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289730PMC
July 2021

Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review.

BMC Public Health 2021 07 22;21(1):1441. Epub 2021 Jul 22.

Centre for Pesticide Suicide Prevention, and Pharmacology, Toxicology & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.

Background: Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years.

Methods: We performed a systematic literature review in Medline, Embase and Google Scholar (1999-2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study.

Results: We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999-2003), the number of deaths declining thereafter (to n = 1714 in 2014-2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths.

Conclusion: Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter's lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions.
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http://dx.doi.org/10.1186/s12889-021-11156-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8296580PMC
July 2021

Can being a 'frontline doctor' in the COVID-19 pandemic be a positive experience?

Asian J Psychiatr 2021 09 13;63:102769. Epub 2021 Jul 13.

Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India. Electronic address:

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http://dx.doi.org/10.1016/j.ajp.2021.102769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276562PMC
September 2021

Retinal Involvement in COVID-19: Results From a Prospective Retina Screening Program in the Acute and Convalescent Phase.

Front Med (Lausanne) 2021 24;8:681942. Epub 2021 Jun 24.

Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

To detect retinal involvement in coronavirus disease 2019 (COVID-19) patients in acute and convalescent phase by their fundus screening. In a prospective, cross-sectional, observational study (July-November 2020), 235 patients (142 acute and 93 convalescent phase) underwent fundus screening in a tertiary care center in North India. For convalescent phase, "hospitalized" patients (73) were screened at least 2 weeks after hospital discharge, and "home-isolated" patients (20) were screened 17 days after symptom onset/COVID-19 testing. None in acute phase showed any retinal lesion that could be attributed exclusively to COVID-19. Five patients (5.38%) in convalescent phase had cotton wool spots (CWSs) with/without retinal hemorrhage, with no other retinal finding, and no visual symptoms, seen at a median of 30 days from COVID-19 diagnosis. CWSs (and retinal hemorrhages) were an incidental finding in COVID-19, detected only in the convalescent phase. These patients were much older (median age = 69 years) than the average age of our sample and had systemic comorbidities (diabetes mellitus, hypertension, etc.). We propose the term "COVID-19 retinopathy" to denote the presence of CWSs at the posterior pole, occasionally associated with intraretinal hemorrhages, in the absence of ocular inflammation in patients with a history of COVID-19 disease.
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http://dx.doi.org/10.3389/fmed.2021.681942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8264127PMC
June 2021

The Conundrum of 'Long-COVID-19': A Narrative Review.

Int J Gen Med 2021 14;14:2491-2506. Epub 2021 Jun 14.

Department of Radiodiagnosis & Imaging, PGIMER, Chandigarh, India.

COVID-19 is an ongoing pandemic with many challenges that are now extending to its intriguing long-term sequel. 'Long-COVID-19' is a term given to the lingering or protracted illness that patients of COVID-19 continue to experience even in their post-recovery phase. It is also being called 'post-acute COVID-19', 'ongoing symptomatic COVID-19', 'chronic COVID-19', 'post COVID-19 syndrome', and 'long-haul COVID-19'. Fatigue, dyspnea, cough, headache, brain fog, anosmia, and dysgeusia are common symptoms seen in Long-COVID-19, but more varied and debilitating injuries involving pulmonary, cardiovascular, cutaneous, musculoskeletal and neuropsychiatric systems are also being reported. With the data on Long-COVID-19 still emerging, the present review aims to highlight its epidemiology, protean clinical manifestations, risk predictors, and management strategies. With the re-emergence of new waves of SARS-CoV-2 infection, Long-COVID-19 is expected to produce another public health crisis on the heels of current pandemic. Thus, it becomes imperative to emphasize this condition and disseminate its awareness to medical professionals, patients, the public, and policymakers alike to prepare and augment health care facilities for continued surveillance of these patients. Further research comprising cataloging of symptoms, longer-ranging observational studies, and clinical trials are necessary to evaluate long-term consequences of COVID-19, and it warrants setting-up of dedicated, post-COVID care, multi-disciplinary clinics, and rehabilitation centers.
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http://dx.doi.org/10.2147/IJGM.S316708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214209PMC
June 2021

Cardiac injury in organophosphate poisoning after acute ingestion.

