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Showing papers in "Journal of Postgraduate Medicine in 2012"


Journal ArticleDOI
I Banerjee, T Bhadury1
TL;DR: The study shows that self-medication is widely practiced among students of the institute and faculties should create awareness and educate their students regarding advantages and disadvantages of self-Medication.
Abstract: Background: Self-medication is a widely prevalent practice in India. It assumes a special significance among medical students as they are the future medical practitioners. Aim: To assess the pattern of self-medication practice among undergraduate medical students. Settings and Design: Tertiary care medical college in West Bengal, India. Material and Methods: A cross-sectional questionnaire-based study was conducted among the undergraduate medical students. Results: Out of 500 students of the institute, 482 consented for the study and filled in the supplied questionnaire. Fourteen incomplete questionnaires were excluded and the remaining 468 analyzed. It was found that 267 (57.05%) respondents practiced self-medication. The principal morbidities for seeking self-medication included cough and common cold as reported by 94 students (35.21%) followed by diarrhea (68 students) (25.47%), fever (42 students) (15.73%), headache (40 students) (14.98%) and pain abdomen due to heartburn/ peptic ulcer (23 students) (8.61%). Drugs/ drug groups commonly used for self-medication included antibiotics (31.09%) followed by analgesics (23.21%), antipyretics (17.98%), antiulcer agents (8.99%), cough suppressant (7.87%), multivitamins (6.37%) and antihelminthics (4.49%). Among reasons for seeking self-medication, 126 students (47.19%) felt that their illness was mild while 76 (28.46%) preferred as it is time-saving. About 42 students (15.73%) cited cost-effectiveness as the primary reason while 23 (8.62%) preferred because of urgency. Conclusion: Our study shows that self-medication is widely practiced among students of the institute. In this situation, faculties should create awareness and educate their students regarding advantages and disadvantages of self-medication.

161 citations


Journal ArticleDOI
TL;DR: Age and gender have substantial influence on presentation of primary hyperparathyroidism, and women have more severe disease as musculoskeletal manifestations are common and iPTH levels are also higher compared to men.
Abstract: Background: The geographical difference in presentation of primary hyperparathyroidism (PHPT) is known. However, there is sparse literature on the influence of age and gender on presentation of PHPT. Aim: To analyze the effect of age and gender on presentation of symptomatic primary hyperparathyroidism. Setting and Design: This is a retrospective analysis of data from the primary hyperparathyroidism registry of a north Indian tertiary care teaching institute. Materials and Methods: Analysis of 184 histopathologically proven PHPT patients registered between March 1990 and March 2010 from a single centre of north India. PHPT patients were divided into three different age groups i.e. children and adolescents less than 25 years, adults 25-49 years, and ≥ 50 years. Clinical presentations, biochemical parameters and parathyroid weight were compared between different age groups and gender using appropriate statistical methods. Results: Mean age of patients was 38.5±13.8 years with female: male ratio of 7:3. Rickets as presenting manifestations were seen in one child and adolescent each. Prevalence of renal stones (P=0.03) and gall stones (P=0.02) was higher in the adult groups compared to the younger and older. There was no difference in bone pain (P=0.7), fracture (P=0.3), osteitis fibrosa cystica (P=0.2), fatigue (P=0.6) and other symptoms among different age groups. There was no difference in serum calcium, phosphate, parathyroid hormone (PTH) and 25 (OH) D levels among different age groups, however, as expected alkaline phosphatase was higher in adolescents compared to adults (P=0.03). Bone pain and muscle aches (P<0.001), fracture (P=0.04), osteitis fibrosa cystica (P=0.01), and gall stones (P=0.03) were more common among women while renal stones (P=0.05) and pancreatitis (P=0.02) were common in men. Serum calcium and phosphate levels were similar in either sex but parathyroid hormone (iPTH) level was higher among women (P=0.02). Parathyroid adenoma weight was higher in older compared to young but did not reach to a level of statistical significance. Conclusion: Age and gender have substantial influence on presentation of PHPT. Bone pain and rickets were common in children and adolescents while renal stones in adults. Women have more severe disease as musculoskeletal manifestations are common and iPTH levels are also higher compared to men.

