scispace - formally typeset
Search or ask a question

Showing papers in "Journal of Postgraduate Medicine in 2006"


Journal Article
TL;DR: The present overview suggests that acute traumatic stress may be a normative response to life threat which tends to subside once conditions of safety are established, and establishing mental health services that are community-based, family-focused and culturally sensitive in the post-emergency phase can create a model that helps shape future mental health policy for countries recovering from disaster.
Abstract: The psychosocial impact of disasters has attracted increasing attention. There is little consensus, however, about what priorities should be pursued in relation to mental health interventions, with most controversy surrounding the relevance of traumatic stress to mental health. The present overview suggests that acute traumatic stress may be a normative response to life threat which tends to subside once conditions of safety are established. At the same time, there is a residual minority of survivors who will continue to experience chronic posttraumatic stress disorder (PTSD) and their needs can be easily overlooked. The ADAPT model offers an expanded perspective on the psychosocial systems undermined by disasters, encompassing threats to safety and security; interpersonal bonds; systems of justice; roles and identities; and institutions that promote meaning and coherence. Social reconstruction programs that are effective in repairing these systems maximize the capacity of communities and individuals to recover spontaneously from various forms of stress. Within that broad recovery context, clinical mental health services can focus specifically on those psychologically disturbed persons who are at greatest survival risk. Only a minority of persons with acute traumatic stress fall into that category, the remainder comprising those with severe behavioural disturbances arising from psychosis, organic brain disorders, severe mood disorders and epilepsy. Establishing mental health services that are community-based, family-focused and culturally sensitive in the post-emergency phase can create a model that helps shape future mental health policy for countries recovering from disaster.

101 citations


Journal Article
TL;DR: Gabapentin effectively suppresses nausea and vomiting in laparoscopic cholecystectomy and post-operative rescue analgesic requirement.
Abstract: Background: Gabapentin is an antiepileptic drug. Its antiemetic effect is demonstrated in chemotherapy-induced acute and delayed onset of nausea and vomiting in breast cancer patients. Aim: To evaluate the antiemetic effect of gabapentin on incidence and severity of postoperative nausea and vomiting in laparoscopic cholecystectomy. Settings and Design: Double-blind, randomized, placebo-controlled study. Materials and Methods: Two hundred and fifty patients of ASA physical status I and II, scheduled for laparoscopic cholecystectomy were randomly assigned into two equal groups to receive 600 mg gabapentin or matching placebo two hours before surgery. Standard anaesthesia technique was used. Fentanyl was used as rescue postoperative analgesic. Ondansetron 4 mg was used intravenously as rescue medication for emesis. The total number of patients who had nausea or vomiting, and its severity and total fentanyl consumption in the first 24 hours were recorded. Statistical Analysis: Z test was used to test the significance of severity of post-operative nausea and vomiting between groups. Fentanyl consumed in each group (Mean±SD) within 24 hrs was compared using student t test. P value Results: There were no demographic difference between the two groups. Incidence of post-operative nausea and vomiting within 24 hrs after laparoscopic cholecystectomy was significantly lower in gabapentin group (46/125) than in the placebo group (75/125) (37.8% vs 60%; P =0.04). There was a significantly decreased fentanyl consumption in gabapentin group (221.2±92.4 µg) as compared to placebo group (505.9±82.0 µg; P =0.01). Conclusion: Gabapentin effectively suppresses nausea and vomiting in laparoscopic cholecystectomy and post-operative rescue analgesic requirement.

92 citations


Journal Article
TL;DR: Despite drug-induced AMI being not a common event, attention to smoking and drugs in teenagers and young adults will have major therapeutic and prognostic implications.
Abstract: There is no published registry for drug-induced acute myocardial infarction (AMI) with subsequent patent coronary angiogram in teenagers. To highlight the mechanism and impact of drug-induced MI with patent coronary arteries among teenagers who have relatively few coronary risk factors in comparison with older patients, we conducted a review of the literature. In this review most of the pertinent published (English and non-English) articles through the Medline, Scopus, Cochrane Database of Systematic Reviews, and EBSCO Host research databases from 1970 to 2005 have been revised. Teenagers and young adults with AMI and subsequent patent coronary angiogram were included. In those cases drug-induced coronary spasm was highlighted. Among 220 articles (>12000 cases) related with AMI with normal coronary angiogram, 50 articles (~100 cases) reported the role of drug in AMI secondary to coronary artery spasm (CAS). There is no well-conducted trial for AMI secondary to CAS in young adults but only a series of case reports, and the diagnosis in most of cases was based on the clinical and laboratory findings without provocation. CAS was associated with 12 illicit substances in teenagers (i.e., cocaine, marijuana, alcohol, butane, and amphetamine). Smoking is not only the initiative but also might harbor other illicit substances that increase the risk for CAS. Cocaine-associated AMI is the most frequent in various research papers. CAS was reported with 19 types of medications (i.e., over-the-counter, chemotherapy, antimigraine, and antibiotics) without strong relation to age. Despite drug-induced AMI being not a common event, attention to smoking and drugs in teenagers and young adults will have major therapeutic and prognostic implications.