Toxicol Res (Camb) 2021 May 26;10(3):446-452. Epub 2021 Apr 26.

Department of Cardiology, Postgraduate Institute of Medical Education and Research, 3rd Floor, Block - C, Advanced Cardiac Center, PGIMER, Chandigarh 160012, India.

Introduction: Sparse data and conflicting evidence exist on the prevalence and prognosis of organophosphate (OP)-related cardiac toxicity. We aimed to characterize the cardiac abnormalities of OP after an acute cholinergic crisis in adults without previous cardiovascular conditions.

Patients And Methods: We did a prospective observational study in a tertiary-care hospital of north India (Postgraduate Institute of Medical Education and Research, Chandigarh) in 74 patients aged ≥ 13 years admitted with acute OP poisoning after self-ingestion. A systemic evaluation, including clinical characteristics, electrocardiography, and echocardiography, was performed to estimate the prevalence and prognosis of cardiac injury. A rate-corrected QT interval was calculated using Bazett's method, and >440 milliseconds was used to define prolongation.

Results: Chlorpyrifos was the most commonly ingested OP ( = 29). The patients had a similar occurrence of hypotension ( = 10) and hypertension ( = 9) at admission, and electrocardiography demonstrated sinus tachycardia in 38 (51.3%) and sinus bradycardia in one case. During the hospital stay, 3 out of 74 patients had a prolonged rate-corrected QT interval (457, 468, and 461 milliseconds), and one patient developed supraventricular tachycardia. Eight (10.8%) patients developed the intermediate syndrome, and six (8.1%) died. None of the hemodynamic or electrocardiographic abnormalities was associated with in-hospital mortality or intermediate syndrome development on univariant analysis. Baseline echocardiography at hospital discharge was performed in 27 patients (admitted during 2018) and normal in all except mild tricuspid regurgitation in one. At a 6-month follow-up, 23 cases were available for cardiovascular screening (including echocardiography) and had a normal evaluation.

Conclusion: Cardiac toxicity is uncommon after acute OP self-ingestion and lacks prognostic significance.
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http://dx.doi.org/10.1093/toxres/tfab036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8201560PMC
May 2021

Absence of SARS-CoV-2 infection in the semen of men recovering from COVID-19 infection: An exploratory study and review of literature.

Andrologia 2021 Sep 11;53(8):e14136. Epub 2021 Jun 11.

Department of Urology, PGIMER, Chandigarh, India.

The effect of COVID-19 on the male reproductive tract has been sparsely studied. This exploratory study was designed to determine the presence of SARS-CoV-2 in the semen of men recovering from COVID-19. A systematic literature review was also performed as per PRISMA guidelines to gather perspective on this topic. The prospective study included men 21 years and older recovering from COVID-19 with nasopharyngeal swab negative for SARS-CoV-2 or at least two weeks from the last COVID RT-PCR positivity. After clinical evaluation, freshly ejaculated semen sample by masturbation was collected in a sterile container. Samples were processed for the detection of SARS-CoV-2 by RT-PCR. Twenty-one patients were contacted for the study, 11 of which consented to provide a semen sample. The mean age of the cohort was 29.72 ± 4.52 years. None of the patients gave a history of epididymo-orchitis or sexual dysfunction at the time of assessment. None of the semen samples demonstrated SARS-CoV-2 on RT-PCR. Median duration of semen sample collection from the COVID positivity was 44 days (Range 19-59 days). Detailed literature review revealed that SARS-CoV-2 is not found in patients recovering from COVID-19 infection. We conclude that SARS-CoV-2 is not found in the semen of patients recovering from COVID-19.
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http://dx.doi.org/10.1111/and.14136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420368PMC
September 2021

Tuberculous meningitis in the elderly.

QJM 2021 Jun 8. Epub 2021 Jun 8.

Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh (India).

Objective: Although the elderly population remains at high risk for tuberculosis, studies addressing tuberculous meningitis (TBM) in this age group are scarce. The present study aimed to evaluate the spectrum and outcome of geriatric TBM and document differences between older and young patients.