57 citations


Journal ArticleDOI
TL;DR: Forskolin is the first pharmaceutical drug and product derived from a plant to be approved in India by the DCGI in 2006 and it is a lipid-soluble compound that can penetrate cell membranes and stimulates the enzyme adenylate cyclase which decreases intraocular pressure (IOP) by reducing aqueous humor inflow.
Abstract: Forskolin is the first pharmaceutical drug and product derived from a plant to be approved in India by the DCGI in 2006. Forskolin (7beta-acetoxy-8, 13-epoxy-1a, 6β, 9a-trihydroxy-labd-14-en-11-one) is a diterpenoid isolated from plant Coleus forskohlii (Lamiaceae). It is a lipid-soluble compound that can penetrate cell membranes and stimulates the enzyme adenylate cyclase which, in turn, stimulates ciliary epithelium to activate cyclic adenosine monophosphate, which decreases intraocular pressure (IOP) by reducing aqueous humor inflow. The topical application of forskolin is capable of reducing IOP in rabbits, monkeys, and humans. In its drug interactions, forskolin may act synergistically with epinephrine, ephedrine and pseudoephedrine. Whereas the effects of anti-clotting medications like warfarin, clopidogre, aspirin, anoxaparin, etc., may be enhanced by forskolin. Forskolin is contraindicated in the medications for people with ulcers as forskolin may increase acid level. Forskolin has a very good shelf-life of five years. Recently, its Ophthalmic inserts and in situ gels for sustained and delayed-release drug delivery systems were tested in New Zealand Albino Rabbits for its antiglaucoma efficacy. This drug review explains Forskolin as a drug, its antiglaucoma potential and recent findings of forskolin as an antiglaucoma agent. The literature search method used for this review was different databases and search engines like PubMed, International Pharmaceutical Abstracts, Google, Medicinal and Aromatic Plants (MAPA).

57 citations


Journal ArticleDOI
TL;DR: Systematic use of available pharmacotherapy as an adjunct to laser photocoagulation, which is gold standard therapy, can be a useful tool in the prevention of vision loss from DR and related disorders.
Abstract: Diabetic retinopathy (DR) is one of the most debilitating disorders of microvasculature of the retina and one of the leading causes of vision loss among the working class worldwide. At present, intravitreal anti-inflammatory (corticosteroids) and anti-angiogenesis (anti-Vascular Endothelial Growth Factor) agents are being used as wide options for the pharmacotherapy of DR and diabetic macular edema (DME). Anti-inflammatory agents (Triamcinolone acetonide and other agents) have shown evidence-based clinical benefits in various randomized clinical trials for the treatment of DR and DME, and also shown improvement in best corrected visual acuity. However, direct intravitreal injections are associated with serious side-effects like cataract and elevation of Intra Ocular Pressure. Despite this, corticosteroid therapy has been effective for DR and DME, therefore current focus is on the development of novel intravitreal steroid delivery devices that release a small quantity over a prolonged period of time. In addition to corticosteroids, anti-angiogenic agents are found to be effective for the treatment of DR and DME. The most popular target of these agents is the subfamily of proteins known as VEGF, whose over-expression is believed to play a role in numerous diseases including DR and Age-related Macular Degeneration. Intravitreal bevacizumab (Avastin®) and Ranibizumab (Lucentis®) are gaining popularity as a clinical adjunct to panretinal photocoagulation in patients with proliferative DR. Moreover, Lucentis has been recently approved by the United States Food and Drug Administration for macular edema following retinal vein occlusion. Further, systemic agents (specially, hypoglycemic, hypolipidemic and anti-hypertensive agents) have shown beneficial results in reducing the progression of DR. In conclusion, it can be stated that for the present scenario systematic use of available pharmacotherapy as an adjunct to laser photocoagulation, which is gold standard therapy, can be a useful tool in the prevention of vision loss from DR and related disorders. This article summarizes the up-to-date developments in the pharmacotherapy of DR. Method- Literature search was done on online database, Pubmed, Google Scholar, clinitrials.gov and browsing through individual ophthalmology journals and leading pharmaceutical company websites.