82 citations


Journal Article
TL;DR: Cerebral malaria should always be suspected in a patient with altered sensorium in a malaria-endemic area and other causes of unconsciousness such as encephalitis, meningitis or hepatic coma should also be excluded.
Abstract: Severe malaria is invariably caused by Plasmodium falciparum. In India, both adults and children are affected by severe malaria. However, children are more prone for developing anemia and convulsions as manifestations of severe malaria, while acute renal failure and jaundice are more common among adults. Pregnant women are vulnerable to hypoglycemia, anemia and pulmonary complications. The case-fatality rate due to severe malaria is 10-15% in spite of therapy but it increases in the presence of renal failure or respiratory distress (pulmonary edema or ARDS). Of late, multi-organ failure and high mortality figures are being reported increasingly from different parts of India. Early diagnosis and prompt treatment will reduce the mortality due to malaria. Cerebral malaria should always be suspected in a patient with altered sensorium in a malaria-endemic area. However, other causes of unconsciousness such as encephalitis, meningitis or hepatic coma should also be excluded. Parenteral quinine is the mainstay of therapy. A recent multi-centric study has demonstrated the efficacy of intravenous artesunate in reducing the mortality by 30%. The usefulness of adjunct therapy is still controversial.

57 citations


Journal Article
TL;DR: Exogenous factors associated with fasting, namely, the changes in food intake and/or sleep timings, affect the circadian rhythm and influence the timing of presentation of acute coronary events.
Abstract: Background: Over one billion Muslims fast worldwide during the month of Ramadan The impact of fasting on circadian presentation with acute cardiac events is unknown Aim: To determine if fasting has any effect on the circadian presentation of acute cardiac events Setting and Design: A prospective study in a general hospital Materials and Methods: Patients with acute coronary events were divided into two groups based on the history of fasting Information about age, gender, cardiovascular risk factor profiles, and outcome was collected The relationship of time of presentation of initial symptoms with fasting was evaluated using Student's t-test, Mann-Whitney U-test, and x2sub analysis Results: Of the 1019 patients hospitalized during the study period, 162 were fasting Although, fasting patients were more likely to present to the emergency department in the time periods 5-6 AM (105% vs 63%) and 11 PM (111% vs 71%) and were less likely to present in the time periods 1-2 PM (37% vs 72%) and 5-6 PM (37% vs 70%); these differences were not statistically significant Fasting patients were less likely to have their symptoms start between 5 and 8 AM (111% vs 194%) and more likely to have symptoms between 5 and 6 PM (111% vs 60%) and 3 and 4 AM (111% vs 69%) These differences for time of initial symptoms were statistically significant (P=0002) Conclusion: Exogenous factors associated with fasting, namely, the changes in food intake and/or sleep timings, affect the circadian rhythm and influence the timing of presentation of acute coronary events

55 citations


Journal Article
TL;DR: Beyond providing new perspectives in fundamental aspects of the HIV-1 transmission and pathogenesis, chemokines and their receptors suggest new areas for developing novel therapeutic and preventive strategies against HIV infections.
Abstract: Chemokines are known to function as regulatory molecules in leukocyte maturation, traffic, homing of lymphocytes and in the development of lymphoid tissues. Besides these functions in the immune system, certain chemokines and their receptors are involved in HIV pathogenesis. In order to infect a target cell, the HIV envelope glycoprotein gp120 has to interact with the cellular receptor CD-4 and co-receptor, CC or CXC chemokine receptors. Genetic findings have yielded major insights into the in vivo roles of individual co-receptors and their ligands in providing resistance to HIV infection. Mutations in chemokine receptor genes are associated with protection against HIV infections and also involved in delayed progression to AIDS in infected individuals. Blocking of chemokine receptors interrupts HIV infection in vitro and this offers new options for therapeutic strategies. Approaches have been made to study the CCR-5 inhibitors as antiviral therapies and possibly as components of a topical microbicide to prevent HIV-1 sexual transmission. Immune strategies aimed at generating anti-CCR-5 antibodies at the level of the genital mucosa might be feasible and represent a strategy to induce mucosal HIV- protective immunity. It also remains to be seen how these types of agents will act in synergy with existing HIV-1 targeted anti viral or those currently in developments. Beyond providing new perspectives in fundamental aspects of the HIV-1 transmission and pathogenesis, chemokines and their receptors suggest new areas for developing novel therapeutic and preventive strategies against HIV infections. Studies in this review were identified through a search for relevant literature in the pubmed database of the national library of medicine. In this review, some developments in chemokine research with particular focus on their roles in HIV pathogenesis, resistance and therapeutic applications have been discussed.