Methods: A prospective cohort study was conducted in the adult TBM patients admitted at PGIMER, Chandigarh (India). Consecutive older patients aged 60 years and above were enrolled from January 2019 to December 2020, and young adults aged 18-59 years were enrolled from July 2019 to December 2019.

Results: Fifty-five older patients with a mean age of 66.6 years and 73 young patients with a mean age of 35.1 years were enrolled. At admission, older patients were more likely to have altered mental status (96.4% versus 78.1%, P- 0.003) and advanced disease with British medical research council staging 2 or 3 (98.2% versus 89.0%, P- 0.043); however, headache (38.2% versus 67.1%, P- 0.001), vomiting (18.2% versus 35.6%, P- 0.030) and fever (80.0% versus 91.8%, P- 0.052) were less common. Cerebrospinal fluid abnormalities were less marked in older patients, with a significant difference in median total cells (70/μL versus 110/μL, P- 0.013). Hydrocephalous and infarct were common neuroimaging abnormalities in both groups; however, tuberculomas were significantly less in the elderly (15.1% versus 35.2%, P- 0.012). Older patients had a significantly low survival rate (56.4% versus 76.7%, P-0.021).

Conclusion: Significant differences in clinical, cerebrospinal fluid and radiological characteristics exist between elderly and young TBM patients, with survival remains dismal in the elderly.
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http://dx.doi.org/10.1093/qjmed/hcab162DOI Listing
June 2021

Buccal swabs as non-invasive specimens for detection of severe acute respiratory syndrome coronavirus-2.

J Int Med Res 2021 May;49(5):3000605211016996

Department of Virology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.

Introduction: The current gold standard for detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) RNA involves subjecting nasopharyngeal or oropharyngeal swabs to reverse transcription quantitative PCR (RT-qPCR). However, both sample types need to be collected by trained professionals. Using self-collected buccal swabs as an alternative could simplify and accelerate diagnosis of coronavirus disease 2019 (COVID-19).

Objective: To assess self-collected buccal swab samples as an alternative method for SARS-CoV-2 detection in patients with COVID-19.

Methods: Buccal swab samples were self-collected by 73 patients with COVID-19. Total RNA was extracted using Qiagen kits. RNA encoding the SARS-CoV-2 Env protein and human RNase P as an internal control was amplified using the TRUPCR SARS-CoV-2 RT-qPCR kit version 2.1 and a Bio-Rad CFX96 Real-Time Detection System.

Result: The sensitivity of RT-qPCR from buccal swabs was 58.9% (43/73; 95% confidence interval [CI] 46.77%-70.27%) and that of RT-qPCR from saliva was 62.90% (39/62; 95% CI 49.69%-74.84%) taking positive SARS-CoV-2 RT-qPCR from nasopharyngeal swabs as the gold standard.

Conclusion: Self-collected buccal swabs are promising alternatives to nasopharyngeal or oropharyngeal swabs for SARS CoV-2 detection.
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http://dx.doi.org/10.1177/03000605211016996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142533PMC
May 2021

A rare case of lung abscess due to esophageo-pulmonary fistula in asymptomatic carcinoma of esophagus.

Monaldi Arch Chest Dis 2021 May 17. Epub 2021 May 17.

Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh .

Acquired esophago-respiratory fistulae are usually esophago-tracheal or esophago-bronchial. Esophago-pulmonary fistulae are rare. Most patients present with cardinal symptoms of esophageal carcinoma or esophago-pulmonary fistula leading to early diagnosis. We report a 56-year-old female with an unusual presentation. She presented with high grade fever with chills and rigor, cough with mucopurulent expectoration and shortness of breath for 15 days without dysphagia, nausea, vomiting or chest pain. Clinically and radiologically a diagnosis of lung abscess was entertained and she was treated with multiple antibiotics without any improvement. Contrast Enhanced Computed Tomography (CECT) chest revealed esophageal malignancy with esophageal-pulmonary fistula communicating with abscess cavity. Patient responded to palliation with self-expandable esophageal stent and drainage of abscess. Although rare, asymptomatic malignant esophageal disease should be considered in the differential diagnosis of lung abscess, which does not follow a usual course. Keywords: Lung abscess, Esophageal cancer, Esophageo-pulmonary fistula, Self expandable metallic stent.
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http://dx.doi.org/10.4081/monaldi.2021.1815DOI Listing
May 2021

COVID-19 infection in a HIV positive health care worker: first case report from a tertiary care hospital of North India.