46 citations


Journal ArticleDOI
TL;DR: It was observed that the prevalence of hypertension was higher among tribal adult population of Kerala and was associated with age, gender, education, HHs wealth index, physical inactivity, alcohol consumption, and overweight/obesity.
Abstract: Background: Increasing prevalence of hypertension is a public health problem in India. Aims: To study prevalence, correlates, and awareness of hypertension among tribal adult population in Kerala. Setting and Design: A community-based, cross-sectional study was carried out in tribal areas of Kerala by adopting multistage random sampling procedure. Materials and Methods: Data was collected on socio-demographic and behavioral factors, and anthropometric measurements were carried out. Body mass index (BMI) was categorized using the classification recommended for Asians. Waist circumference ≥90 cm for men and ≥80 cm for women was used cut off for defining an abdominal obesity. Bivariate and multivariate analysis was carried out to study association of hypertension with socio-demographic variables, personal habits, and obesity. Results: A total of 4,193 adults (men 1,891, women: 2,302) of ≥20 years of age were covered. The overall prevalence of hypertension was 40% (n=1671). The prevalence of hypertension increases with increase in age among both the genders. Regression analysis showed that the risk of hypertension was significantly (P<0.001) lower among educated and among higher socio-economic status group. Sedentary activity had 1.3 times (CI=1.09-1.60) and alcohol consumption had 1.4 (CI=1.17-1.73) times higher risk of hypertension. The risk of hypertension was 1.7 times higher among overweight/obese subjects. Overall, only 10% (n=164) of the adult population was aware of hypertension status, and about 8% (n=129) were on regular treatment. Conclusion: It was observed that the prevalence of hypertension was higher among tribal adult population of Kerala and was associated with age, gender, education, HHs wealth index, physical inactivity, alcohol consumption, and overweight/obesity.

45 citations


Journal ArticleDOI
TL;DR: Though there are some positive aspects to the list, a critical review of the list reveals areas of major and minor concerns, and an urgent revision of the NLEMI 2011 is suggested so as to avert misinforming the wider international and local readers.
Abstract: Essential medicines lists have been shown to improve the quality and cost-effectiveness of health care delivery when combined with proper procurement policies and good prescribing practices. The Ministry of Health, Government of India revised the National List of Essential Medicines of India (NLEMI 2011) in June 2011, eight years after the last revision. The NLEMI 2011 contains 348 medicines and was prepared over one and a half years by 87 experts. Though there are some positive aspects to the list such as the documentation of a detailed description of the revision process, inclusion of many experts from various fields in the review committee, well written description of the essential medicines concept and others, a critical review of the list reveals areas of major and minor concerns. Improper medicine selection like the inclusion of a nearly obsolete medicine such as ether, an anesthetic agent; non-inclusion of pediatric formulations; spelling errors; and errors in the strengths of formulations diminishes the significance of the NLEMI 2011. In its present form, the NLEMI 2011 did not align with the Indian Pharmacopoeia, and the National Health Programs as well as the National Formulary of India 2010. Formatting errors, non-inclusion of an index page, syntax and spelling errors may also undermine the usefulness of the NLEMI 2011 as a reference material. An urgent revision of the NLEMI 2011 is suggested so as to avert misinforming the wider international and local readers.

42 citations


Journal ArticleDOI
TL;DR: MDR-TB is gradually increased in E PTB cases and predominant resistance to previous treated cases of EPTB, and the molecular drug sensitivity test (DST) method can be an early decision for chemotherapy in MDR- TB patients.
Abstract: Background: Drug-resistant tuberculosis is one of major current challenges to global public health. The transmission of resistant strains is increasing as a burden of multidrug-resistant tuberculosis (MDR-TB) patients in extra pulmonary tuberculosis (EPTB) cases in India. Aim and Objectives: The aim was to study trends of anti-tuberculosis drug resistance pattern in new cases and previously treated cases of EPTB in referral hospitals in northern India. Study Design and Setting: A prospectively observational study and referral medical institutions in northern India. Materials and Methods: All EPTB specimens were processed for Ziehl Neelsen staining, BACTEC culture and BACTEC NAP test for Mycobacterium tuberculosis complex. All M. tuberculosis complex isolates were performed for radiometric-based drug susceptibility pattern against streptomycin, isoniazid, rifampicin and ethambutol using the 1% proportion method. Results: We found that 165/756 (20.5%) isolates were identified as M. tuberculosis complex by the NAP test. We observed that 39.9% were resistant to first-line antitubercular drugs. The resistance rate was higher in previously treated patients: H (30.3%), R (16.3%), E (15.7%) and S (16.3%). MDR-TB was observed in 13.4%, but, in new cases, this was 11.4% and 19.1% of the previously treated patients (P<0.05). Conclusion: MDR-TB is gradually increased in EPTB cases and predominant resistance to previous treated cases of EPTB. The molecular drug sensitivity test (DST) method can be an early decision for chemotherapy in MDR-TB patients. The International Standards of TB Care need to be used by the RNTCP and professional medical associations as a tool to improve TB care in the country.