50 citations


Journal Article
TL;DR: A simple technique of generating a sheet of corneal epithelium from a limbal biopsy is demonstrated and could pave the way for a novel form of cell therapy.
Abstract: Background : The technique of transplantation of cultivated limbal epithelium rather than direct limbal tissue isa novel method of "cell therapy" involved in reconstructing the ocular surface in severe limbal stem celldeficiency [LSCD], caused by chemical burns Aim : To describe a simple feeder-cell free technique of cultivating limbal epithelium on human amniotic membrane[HAM] Materials and Methods : The limbal tissues (2 mm) were harvested from patients with LSCD These tissueswere proliferated in vitro on HAM supplemented by human corneal epithelial cell medium and autologousserum Cultures covering more ?50% area of 25x5 cm HAM were considered adequate for clinical use Thecultured epithelium was characterized by histopathology and immunophenotypingResults: A total of 542 cultures out of 250 limbal tissues were cultivated in the laboratory from January 2001through July 2005 The culture explants showed that clusters of cells emerging from the edge of the explantsin one-three days formed a complete monolayer within 10-14 days In 86% of cultures (464 of 542), thegrowth was observed within one-two days Successful explant cultures were observed in 985% (534 of 542cultures) with 91% explant cultures showing an area of ?625 cm2 (625 - 125 cm2 range) The cultivatedepithelium was terminated between 10-14 days for clinical transplantation The problems encountered wereinadequate growth (2 of 542) and contamination (2 of 542) Conclusions : We demonstrate a simple technique of generating a sheet of corneal epithelium from a limbalbiopsy This new technique could pave the way for a novel form of cell therapy

46 citations


Journal Article
TL;DR: The prevalence of hepatitis B and C coinfection was fairly high in this largely heterosexually infected population supporting the use of more careful screening for these viruses in HIV positive persons in this region.
Abstract: Background: Tuberculosis (TB) and hepatitis are the two common co-infections in patients infected with human immunodeficiency virus (HIV). Anti-tuberculosis treatment (ATT) may have an effect on the liver enzymes in these co-infected HIV patients. Aims: To determine the prevalence of Hepatitis B and C virus coinfection in HIV infected patients in Tamilnadu and assess effects of anti-tuberculosis drugs on their liver function. Settings: HIV positive subjects referred to the Tuberculosis Research Centre, Chennai Materials and Methods: All HIV infected patients referred to the Tuberculosis Research centre, from March 2000 to May 2004, were screened for Hepatitis B surface antigen (HBsAg) & Hepatitis C virus (HCV) antibodies by enzyme linked immunoabsorbent assay (ELISA). HIV infection was confirmed using two rapid tests and one ELISA.Patients were given either short- course anti-tuberculosis treatment or preventive therapy for tuberculosis, depending on the presence or absence of active TB, if their baseline liver functions were within normal limits. None of these patients were on antiretroviral therapy during the study period. Statistical Analysis: Paired t-test was used to find the significance between baseline and end of treatment liver enzymes levels, while logistic regression was done for assessing various associations. Results: Of the 951 HIV-infected patients, 61 patients (6.4%) were HBsAg positive, 20 (2.1%) had demonstrable anti HCV antibodies in their blood. Serial estimation of liver enzymes in 140 HIV patients (81 being co-infected with either HBV or HCV) showed that 95% did not develop any liver toxicity while they were on anti-tuberculosis treatment or prophylaxis. Conclusions: The prevalence of hepatitis B and C coinfection was fairly high in this largely heterosexually infected population supporting the use of more careful screening for these viruses in HIV positive persons in this region. Anti-tuberculosis therapy as well as TB preventive therapy can be safely employed in HIV and hepatitis coinfected patients, if baseline liver function tests are within normal limits.

45 citations


Journal Article
TL;DR: The emergence of state-sponsored terrorism proliferation of chemical and biological agents availability of materials and scientific weapons expertise all point toward a growing threat of a mass casualty incident (MCI).
Abstract: Disaster scenarios once seemed merely theoretical have become disturbingly reality. Disasters in the communities come in all shapes and sizes. Some impact a small number of people and put intense demands on the health system for a short period. Others may involve a large number of casualties but reach a plateau only after a latent period placing heavy continuing demands on the health system. For some natural disasters like hurricanes floods and volcanoes -- hospitals are likely to receive advance warning and be able to activate their disaster plan before the event. For other natural disasters such as earthquakes and tsunami there is no advance warning as of now. Many man-made disasters also provide no advance warning; these include chemical plant explosions industrial accidents building collapses and acts of terrorism. The emergence of state-sponsored terrorism proliferation of chemical and biological agents availability of materials and scientific weapons expertise all point toward a growing threat of a mass casualty incident (MCI). (excerpt)

40 citations


Journal Article
TL;DR: The first case of abacavir-induced reversible FS with NDI in a patient with acquired immunodeficiency syndrome, who recovered completely with supportive treatment and discontinuation of abACavir is reported.
Abstract: There are several reports of Fanconi syndrome (FS) with or without nephrogenic diabetes insipidus (NDI) in patients with human immunodeficiency virus (HIV) infection, treated with various antiretroviral medications like cidofovir, adefovir, didenosine and tenofovir But neither FS nor NDI has been documented with abacavir therapy We are reporting the first case of abacavir-induced reversible FS with NDI in a patient with acquired immunodeficiency syndrome, who recovered completely with supportive treatment and discontinuation of abacavir