Virusdisease 2021 Apr 7:1-5. Epub 2021 Apr 7.

Department of Internal Medicine, PGIMER, Chandigarh, India.

People living with Human Immunodeficiency Virus (PLHIV) are at greater risk of developing prolonged illness due to COVID 19 leading to longer duration of virus shedding owing to their underlying immune defects. The present study compared SARS-CoV-2 infection developing at the same time among two health care workers living with and without a history of HIV and working in the same ward of a tertiary care hospital of North India. A higher viral load was reported in the SARS-CoV-2 infected worker who was immunocompromised as compared to immunocompetent patient (19,193 copies/µL vs 9.4 copies/µL). In this preliminary case report, no difference was observed in the clinical presentation of both patients at the time of diagnosis. Further studies are required to investigate the COVID-19 susceptibility and severity among HIV-infected patients.
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http://dx.doi.org/10.1007/s13337-021-00657-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8024933PMC
April 2021

Demographic & clinical profile of patients with COVID-19 at a tertiary care hospital in north India.

Indian J Med Res 2021 Jan & Feb;153(1 & 2):115-125

Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India.

Background & Objectives: The COVID-19 pandemic emerged as a major public health emergency affecting the healthcare services all over the world. It is essential to analyze the epidemiological and clinical characteristics of patients with COVID-19 in different parts of our country. This study highlights clinical experience in managing patients with COVID-19 at a tertiary care centre in northern India.

Methods: Clinical characteristics and outcomes of consecutive adults patients admitted to a tertiary care hospital at Chandigarh, India, from April 1 to May 25, 2020 were studied. The diagnosis of SARS-CoV-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) on throat and/or nasopharyngeal swabs. All patients were managed according to the institute's consensus protocol and in accordance with Indian Council of Medical Research guidelines.

Results: During the study period, 114 patients with SARS-CoV-2 infection were admitted. The history of contact with COVID-19-affected individuals was available in 75 (65.8%) patients. The median age of the patients was 33.5 yr (13-79 yr), and there were 66 (58%) males. Of the total enrolled patients, 48 (42%) were symptomatic. The common presenting complaints were fever (37, 77%), cough (26, 54%) and shortness of breath (10, 20.8%). Nineteen (17%) patients had hypoxia (SpO<94%) at presentation and 36 (31%) had tachypnoea (RR >24). Thirty four (29.8%) patients had an accompanying comorbid illness. Age more than 60 yr and presence of diabetes and hypertension were significantly associated with severe COVID-19 disease. Admission to the intensive care unit (ICU) was needed in 18 patients (52%), with three (2.6%) patients requiring assisted ventilation. Mortality of 2.6 per cent (3 patients) was observed.

Interpretation & Conclusions: Majority of the patients with COVID-19 infection presenting to our hospital were young and asymptomatic. Fever was noted only in three-fourth of the patients and respiratory symptoms in half of them. Patients with comorbidities were more vulnerable to complications. Triaged classification of patients and protocol-based treatment resulted in good outcomes and low case fatality.
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http://dx.doi.org/10.4103/ijmr.IJMR_2311_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184067PMC
April 2021

System for administering and monitoring hydroxychloroquine prophylaxis for COVID-19 in accordance with a national advisory: preliminary experience of a tertiary care institute in India.

Expert Rev Anti Infect Ther 2021 Oct 15;19(10):1331-1339. Epub 2021 Apr 15.

Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Background: Hydroxychloroquine (HCQ) was one of the earliest drugs to be recommended for tackling the COVID-19 threat leading to its widespread usage. We provide preliminary findings of the system, established in a tertiary care academic center for the administration of HCQ prophylaxis to healthcare workers (HCW) based on Indian Council of Medical Research (ICMR) advisory.

