Almost all bio-statisticians and medical researchers believe that a large sample is always helpful in providing more reliable results. Whereas this is true for some specific cases, a large sample may not be helpful in more situations than we contemplate because of the higher possibility of errors and reduced validity. Many medical breakthroughs have occurred with self-experimentation and single experiments. Studies, particularly analytical studies, may provide more truthful results with a small sample because intensive efforts can be made to control all the confounders, wherever they operate, and sophisticated equipment can be used to obtain more accurate data. A large sample may be required only for the studies with highly variable outcomes, where an estimate of the effect size with high precision is required, or when the effect size to be detected is small. This communication underscores the importance of small samples in reaching a valid conclusion in certain situations and describes the situations where a large sample is not only unnecessary but may even compromise the validity by not being able to exercise full care in the assessments. What sample size is small depends on the context.

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Donor-type aplasia (DTA) is a condition where an individual continues to be aplastic even after a successful engraftment of a hematopoeitic stem cell transplant with a majority of donor type cells in the bone marrow. This entity has been seen with varying frequency around the world, especially in Southeast Asia. However, its incidence in the Indian subcontinent remains fairly low. Here is a case of a 17-year-old child with DTA who had a 89% population of donor cells after a successful transplant and presented with recurrent severe aplastic anemia later. The patient eventually succumbed to his condition before a second transplant could be performed. The awareness about the seriousness of this relatively rare condition, therefore, needs to be emphasized.

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Objective: In India, about one third of tuberculosis (TB) patients diagnosed at tertiary hospitals are missed during a referral to peripheral health institutes for treatment. To address this, we assessed whether mobile voice call reminders to TB patients after diagnosis at a tertiary hospital decrease the proportion of “pretreatment loss to follow-up” (PTLFU), compared with the conventional paper-based referral. Design: A two-group parallel-arm randomized controlled trial was conducted. Setting: The study was conducted in a tertiary care hospital at Puducherry, South India. Participants: All newly diagnosed TB patients, both pulmonary and extrapulmonary, who were referred for treatment from the selected tertiary care hospital and possessed a mobile phone were eligible to participate. The participants were enrolled between March 2015 and June 2016 and were randomized to study groups using the block randomization with allocation concealment. Intervention: The participants in the intervention arm received standardized mobile voice calls reminding them to register for anti-TB treatment on the second and seventh day after referral in addition to the conventional paper-based referral received by the control group. Primary outcomes: Patients not started on anti-TB treatment within 14 days of referral were considered as PTLFU. The outcome of PTLFU was ascertained through phone calls made on the 14^th day after referral. The intention-to-treat analysis was used, and the proportion of PTLFU in the study groups and the risk difference with 95% confidence interval (CI) were calculated. Results: Of the 393 patients assessed for eligibility, 310 were randomized to the intervention (n = 155) and control (n = 155) arms. In the intervention arm, 14 (9%) out of 155 were PTLFU compared with 28 (18%) of the 155 patients in the control arm. The absolute risk difference was 9% (95% CI [1.5, 16.6], P = 0.01). Conclusion: Mobile voice call reminder to patients is a feasible intervention and can reduce PTLFU among referred TB patients.

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One of the common long-term consequences observed in survivors of COVID-19 pneumonia is the persistence of respiratory symptoms and/or radiological lung abnormalities. The exact prevalence of these post-COVID pulmonary changes is yet unclear. Few authors, based on their early observations, have labeled these persistent computed tomography (CT) abnormalities as post-COVID lung fibrosis, which appears to be an overstatement. Lately, it is being observed that many of the changes seen in post-COVID lungs are temporary and tend to show resolution on follow-up, with only a few developing into lung fibrosis. Thus, based on the presumptive diagnosis of lung fibrosis, these patients should not be blindly started on anti-fibrotic drugs. One must not forget that these drugs can do more harm than good, if used injudiciously. It is better to use the term “post-COVID interstitial lung changes”, which covers a broader spectrum of pulmonary changes seen in patients who have recovered from COVID-19 pneumonia. At the same time, it is essential to identify the sub-set of COVID-19 survivors who are at an increased risk of developing lung fibrosis and to carefully chalk out management strategies so as to modify the course of the disease and prevent irreversible damage. Meticulous and systematic longitudinal follow-up studies consisting of clinical, laboratory, imaging, and pulmonary function tests are needed for the exact estimation of the burden of lung fibrosis, to understand the nature of residual pulmonary changes, and to predict the likelihood of development of lung fibrosis in COVID-19 survivors.