38 citations


Journal Article
TL;DR: This review sums up the methods of assay currently available for measuring resistance to antiretroviral drugs and outlines the clinical utility and limitations of these assays.
Abstract: While antiretroviral drugs, those approved for clinical use and others under evaluation, attempt in lowering viral load and boost the host immune system, antiretroviral drug resistance acts as a major impediment in the management of human immune deficiency virus type-1 (HIV-1) infection. Antiretroviral drug resistance testing has become an important tool in the therapeutic management protocol of HIV-1 infection. The reliability and clinical utilities of genotypic and phenotypic assays have been demonstrated. Understanding of complexities of interpretation of genotyping assay, along with updating of lists of mutation and algorithms and determination of clinically relevant cut-offs for phenotypic assays are of paramount importance. The assay results are to be interpreted and applied by experienced HIV practitioners, after taking into consideration the clinical profile of the patient. This review sums up the methods of assay currently available for measuring resistance to antiretroviral drugs and outlines the clinical utility and limitations of these assays.

Journal Article
TL;DR: In this article, the authors determined the incidence of cardiac abnormalities and vascular lesions at autopsy and assessed their contribution to the mortality in patients with systemic lupus erythematosus (SLE).
Abstract: Background: Although cardiovascular disease (CVD) is recognized as a leading cause of death in patients with systemic lupus erythematosus (SLE) in western countries, there is hardly any data regarding Indian subjects with SLE. Aims: To determine the incidence of cardiac abnormalities and vascular lesions at autopsy and to assess their contribution to the mortality in patients with SLE Settings and Design: Retrospective retrieval of reports of autopsies performed on 35 patients with SLE over a 11 year period and analysis of 27 cases with cardiac and/or vascular lesions. Materials and Methods: Gross and microscopic features in 27 autopsies were analyzed with special attention to the heart and the vasculature of all organs. Findings were correlated with clinical features and ante-mortem investigations. Their contribution towards mortality was assessed. Results: Valvar lesions were the commonest cardiac lesions noted with non-bacterial thrombotic endocarditis in nine (33.33%), valvar thickening in two (7.41%), Libman-Sacks endocarditis and infective endocarditis in one (3.70%) each. Myocarditis and myocardial scarring were seen in 10 (37.03%) and seven (25.92%) cases, respectively. Fibrinous pericarditis was noted in seven (25.92%). Thromboses/ embolism, vasculitis and severe coronary atherosclerosis were seen in nine (33.33%), five (18.52%) and one (3.70%) subjects, respectively. Renal disease [13, 48.14%] and cardiovascular manifestations [8, 29.62%] were the leading causes of death in our patient population. Conclusion: CVD contributes significantly to the mortality in patients with SLE in India. It is second only to renal disease in this regard

Book ChapterDOI
TL;DR: Women with epilepsy (WWE) who are using enzyme-inducing AEDs (phenobarbitone, primidone, phenytoin, carbamazepine and oxcarbazepine) need to know that these AEDS may lead to failure of oral contraception.
Abstract: Epilepsy is recognized as the commonest serious neurological disorder in the world. Women with epilepsy (WWE) experience several gender-related physical and social problems. They constitute high obstetric risk because of reduced fertility, risk of seizures during pregnancy and complications of pregnancy. Hormonal and other factors can alter the pharmacokinetics of antiepileptic drugs (AED) during pregnancy and puerperium. Antenatal exposure to AEDs, particularly at higher dosage and in polytherapy, increases the risk of fetal malformation. Recent reports raise the possibility of selective developmental language deficits and neurocognitive deficits with antenatal exposure to AEDs. There are concerns regarding the effect of traces of AEDs that pass to the infant during breast-feeding. The pre conception management is the cornerstone for epilepsy care in WWE. A careful reappraisal of each case should ascertain the diagnosis, the need for continued AED therapy, selection of appropriate AEDs, optimization of the dosage and prescription of folic acid. During pregnancy, the fetal status needs to be monitored with estimation of serum a-feto-protein and ultrasound screening for malformations. The dosage of AEDs can be adjusted according to clinical requirement and blood levels of AEDs. Several institutions recommend oral vitamin K toward the end of pregnancy when enzyme-inducing AEDs are prescribed because the latter may potentially predispose the new born to hemorrhagic disease, but recent reports indicate that such a risk is practically negligible. WWE who are using enzyme-inducing AEDs (phenobarbitone, primidone, phenytoin, carbamazepine and oxcarbazepine) need to know that these AEDs may lead to failure of oral contraception.