41 citations


Journal ArticleDOI
TL;DR: Two cases of human fascioliasis from different states in India are presented, one of which had significant symptoms with episodes of fever, abdominal pain and eosiniphilia and underwent multiple diagnostic procedures before the correct diagnosis was reached, which was confirmed by microscopic examination of bile.
Abstract: This report presents two cases of human fascioliasis from different states in India. Although only few cases of human fascioliasis have been reported from India previously, both these cases were encountered within a span of three months at this tertiary care centre. Case 1 had significant symptoms with episodes of fever, abdominal pain and eosiniphilia and underwent multiple diagnostic procedures before the correct diagnosis was reached. Case 2, who had few symptoms, had fascioliasis diagnosed with minimal evaluation. These different presentations seen at two ends of the clinical spectrum of disease along with findings of peripheral eosinophilia, and radiological findings led to a presumptive diagnosis that was then confirmed by microscopic examination of bile. Morphometric analysis of ova from these cases was suggestive of infestation with F. gigantica or a F. gigantica-like hybrid. Both patients were treated with triclabendazole which was imported from Geneva. The need to be aware of the possibility of occurrence of this disease and the inclusion of drugs used for treating the disease, in the Indian drug list, should be emphasized.

34 citations


Journal ArticleDOI
TL;DR: Azithromycin can be recommended as a second-line drug in MDR typhoid fever, however, large trials involving pediatric age group patients are recommended to arrive at a definite conclusion.
Abstract: Background: Drug-resistant typhoid fever is a major clinical problem globally. Emergence of multidrug-resistant (MDR) S. Typhi has complicated therapy by limiting treatment options. Objectives: A meta-analysis was planned to determine the strength of evidence supporting use of azithromycin over the alternate drugs available for treatment of uncomplicated typhoid fever. Materials and Methods: Studies were identified using electronic database such as MEDLINE and other data at the National Library of Medicine assessed using PUBMED search engine as well as Cochrane Clinical Trial Register. Randomized control trials (RCTs) comparing azithromycin with chloramphenicol, fluoroquinolones and cephalosporins in culture-proven enteric fever were included. Data was extracted and methodological quality was assessed. Risk ratio (RR) with 95% confidence intervals was estimated for the dichotomous outcomes and mean difference (MD) with 95% confidence was estimated for continuous data. Primary outcomes studied were clinical failure (CF), microbiological failure, and relapse. Results: A total of seven RCTs involving 773 patients met with our inclusion criteria. In comparison to older fluoroquinolones, azithromycin is marginally better in reducing the chance of CF with RR 0.46 (95% CI 0.25-0.82), while in comparison to ceftriaxone, it significantly reduced the chance of relapse with RR 0.1 (95% CI 0.01- 0.76). There were no serious adverse events reported in any of the trials. Conclusion: Azithromycin can be recommended as a second-line drug in MDR typhoid fever, however, large trials involving pediatric age group patients are recommended to arrive at a definite conclusion.

30 citations


Journal ArticleDOI
TL;DR: The authors suggest that though, there are a few challenging and unanswered questions, the public health preparedness still remains the key to control emerging and re-emerging diseases.
Abstract: The emerging and re-emerging diseases are posing a great health risk for the last few years. One such category of diseases is viral haemorrhagic fevers (VHFs), which have emerged in the new territories, worldwide. Crimean Congo Hemorrhagic Fever (CCHF) cases, for the first time in India, were reported from Gujarat, in January 2011. The emergence of diseases not reported earlier, pose great economic and social challenge, burden health system, and create panic reaction. Nonetheless, with recent experience in control of epidemic diseases, and advances in basic scientific knowledge; the public health community is better prepared for these unexpected events. This review provides information to physicians on CCHF for managing outbreak, and identifies public health measures to prevent emergence and re-emergence of VHFs (including CCHF) in future. The authors suggest that though, there are a few challenging and unanswered questions, the public health preparedness still remains the key to control emerging and re-emerging diseases. The countries where virus activities have been reported need to be prepared accordingly.