Methods: A dedicated clinical pharmacology and internal medicine team screened for contraindications, administered informed consent, maintained compliance and monitored for adverse events.

Results: Among the 194 HCWs screened for ruling out contraindications for prophylaxis, 9 were excluded and 185 were initiated on HCQ. A total of 55 adverse events were seen in 38 (20.5%) HCWs out of which 70.9%, 29.1% were mild and moderate & none were severe. Before the completion of therapy, a total of 23 participants discontinued. Change in QTc interval on day 2 was 5 (IQR: -3.75, 11) ms and the end of week 1 was 15 ms (IQR: 2, 18). Out of the 5 HCW who turned positive for COVID-19, 2 were on HCQ.

Conclusion: HCQ prophylaxis was found to be safe and well tolerated in HCW when administered after appropriate screening and with monitoring for adverse events.
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http://dx.doi.org/10.1080/14787210.2021.1909476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054489PMC
October 2021

Assessment of Potential Risk Factors for 2019-Novel Coronavirus (2019-nCov) Infection among Health Care Workers in a Tertiary Care Hospital, North India.

J Prim Care Community Health 2021 Jan-Dec;12:21501327211002099

PGIMER, Chandigarh, India.

Introduction: Health care workers (HCWs) are at the forefront to fight against COVID-19 pandemic. They are at more risk of contracting the infection. This study was planned to assess potential risk factors of 2019-novel coronavirus infection among HCWs working in a health facility and to evaluate the effectiveness of infection prevention and control measures among them.

Methods: A study was conducted in a tertiary care hospital among HCWs who were directly or indirectly involved in the management of a confirmed or suspected case of COVID-19. The socio-demographic characteristics, history of exposure, IPC measures followed and clinical symptoms were compared between health care workers in COVID and non-COVID areas.

Results: Majority (45%) of HCWs were nurses, followed by hospital/sanitary/technical attendants (30%) and doctors (24%). Out of a total of 256 HCWs, 2% tested positive. Around 80% of HCWs had ever attended any IPC training. A statistically significant association was found between posting area of HCWs and their exposure to COVID patients (duration of exposure, PPE has worn by HCWs, direct contact of HCWs with the patient's material) and COVID positivity ( value <.001).

Conclusion: If health care workers were trained and take adequate precautions then the risk of getting an infection is minimized.
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http://dx.doi.org/10.1177/21501327211002099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968012PMC
March 2021

Rare case of red tears: ocular vicarious menstruation.

BMJ Case Rep 2021 Mar 9;14(3). Epub 2021 Mar 9.

Internal Medicine, PGIMER, Chandigarh, Chandigarh, India.

Bloody tears or haemolacria is a rare clinical entity. It is caused by various ocular and systemic conditions. Haemolacria due to vicarious menstruation is even rarer. In this article, we presented a case of cyclical episodes of bloody tears coinciding with menstrual cycle in a 25-year-old married female patient. Extensive physical, ophthalmological and radiological evaluation failed to reveal other potential causes of her complaint. A diagnosis of ocular vicarious menstruation was made and she was treated with oral contraceptive pills. No such episode recurred during 3 months follow-up period.
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http://dx.doi.org/10.1136/bcr-2020-237294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945043PMC
March 2021

Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.

BMJ Open 2021 02 22;11(2):e043837. Epub 2021 Feb 22.

Department of Hospital Administration, PGIMER, Chandigarh, India.

Objectives: Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty.

Setting: Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless.

Participants: We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone.

Results: Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment.

Conclusion: A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic.
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http://dx.doi.org/10.1136/bmjopen-2020-043837DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902325PMC
February 2021

Surgical and Trauma Capacity Assessment in Rural Haryana, India.

Ann Glob Health 2021 02 12;87(1):15. Epub 2021 Feb 12.

Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, USA.

Background: Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified.

Objective: The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools.

Methods: The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively.

Findings: Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures.

Conclusions: Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India.
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http://dx.doi.org/10.5334/aogh.3173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879992PMC
February 2021

Cost concerns, not the guidelines, drive clinical care of IBD during COVID pandemic in a resource limited setting.

Expert Rev Gastroenterol Hepatol 2021 Apr 19;15(4):465-466. Epub 2021 Feb 19.

Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1080/17474124.2021.1890583DOI Listing
April 2021

Relationship of substance dependence and time to RT-PCR negative status in patients with COVID-19 infection.

Asian J Psychiatr 2021 Mar 21;57:102562. Epub 2021 Jan 21.

Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India. Electronic address:

Background: To date, no study has evaluated the association of alcohol dependence with the outcome of the COVID-19 infection.

Aim: The current study aimed to evaluate the association of substance dependence (alcohol and tobacco) with the outcome (i.e., time to have two consecutive negative test reports) of the COVID-19 infection.

Results: The mean age of the study participants (n = 95) was 37.2 yrs (SD-13.2). More than half of the participants were males. About one-fourth (N = 25; 26.3 %) were consuming various substances in a dependent pattern. Alcohol dependence was present in 21 participants (22.1 %), and Tobacco dependence was present in 10.5 % of participants. Even after using gender, age, and physical illness as covariates, patients with any kind of substance dependence had a significantly lower chance of having a negative report on RT-PCR on 14th day, 18th 23rd day.

Conclusion: Persons with substance dependence takes a longer time to test negative on RT-PCR, once diagnosed with COVID-19 infection. Mental health professionals involved in the care of patients with COVID-19 should accordingly prepare these patients for a possible longer hospital stay to reduce the distress associated with prolongation of hospital stay.
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http://dx.doi.org/10.1016/j.ajp.2021.102562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825882PMC
March 2021

Some reflections on vaccine research ethics during COVID-19 pandemic.

Postgrad Med J 2021 Feb 9. Epub 2021 Feb 9.

Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

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http://dx.doi.org/10.1136/postgradmedj-2020-139145DOI Listing
February 2021

Coronavirus Disease (Covid-19) Associated Mucormycosis (CAM): Case Report and Systematic Review of Literature.

Mycopathologia 2021 May 5;186(2):289-298. Epub 2021 Feb 5.

Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India.

Severe coronavirus disease (COVID-19) is currently managed with systemic glucocorticoids. Opportunistic fungal infections are of concern in such patients. While COVID-19 associated pulmonary aspergillosis is increasingly recognized, mucormycosis is rare. We describe a case of probable pulmonary mucormycosis in a 55-year-old man with diabetes, end-stage kidney disease, and COVID-19. The index case was diagnosed with pulmonary mucormycosis 21 days following admission for severe COVID-19. He received 5 g of liposomal amphotericin B and was discharged after 54 days from the hospital. We also performed a systematic review of the literature and identified seven additional cases of COVID-19 associated mucormycosis (CAM). Of the eight cases included in our review, diabetes mellitus was the most common risk factor. Three subjects had no risk factor other than glucocorticoids for COVID-19. Mucormycosis usually developed 10-14 days after hospitalization. All except the index case died. In two subjects, CAM was diagnosed postmortem. Mucormycosis is an uncommon but serious infection that complicates the course of severe COVID-19. Subjects with diabetes mellitus and multiple risk factors may be at a higher risk for developing mucormycosis. Concurrent glucocorticoid therapy probably heightens the risk of mucormycosis. A high index of suspicion and aggressive management is required to improve outcomes.
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http://dx.doi.org/10.1007/s11046-021-00528-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862973PMC
May 2021

Psychological Morbidity among People in Quarantine.

J Neurosci Rural Pract 2021 Jan 29;12(1):67-70. Epub 2021 Jan 29.

Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, India.

 This study aimed to evaluate psychological distress of persons in quarantine and compare the same with a group of persons, who are currently in lockdown.  Forty-four persons in quarantine and 45 subjects currently in lockdown were evaluated on Depression Anxiety Stress Scale II.  About three-fourth (77.3%) of the participants in the quarantine group and one-third (37.8%) in the comparator group had depression. About one fourth (22.7%) in the quarantine group and one-third (35.6%) in the lockdown group had anxiety.  The present study suggests that lockdown and being in quarantine are associated with significantly higher psychiatric morbidity, especially anxiety.
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http://dx.doi.org/10.1055/s-0040-1718855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846334PMC
January 2021
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