Journal Article
TL;DR: The growing problem of drug resistance has greatly complicated the treatment for falciparum malaria, and new combinations are urgently needed particularly because addition of a single drug to an already failing regimen is rarely effective for very long.
Abstract: The growing problem of drug resistance has greatly complicated the treatment for falciparum malaria. Whereaschloroquine and sulfadoxine/ pyrimethamine could once cure most infections, this is no longer true and requiresexamination of alternative regimens. Not all treatment failures are drug resistant and other issues such asexpired antimalarials and patient compliance need to be considered. Continuation of a failing treatment policyafter drug resistance is established suppresses infections rather than curing them, leading to increasedtransmission of malaria, promotion of epidemics and loss of public confidence in malaria control programs.Antifolate drug resistance (i.e. pyrimethamine) means that new combinations are urgently needed particularlybecause addition of a single drug to an already failing regimen is rarely effective for very long. Atovaquone/proguanil and mefloquine have been used against multiple drug resistant falciparum malaria with resistance toeach having been documented soon after drug introduction. Drug combinations delay further transmission ofresistant parasites by increasing cure rates and inhibiting formation of gametocytes. Most currentlyrecommended drug combinations for falciparum malaria are variants of artemisinin combination therapy wherea rapidly acting artemisinin compound is combined with a longer half-life drug of a different class. Artemisininsused include dihydroartemisinin, artesunate, artemether and companion drugs include mefloquine, amodiaquine,sulfadoxine/ pyrimethamine, lumefantrine, piperaquine, pyronaridine, chlorproguanil/dapsone. The standard ofcare must be to cure malaria by killing the last parasite. Combination antimalarial treatment is vital not only tothe successful treatment of individual patients but also for public health control of malaria.

Journal Article
TL;DR: A high prevalence of NCD risk factors in industrial setting was seen; therefore public health approaches are required at workplace settings to curtail the rising epidemic in the productive populations.
Abstract: Aim: The profile of non communicable diseases (NCD) risk factors was identified in an industry by pre tested WHO's STEPS questionnaire Settings and Design : A cross - sectional survey of all employment categories of an Industry (2000 employees) was done after randomly selecting subjects (220) from worker (52%) and non worker categories (474%), after informed consent Materials and Methods: Information was collected on behavioural risk factors (STEP I), followed by anthropometric and blood pressure measurements by a trained investigator (STEP II) STEP III constituted biochemical assessment of at risk subjects (> 3 risk factors) Statistical Analysis : Percentage of subjects having NCD risk factors and the odds ratios were calculated Results : Overall risk factor profile of the study subjects revealed universal prevalence of 3 risk factors) with prevalence of hypercholesterolemia, hypertension and diabetes of 405, 382 and 191% respectively Conclusions : A high prevalence of NCD risk factors in industrial setting was seen; therefore public health approaches are required at workplace settings to curtail the rising epidemic in the productive populations

Journal Article
TL;DR: A patient with long-standing primary thyroid failure whose thyroxine dose requirements increased upon development of massive proteinuria is described, whose nephrotic syndrome and amyloid deposition in association with myeloma was demonstrated.
Abstract: Rising thyroid stimulating hormone (TSH) levels in patients being treated for primary hypothyroidism usually indicate poor compliance with thyroxine therapy. In rare instances, drugs or diseases affecting absorption of thyroxine or drugs that accelerate thyroxine metabolism can manifest in a similar fashion. Nephrotic syndrome is a rare cause of such a presentation though its presence can rapidly be suspected by dipstick urine testing. In this report we describe a patient with long-standing primary thyroid failure whose thyroxine dose requirements increased upon development of massive proteinuria. Biochemical testing and renal biopsy subsequently demonstrated nephrotic syndrome and amyloid deposition in association with myeloma. Dipstick urine testing should be considered in all hypothyroid patients with rising TSH levels, where good compliance with thyroxine therapy is likely.

Journal Article
TL;DR: An epidemiological background and understanding of developing and developed countries, and chronic or smoldering countries' CEs, is provided, and the prevailing models of response seen by the international community are explained.
Abstract: Complex emergencies (CEs) have been the most common human-generated disaster of the past two decades. These internal conflicts and associated acts of genocide have been poorly understood and poorly managed. This article provides an epidemiological background and understanding of developing and developed countries, and chronic or smoldering countries' CEs, and explains in detail the prevailing models of response seen by the international community. Even though CEs are declining in number, they have become more complex and dangerous. The UN Charter reform is expected to address internal conflicts and genocide but may not provide a more effective and efficient means to respond.