26 citations


Journal ArticleDOI
TL;DR: Children with newly-diagnosed SpLD perceive their psychosocial, physical, and overall HRQoL to be significantly compromised.
Abstract: Background: Specific learning disability (SpLD) often remains undetected, resulting in the afflicted child experiencing chronic poor school performance. Aims: To measure and analyze the self-perceived health-related quality of life (HRQoL) of children with newly-diagnosed SpLD. Settings and Design: Cross-sectional questionnaire-based study in our clinic. Materials and Methods: From February to December 2008, 150 children consecutively diagnosed as having SpLD were enrolled and their HRQoL documented using the DISABKIDS chronic generic module self-report version instrument. Statistical Analysis: Multiple regression analysis was carried out for determining the 'independent' impact that each of the clinical and socio-demographic variables had on a poor facet score outcome and on a poor total score outcome. Results: Clinically significant deficits were detected in all 6 facets, namely: 'large deficits (effect size ≥−0.8)' in social exclusion, emotion, limitation, treatment, and independence; and 'medium deficit (effect size −0.5 to <−0.8)' in social inclusion; and 'large deficit' in total score. Multivariate analysis revealed that: (i) not belonging to the upper socio-economic strata of society was an independent predictor of a poor independence facet outcome (P=0.010, OR=1.99, 95% CI: 1.18 to 3.37); (ii) not having experienced class detainment was an independent predictor of a poor emotion facet outcome (P=0.008, OR=3.04, 95% CI: 1.34 to 6.85); (iii) first-born status was an independent predictor of a poor limitation facet outcome (P=0.022, OR=2.60, 95% CI: 1.15 to 5.90); and (iv) female gender was an independent predictor of a poor social exclusion facet outcome (P=0.024, OR=0.28, 95% CI: 0.09 to 0.85) and a poor overall health outcome (P=0.025, OR=0.32, 95% CI: 0.12 to 0.87). Conclusions: Children with newly-diagnosed SpLD perceive their psychosocial, physical, and overall HRQoL to be significantly compromised.

Journal ArticleDOI
TL;DR: The current available literature on medication errors in ambulatory settings and the possible strategies that can be adopted to reduce the burden of these errors in order to improve child care and patient safety are summarized.
Abstract: Worldwide, a large number of children are prescribed drugs on an outpatient basis. Medication errors are fairly common in these settings. Though this matter has been well recognized as a cause of concern, limited data is available from ambulatory settings. Medication errors can be defined as errors that may occur at any step, starting from ordering a medication, to dispensing, administration of the drug and the subsequent monitoring. The outcomes of such errors are variable and may range between those that are clinically insignificant to a life-threatening event. The reasons for these medication errors are multi-factorial. Children are unable to administer medications to themselves and also require a strict weight-based dosing regimen. The risk factors associated with medication errors include complex regimens with multiple medications. Overdosing and under-dosing (10-fold calculation errors), an increased or a decreased frequency of dosing or an inappropriate duration of administration of the medication, are frequently detected errors. The lack of availability of proper formulations adds to the confusion. The low level of literacy among the caregivers can aggravate this problem. There is a lack of proper reporting and monitoring mechanisms in most ambulatory settings, hence these errors remain unrecognized and often go unreported. This article summarizes the current available literature on medication errors in ambulatory settings and the possible strategies that can be adopted to reduce the burden of these errors in order to improve child care and patient safety. Voluntary, anonymous reporting can be introduced in the healthcare institutions to determine the incidence of these errors.