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Aim: To determine the risk factors affecting outcome at the end of 90 days of post-angiogram-negative subarachnoid hemorrhage (SAH). Methods: Non-traumatic SAH cases were reviewed from the case records of patients who had reported to the Department of Neurology of a tertiary care hospital and 50 angio-negative SAH cases were included after excluding all the cases with known cause of hemorrhage after doing computed tomography angiography (CTA)/digital subtraction angiography (DSA). The presence of hypertension, diabetes mellitus, coronary artery disease (CAD), history of alcohol and smoking, and various scales like Hunt and Hess Scale (HHS), World Federation of Neurological Surgeons (WFNS), and Fisher scale had been recorded at admission. The outcome was assessed at 90 days post-SAH using the Modified Rankin Scale (mRS). Statistical analyses: The association between the outcome and the factors was assessed using the Pearson Chi-Square test and the risk factors/predictors of outcome were assessed using logistic regression. Results: The following variables were important risk factors for predicting poor outcome of angio-negative SAH (mRS 3 to 6): hypertension (P = 0.011), diabetes mellitus (P = 0.032), being an alcoholic (P = 0.019), HHS grade 4 to 5 (P < 0.01), and WFNS grade 4 to 5 (P < 0.01). On multivariate regression analysis, hypertension (P = 0.032) was an independent predictor of unfavorable outcome. Conclusions: At time of admission, presence of hypertension, diabetes mellitus, history of alcohol consumption, and poor grades of HHS and WFNS scale are predictors of poor outcome of angio-negative SAH.

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Introduction: At the onset of the first wave of COVID-19 pandemic, the publications on managing surgical emergencies were sparse. Health care personnel were facing an unprecedented problem with limited information. On this background, we have reviewed the operational challenges faced and the protocols followed by us while managing emergency surgical patients. The clinical presentations, RT-PCR testing rates, trend of COVID-19 positivity in emergency surgical patients and its comparison to the general population, swab positivity among screen positive and negative patients, grade of COVID-19 affection, the outcomes in emergency surgical patients, and COVID-19 affection in treating personnel is studied. Patients and Methods: A protocol for triaging patients at presentation into screen positive or negative for COVID-19 was instituted. A proforma for all admitted patients over the period of March 2020 to August 2020 was maintained. A retrospective review of this data was carried out after Institutional Ethics Committee permission. Results: A total of 222 patients presented to the surgical emergency, of which 110 required admission. Of the admitted patients, 28 were COVID-19 positive. The positivity amongst admitted and operated patients increased to 50% and 66.67%, respectively in August. The difference in mortality rate amongst the operated COVID-19 positive (11.1%) and negative (14.28%) patients was nonsignificant. None of the treating doctors had to be quarantined during this period. Conclusions: The number of COVID-19 positive patients rose serially over the study period. The outcome was not affected by the COVID-19 status in mild cases. A high rate of COVID-19 positivity was seen in patients requiring emergency surgery. Universal precautions ensured delivering treatment to emergency patients in standard time. Testing should continue for all as screening alone is not effective as the virus spreads into the population. Proper protocols helped us to protect the health care workers.

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Duodenal inversum is a rare disease not frequently encountered in clinical practice. The diagnosis is usually made late due to its rarity. Many other causes of abdominal pain like ulcer disease, pancreatitis, malrotation are mostly thought of initially and the diagnosis is usually missed. Only a few cases of duodenal inversum present with outlet obstruction. Duodenojejunostomy is perhaps the ideal management for duodenal inversum if the patient presents with outlet obstruction. Our intention is to create awareness of such a rare disease with an available definitive treatment option in the form of minimally invasive surgery. One such case of a 31-year-old man is described that was successfully managed by laparoscopic duodenojejunostomy.

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Congenital hypothyroidism (CH) occurs due to thyroid dysgenesis, thyroid ectopy, and dyshormonogenesis. A proportion of CH is transient which might be due to iodine deficiency/excess or maternal antibody-mediated. Certain forms of dyshormonogenetic defects may cause transient hypothyroidism. Here is a report of a neonate with overt clinical and biochemical hypothyroidism, who on evaluation was found to have dyshormonogenesis with a homozygous mutation in dual oxidase 2 (DUOX2) gene. During infancy, she became euthyroid. Severe in utero deficiency of thyroid hormone, very short duration of hypothyroidism and first-reported mutation of the DUOX2 gene in the Indian subcontinent were interesting features in this infant.

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Meningoencephaloceles (MECs) occur due to herniation of brain tissue through a bony defect in the skull base. They can be spontaneous or acquired. These are secondary to trauma, infection or neoplasia. Adult-onset spontaneous or idiopathic MECs are rare. Temporal bone MECs can present with watery discharge from the ear, conductive hearing loss or symptoms of meningitis like headache, fever, vomiting or seizures. These symptoms mimic chronic suppurative or serous otitis media. Computed tomography scan and magnetic resonance imaging differentiate between them. Awareness of this disease entity is necessary for early detection to avoid complications. We report a case of bilateral idiopathic temporal bone MECs with a rare presentation of autophony as the chief complaint. The differentiating features on computed tomography scan and magnetic resonance imaging and the surgical management are discussed.

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