Journal Article
TL;DR: Public health management issues during disasters include the safety and survival of the afflicted, providing food, safe water and medical services, relocation of those affected and implementing primary prevention measures are the key areas of action during a disaster.
Abstract: Dean (G & K), Prof & isaster scenarios once deemed theoretical have become a reality. Some impact a small number Head, Departments of D of people, others involve casualties but reach a plateau after a latent period. On 26 July Clinical Pharmacolcogy, 2005, Mumbai city received 944 mm of rainfall in a single day, the heaviest rainfall recorded in the *Preventive and Social past 90 years. The city was flooded and waterlogged for 48 hours. This event disrupted the physical, Medicine, **Medicine, social and environmental milieu of the city. Mumbai floods and later the floods in the European Seth G. S. Medical countries and the Hurricane Katrina disaster in New Orleans are comparable in terms of public College & KEM health concerns, although differences existed in terms f pre-disaster medical care, disease prevention Hospital, Mumbai, methods used and resources available. Public health management issues during disasters include the safety and survival of the afflicted. Providing food, safe water and medical services, relocation of those affected and implementing primary prevention measures are the key areas of action during a Correspondence: Nilima Kshirsagar, disaster. This communication wishes to share the experiences during Mumbai floods so that views E-mail: dcpkem@vsnl.com regarding this important public health agenda are discussed on a global platform.

Journal Article
TL;DR: The authorities need to consider (and take seriously) how individuals and the community are likely to react thereto and to identify (and rehearse in a realistic climate) what steps would need to be taken to ameliorate the effects of such an event.
Abstract: Terrorism is not a new phenomenon, but, in the contemporary scene, it has established itself in a manner which commands the most serious attention of the authorities. Until relatively recently, the major threat has been through the medium of conventional weaponry and explosives. Their obvious convenience of use and accessibility guarantees that such methods will continue to represent a serious threat. However, over the last few years, terrorists have displayed an enthusiasm for higher levels of carnage, destruction and publicity. This trend leads inexorably to the conclusion that chemical, biological, radiological and nuclear (CBRN) methods will be pursued by terrorist organisations, particularly those which are well organised, are based on immutable ideological principles, and have significant financial backing. Whilst it is important that the authorities and the general public do not risk over-reacting to such a threat (otherwise, they will do the work of the terrorists for them), it would be equally ill-advised to seek comfort in denial. The reality of a CBRN event has to be accepted and, as a consequence, the authorities need to consider (and take seriously) how individuals and the community are likely to react thereto and to identify (and rehearse in a realistic climate) what steps would need to be taken to ameliorate the effects of such an event.

Journal Article
TL;DR: Certain patient and ocular features are indicative of a high risk for posterior segment pathology and such patients should be evaluated by ultrasonography prior to cataract surgery and the likelihood of detecting abnormalities on preoperative Ultrasonography in eyes with advanced cataracts is miniscule.
Abstract: Background: Ultrasonography is an important tool for evaluating the posterior segment in eyes with opaque media. Aim: To study the incidence of posterior segment pathology in eyes with advanced cataract and to see whether certain features could be used as predictors for an abnormal posterior segment on ultrasound. Setting: Tertiary care hospital in South India. Methods and Materials: In this prospective study conducted over a 6-month period, all eyes with dense cataracts precluding visualization of fundus underwent assessment with ultrasound. Presence of certain patient and ocular "risk" factors believed to be associated with a higher incidence of abnormal posterior segment on ultrasound were looked for and the odds ratio (OR) for posterior segment pathology in these eyes was calculated. Results: Of the 418 eyes assessed, 36 eyes (8.6%) had evidence of posterior segment pathology on ultrasound. Retinal detachment (17 eyes; 4.1%) was the most frequent abnormality detected. Among patient features, diabetes mellitus (OR= 4.9, P=0.003) and age below 50 years (OR= 15.4, P=0.001) were associated with a high incidence of abnormal ultrasound scans. In ocular features, posterior synechiae (OR= 20.2, P=0.000), iris coloboma (OR= 34.6, P=0.000), inaccurate projection of rays (OR= 15.1, P=0.002), elevated intraocular pressure (OR= 15.1, P=0.004), and keratic precipitates (OR= 22.4, P=0.004) were associated with high incidence of posterior segment pathology. Only four eyes (1.5%) without these features had abnormal posterior segment on ultrasonography. Conclusions: Certain patient and ocular features are indicative of a high risk for posterior segment pathology and such patients should be evaluated by ultrasonography prior to cataract surgery. In the absence of these risk factors, the likelihood of detecting abnormalities on preoperative ultrasonography in eyes with advanced cataracts is miniscule.

Journal Article
TL;DR: Recent advances in the understanding of the genetics and molecular mechanisms of CQR are highlighted, with particular emphasis on the role of genes such as pfcrt and pfmdr1 in the resistance to CQ and other drugs.
Abstract: Chloroquine (CQ) is the most successful antimalarial drug ever discovered. Unfortunately, parasites resistant to the drug eventually emerged after its large scale use and are now widespread. Although great progress in our understanding of the mechanisms of CQ action and CQ resistance (CQR) has been achieved over the past two decades, including the identification of the molecules responsible for CQR (e.g., Plasmodium falciparum chloroquine resistant transporter, PfCRT) many questions remain unanswered. Here we highlight recent advances in our understanding of the genetics and molecular mechanisms of CQR, with particular emphasis on the role of genes such as pfcrt and pfmdr1 in the resistance to CQ and other drugs. New drug development and applications will undoubtedly benefit from a better understanding of CQR, eventually leading to more effective malaria control measures.