Journal ArticleDOI
TL;DR: Among identified gaps, delays in the initiation of the investigation of the epidemic and repairing of leakages were most important.
Abstract: Background: On December 19, 2010, 57 cases of gastroenteritis were reported in the community health center of Lalpur town. A rapid response team was sent to investigate the outbreak on December 21, 2010. Aim: To identify the source, to institute control and prevention measures. Materials and Methods: The outbreak was confirmed using the previous Integrated Integrated Disease Surveillance Project (IDSP) data. Detailed history was taken, line listing of patients and house-to-house investigations were done. Environmental investigation and laboratory investigation of stool samples were also done. As the study was conducted during emergency response to the outbreak and was designed to provide information to orient the public health response, ethical approval was not required. Remedial measures were implemented. Results: Three hundred and thirty cases were reported during December 19, 2010 to January 2, 2011 in Lalpur town of Jamnagar district. Nineteen patients were found to be positive for Vibrio Cholerae 01 serotype ogawa biotype out of 117 stool samples. The mean age of patients was 24.23΁19.01 years. The outbreak had 1.88% attack rate with no mortality and 59.1% cases had to be admitted. Investigations revealed that the epidemic was waterborne. Ten leakages were found in the pipelines of the affected areas of Lalpur town near two riverbanks. Conclusion: Among identified gaps, delays in the initiation of the investigation of the epidemic and repairing of leakages were most important. In India, waterborne epidemics are usual occurrences during the year. In this scenario, the village health and sanitation committee and water board should follow guidelines, and monitoring of water sources, proper sewage disposal and sanitation measures should be undertaken.

Journal ArticleDOI
TL;DR: The present study evaluated the transverse cervical pedicle diameter of C2-C7 vertebrae in a pilot study in 27 Indian subjects using computed tomography (CT) imaging and evaluated the feasibility of transpedicular screw fixation in them, finding that the transversal pedicles in the Indian subjects is smaller compared to the Western population.
Abstract: Background: Cervical transpedicular screw fixation is safe and is probably going to be the gold standard for cervical spine fixation. However, cervical transpedicular screw use in the Asian population can be limited as the transverse diameter in this group of patients may not be adequate to accommodate the 3.5-mm pedicular screw thus injuring the vital structures located in the close proximity of the pedicles. Thus lateral mass fixation remains the mainstay of treatment. The present study evaluated the transverse cervical pedicle diameter of C2-C7 vertebrae in a pilot study in 27 Indian subjects using computed tomography (CT) imaging and evaluated the feasibility of transpedicular screw fixation in them. Aims: To evaluate the feasibility of transpedicular screw fixation in the Indian population. Settings and Design: The cervical pedicle diameter size differs between the Asian and non-Asian population. The authors studied the transverse pedicle diameter of the C2-C7 of the cervical spine in the Indian population using CT measurements. This cross-sectional study was carried out at a tertiary care centre for a period of four months from October 2010 to December 2010. Material and Methods: Measurements of cervical pedicles in the subjects were performed on the CT workstation from the CT images taken at 2.5-mm interval. The transverse pedicle diameter was defined as the outermost diameter of the pedicle, taken perpendicular to the axis of the pedicle at the narrowest point and measured in millimeters±0.1 mm. Statistical Analysis: Descriptive statistics was used to represent percentage of transverse diameter of cervical pedicles less than 5 mm in male and female subjects at C2-C7 levels. Since there is no previous study done in India, we initiated the study with sample size of 27 as a pilot study. The statistical analysis was performed using SPSS software. Results: The mean transverse diameters of the cervical pedicles of C2, C3, C4, C5, C6 and C7 in males were 5.3, 5.3, 5.3, 5.6, 5.6 and 6.1 mm respectively and ranged between 5.3 to 6.1 mm. The mean transverse diameters of the cervical pedicles of C2, C3, C4, C5, C6 and C7 in females were 5.1, 4.6, 4.7, 4.7, 5.3 and 5.6 mm respectively and ranged between 4.6 to 5.6 mm. Between 2.1% and 55.7% of pedicles in our male population and between 5.5% and 74.3% pedicles in our female population was smaller than 5.0 mm in transverse diameter and thus cannot have fixation with a 3.5 mm screw using this technique. Conclusions: We found that the transverse pedicle diameter of cervical pedicles in the Indian subjects is smaller compared to the Western population. Although transpedicular screw fixation has stronger pullout strength compared to lateral mass fixation, its use must be considered carefully and individually. Preoperative CT evaluation is a must before transpedicular fixation in the cervical spine, especially in the Indian female population. As an option 2.7-mm screws can be devised for the Indian population giving a wider safety margin.

Journal ArticleDOI
TL;DR: Reporting of MLR in many Indian journals is incomplete, and Appropriate guidelines in instructions to authors, and pre-publication review of articles using MLR by a qualified statistician may improve quality of reporting.
Abstract: Background: Use of multivariable logistic regression (MLR) modeling has steeply increased in the medical literature over the past few years. Testing of model assumptions and adequate reporting of MLR allow the reader to interpret results more accurately. Aims: To review the fulfillment of assumptions and reporting quality of MLR in selected Indian medical journals using established criteria. Setting and Design: Analysis of published literature. Materials and Methods: Medknow.com publishes 68 Indian medical journals with open access. Eight of these journals had at least five articles using MLR between the years 1994 to 2008. Articles from each of these journals were evaluated according to the previously established 10-point quality criteria for reporting and to test the MLR model assumptions. Statistical Analysis: SPSS 17 software and non-parametric test (Kruskal-Wallis H, Mann Whitney U, Spearman Correlation). Results: One hundred and nine articles were finally found using MLR for analyzing the data in the selected eight journals. The number of such articles gradually increased after year 2003, but quality score remained almost similar over time. P value, odds ratio, and 95% confidence interval for coefficients in MLR was reported in 75.2% and sufficient cases (>10) per covariate of limiting sample size were reported in the 58.7% of the articles. No article reported the test for conformity of linear gradient for continuous covariates. Total score was not significantly different across the journals. However, involvement of statistician or epidemiologist as a co-author improved the average quality score significantly (P=0.014). Conclusions: Reporting of MLR in many Indian journals is incomplete. Only one article managed to score 8 out of 10 among 109 articles under review. All others scored less. Appropriate guidelines in instructions to authors, and pre-publication review of articles using MLR by a qualified statistician may improve quality of reporting.

Journal ArticleDOI
TL;DR: 5HT 3 antagonists are superior to other pharmacological interventions for the prevention of PONV in patients undergoing breast surgery under general anesthesia.
Abstract: Background: Postoperative nausea and vomiting (PONV) are distressing adverse events following breast cancer surgery with an incidence of up to 80%. 5HT 3 antagonists are commonly employed as drugs of first choice for PONV although there is no clear evidence favoring one pharmacological approach over another. Aims: The objective of this meta-analysis is to compare the efficacy of 5HT 3 antagonists against all non-5HT 3 antagonism-based pharmacological approaches as a preemptive strategy for PONV in women undergoing breast surgery. Design: Meta-analysis of Randomized Controlled Trials. Materials and Methods: Literature search was conducted through PUBMED, reference lists, and Cochrane Central Register of Controlled Trials till June 2010 to identify eligible studies. Trials comparing 5-HT 3 antagonists with placebo or active controls for prophylaxis against PONV in women undergoing breast surgery were included. Two reviewers extracted the data independently. Methodological quality of each trial was assessed using Jadad score. Results: Nineteen trials were included. All trials were of good methodological quality (Jadad score >3). 5HT 3 antagonists were found superior to placebo [Odds ratio (OR)=0.18 (0.13-0.26)] or active controls [OR=0.65 (0.47-0.91)] in the prevention of PONV. 5HT 3 antagonists were also superior to placebo in preventing nausea alone [OR=0.51 (0.34-0.76)], vomiting [OR=0.31 (0.20-0.47)] and the use of rescue antiemetics [OR=0.18 (0.11-0.28)]. No significant difference was observed in the use of rescue antiemetics as compared to active controls [0.59 (0.19 to 1.86)]. Conclusion: 5HT 3 antagonists are superior to other pharmacological interventions for the prevention of PONV in patients undergoing breast surgery under general anesthesia.