Journal Article
TL;DR: mPCR is a cost effective, single tube method for the simultaneous detection of eubacterial, P. acnes and panfungal genomes in intraocular specimens from patients with infective endophthalmitis and requires only a single thermalcycler.
Abstract: Background: Uniplex polymerase chain reaction (PCR) for detection of bacterial and panfungal genome has been applied onto a large number of intraocular fluids facilitating management of infective endophthalmitis. Aim: To develop and apply a novel, rapid multiplex polymerase chain reaction (mPCR) to detect the presence of eubacterial, Propionibacterium acnes and panfungal genomes in intraocular fluids from patients clinically diagnosed to have infective endophthalmitis. Settings and Design: Prospective study . Materials and Methods: Conventional methods of direct microscopy by KOH/calcofluor mount, Gram's staining and culture were done on 30 (19 Aqueous humor-AH and 11 Vitreous fluid-VF) intraocular specimens and mPCR done for simultaneous detection of eubacterial, P. acnes and panfungal genomes. Results: mPCR detected an infectious etiology in 18 (60%) of 30 intraocular specimens. Eubacterial genome was detected in 12 (40%) specimens, P. acnes genome in 4 (13.3%) specimens and panfungal genome in 2 (6.6%) specimens. mPCR results correlated with those of uniplex PCR. mPCR results were available within 5-6 hours after receipt of specimen, as against 8 hours required for each uniplex PCR with three separate thermalcyclers for their completion. Consumption of Taq polymerase was reduced considerably for mPCR. Conclusion: mPCR is a cost effective, single tube method for the simultaneous detection of eubacterial, P. acnes and panfungal genomes in intraocular specimens from patients with infective endophthalmitis. It is a more rapid procedure than uniplex PCRs and requires only a single thermalcycler.

Journal Article
TL;DR: A review of the literature addressing hospital experiences with weapons of mass destruction incidents and the planning lessons thus learned is reported, with a discussion of the importance of training and exercises in maintaining and improving the disaster plan.
Abstract: As terrorists attacks increase in frequency, hospital disaster plans need to be scrutinized to ensure that they take into account issues unique to weapons of mass destruction. This paper reports a review of the literature addressing hospital experiences with such incidents and the planning lessons thus learned. Construction of hospital disaster plans is examined as an ongoing process guided by the disaster planning committee. Hospitals are conceived as one of the components of a larger community disaster planning efforts, with specific attention devoted to defining important linkages among response organizations. This includes the public health authorities, political authorities, prehospital care agencies, and emergency management agencies. A review is completed of six special elements of weapons of mass destruction incidents that should be addressed in hospital disaster plans: incident command, hospital security, patient surge, decontamination, mental health consequences, and communications. The paper closes with a discussion of the importance of training and exercises in maintaining and improving the disaster plan.

Journal Article
TL;DR: The availability of counterfeit and poor quality drugs contribute to resistance and erroneous efficacy study results as well as directly affecting the health of individuals.
Abstract: The availability of counterfeit and poor quality drugs contribute to resistance and erroneous efficacy study results as well as directly affecting the health of individuals. This report describes the importance of drug quality monitoring as part of a comprehensive disease surveillance program.

Journal Article
TL;DR: The SICK score can predict severity of illness with nearly the same accuracy as the PRISM score and can help to prioritize care for the more sick children who need urgent aggressive management.
Abstract: Background : Signs of Inflammation in Children that can Kill (SICK score) is a new severity-of-illness score. It uses the physical signs of the Systemic Inflammatory Response Syndrome (SIRS) and its continuum - the Multiple Organ Dysfunction Syndrome (MODS). The development of the score used multiple logistic regression model coefficients converted to integer scores that have been published earlier. Aims: The present study was done to validate the scoring system by predicting outcomes in a fresh data set. Setting: Intensive care unit in a tertiary referral hospital Design: Prospective Materials and Methods: 125 admissions to the intensive care unit were evaluated so that the SICK score and the PRISM score could be calculated. In-hospital mortality was noted Statistical Analysis: Calibration (Hosmer-Lemeshow goodness of fit) and discrimination (area under the ROC curve) were used to measure performance. Results: Of the 125 patients studied 23 died. The area under the ROC curve was 0.76 compared to 0.80 in the development sample. Using PRISM in the validation group, the ROC was 0.78. Calibration was excellent. Conclusion: The SICK score can predict severity of illness with nearly the same accuracy as the PRISM score. The SICK score can be calculated immediately on admission and can help to prioritize care for the more sick children who need urgent aggressive management. Larger studies, that includes all admissions to the hospital, will now need to be done.


Journal Article
TL;DR: Carotid IMT can be used to predict CAD in patients with ESRD and in the absence of other risk factors, patients with IMT< 0.75 mm may not need a pretransplant CAG.
Abstract: Background : Coronary artery disease (CAD) is associated with a higher incidence of allograft failure and mortalityin patients with end-stage renal disease (ESRD) following renal transplant. Aim : To evaluate the efficacy of using carotid intimal medial thickness (CIMT) to predict the presence of CADin patients with ESRD, using coronary angiography (CAG) as the gold standard. Materials and Methods : This prospective study enrolled consecutive patients with ESRD who underwent CAGas a part of pretransplant evaluation to rule out the presence of atherosclerotic CAD. An operator who wasblinded with respect to the results of the CAG, measured carotid IMT in all patients prior to CAG and recordedit on videotape. Two independent observers blinded to the results of CAG measured carotid IMT offline tovalidate its predictive accuracy as a noninvasive test in predicting the presence or absence of CAD. Measurementof carotid IMT was done on USG B mode 7.5 MHZ probe [HP 5500 andover, Massachusetts]. Student's t-testwas used for inter-group comparisons. Pearson correlation coefficient test was used to assess the relationbetween CAD and various risk factors and carotid IMT. Linear regression analysis was applied to identifyindependent factors determining presence of CAD. A P value Results : Mean CIMT was significantly higher in those with CAD as compared to those without [0.80± 0.06 vs.0.70±0.06 mm, P 0.75 mm were older and had more incidence of diabetes(78% vs. 47%; P=0.001). Only 4/53 (7%) of patients with CIMT 0.75 mm. The sensitivity and specificity of using CIMT > 0.75 as a predictor of CAD was 90.47%and 73% and its positive and negative predictive values were 0.73 and 0.92. On multivariate analysis, onlyCIMT was a significant predictor of CAD. Conclusion : Carotid IMT can be used to predict CAD in patients with ESRD. In the absence of other risk factors,patients with IMT< 0.75 mm may not need a pretransplant CAG.

Journal Article
TL;DR: For patients on Cellcept with prednisolone +/- cyclosporine the 6-hour corrected is an accurate measure of the full 12-hour AUC, which is very good for all three groups.
Abstract: Background : Therapeutic drug monitoring for mycophenolic acid (MPA) is increasingly being advocated. Thepresent therapeutic range relates to the 12-hour area under the serum concentration time profile (AUC).However, this is a cumbersome, tedious, cost restricting procedure. Is it possible to reduce this samplingperiod? Aim : To compare the AUC from a reduced sampling strategy with the full 12-hour profile for MPA. Settings and Design : Clinical Pharmacology Unit of a tertiary care hospital in South India. Retrospective, paireddata. Materials and Methods : Thirty-four 12-hour profiles from post-renal transplant patients on Cellcept® wereevaluated. Profiles were grouped according to steroid and immunosuppressant co-medication and the timeafter transplant. MPA was estimated by high performance liquid chromatography with UV detection. From the12-hour profiles the AUC up to only six hours was calculated by the trapezoidal rule and a correction factorapplied. These two AUCs were then compared. Statistical Analysis : Linear regression, intra-class correlations (ICC) and a two-tailed paired t-test were appliedto the data. Results : Comparing the 12-hour AUC with the paired 6-hour extrapolated AUC, the ICC and linear regression(r2) were very good for all three groups. No statistical difference was found by a two-tailed paired t-test. Nobias was seen with a Bland Altman plot or by calculation. Conclusion : For patients on Cellcept® with prednisolone ± cyclosporine the 6-hour corrected is an accuratemeasure of the full 12-hour AUC.


Journal Article
TL;DR: In a study of work environment of residency programs, differential impact was found for the four groups on work environment perceptions, indicating either underreporting or cultural dynamics of the setting.
Abstract: Background: In Pakistan, there is a lack of information about the work environment of residency programs This lack is a major impediment in their improvement One of the approaches for improvement in these programs can be directed through the residents' own perception of their working conditions Therefore, we collected data which would reflect working conditions of residents Aim: To assess the perceived status of work environment in different specialities Materials and Methods: A cross-sectional survey was conducted in four teaching hospitals of Karachi from July 1999 to January 2000 Residents from selected programs were grouped into four broad groups: specialist, medical, surgical, and multidisciplinary Responses of residents were obtained on a Likert scale of 0 to 4 Indices were formed for two components of work environment: academic and mistreatment Statistical Analysis: Differences between residents' groups were assessed through analysis of variance (ANOVA) at 5% significance Results: A total of 341 registered residents responded (response rate: 75%) Surgical residents were working more than 80 h/week and this was more than the other three groups Medical residents were spending the highest actual time on research and teaching activities (10% and 14%, respectively) Academic index score was highest for surgical group (1581, SD = 469) and lowest for multidisciplinary group (1182, SD = 480) Medical group had the highest perceived mistreatment index score (556, SD = 457) Conclusions: In a study of work environment of residency programs, differential impact was found for the four groups on work environment perceptions Most of the residents recognized undergraduate teaching, grand rounds, patient rounds, and seminars or workshops as contributing to their academic learning Reporting of sexual harassment was low, indicating either underreporting or cultural dynamics of our setting