Journal ArticleDOI
TL;DR: Prophylactic use of gabapentin 600 mg in laparoscopic cholecystectomy decreases the incidence and severity of myalgia and fentanyl consumption and decreases fentanyl consumption significantly in the study group.
Abstract: Background: Succinylcholine is used for rapid-sequence induction of anesthesia. Fasciculations and myalgia are adverse effects. The pretreatment modalities prevent or minimize its adverse effects. Aims: The present study is designed to evaluate the efficacy of gabapentin on the incidence of fasciculation and succinylcholine-induced myalgia. Settings and Design: The study was conducted at a tertiary care teaching hospital in a randomized, double-blinded, placebo-controlled manner. Materials and Methods: Patients of both genders undergoing laparoscopic cholecystectomy were randomly assigned to two groups. Patients in Group I (Gabapentin group) received 600 mg of gabapentin orally 2 h prior to surgery and patients in Group II (placebo group) received matching placebo. Anesthesia was induced with fentanyl 3 μg/kg, thiopentone 3-5 mg/kg and succinylcholine 1.5 mg/kg. All patients were observed and graded for fasciculations by a blinded observer and patients were intubated. Anesthesia was maintained with oxygen in air, sevoflurane and intermittent vecuronium bromide. After completion of surgery, neuromuscular blockade was reversed. A blinded observer recorded myalgia grade at 24 h. Patients were provided patient-controlled analgesia with fentanyl for postoperative pain relief. Statistical analysis: Demographic data, fasciculation grade, fentanyl consumption, and myalgia grade were compared using student t test and test of proportions. Results: The study included 76 American Society of Anesthesiologists' Grade I or II patients of either gender undergoing laparoscopic cholecystectomy. But only 70 patients completed the study. Results demonstrated that the prophylactic use of gabapentin significantly decreases the incidence and the severity of myalgia (20/35 vs. 11/35) (P<0.05) and decreases fentanyl consumption significantly in the study group (620+164 μg vs. 989+238 μg) (P<0.05) without any effects on the incidence and severity of fasciculations. Conclusions: Prophylactic use of gabapentin 600 mg in laparoscopic cholecystectomy decreases the incidence and severity of myalgia and fentanyl consumption.

Journal ArticleDOI
TL;DR: The utility of repeat C. diff testing for hospitalized patients has low clinical utility and may be considered in outbreak settings or when the pre-test probability of disease is high, but future studies should aim to identify patients with a likelihood of disease and determine the utility ofrepeat testing compared with empiric treatment.
Abstract: Over the last 20 years, the prevalence of healthcare-associated Clostridium difficile (C. diff) disease has increased. While multiple tests are available for the diagnosis of C. diff infection, enzyme immunoassay (EIA) testing for toxin is the most used. Repeat EIA testing, although of limited utility, is common in medical practice. To assess the utility of repeat EIA testing to diagnose C. diff infections. Systematic literature review. Eligible studies performed >1 EIA test for C. diff toxin and were published in English. Electronic searches of MEDLINE and EMBASE were performed and bibliographies of review articles and conference abstracts were hand searched. Of 805 citations identified, 32 were reviewed in detail and nine were included in the final review. All studies except one were retrospective chart reviews. Seven studies had data on number of participants (32,526), and the overall reporting of test setting and patient characteristics was poor. The prevalence of C. diff infection ranged from 9.1% to 18.5%. The yield of the first EIA test ranged from 8.4% to 16.6%, dropping to 1.5-4.7% with a second test. The utility of repeat testing was evident in outbreak settings, where the yield of repeat testing was 5%. Repeat C. diff testing for hospitalized patients has low clinical utility and may be considered in outbreak settings or when the pre-test probability of disease is high. Future studies should aim to identify patients with a likelihood of disease and determine the utility of repeat testing compared with empiric treatment.

Journal ArticleDOI
TL;DR: In CA SSTIs, methicillin-susceptible S. aureus is the predominant pathogen and penicillinase-resistant penicillins, clindamycin and erythromycin in that order can be used as suitable antimicrobials for empiric therapy.
Abstract: Background: To improve the empiric antimicrobial therapy of community-acquired (CA) skin and soft tissue infections (SSTIs), it is necessary to generate data on the current spectrum and susceptibility profile of associated bacteria. CA methicillin-resistant Staphylococcus aureus (CA MRSA) is increasingly being reported in SSTIs in India and globally. Aims: The present study was undertaken to determine the bacterial profile of CA-SSTIs, to know the contribution of MRSA in these infections, to determine inducible clindamycin resistance in S. aureus and to compare the resistance patterns of isolates from hospital-acquired (HA) SSTIs. Materials and Methods: Eight hundred and twenty patients with CA SSTIs were prospectively studied. Pus samples were cultured and antimicrobial susceptibility pattern determined. Inducible clindamycin resistance was detected by D-test. Laboratory records were analyzed retrospectively to generate data on HA SSTIs. Results: 619 isolates were recovered in CA-SSTIs, of which S. aureus (73%) and Streptococci (12%) were the most common. Pseudomonas aeruginosa (28%) and Acinetobacter spp (18%) were the predominant HA-SSTI pathogens. Susceptibility of CA S. aureus to antibiotics tested was, penicillin (6%), co-trimoxazole (20%), ciprofloxacin (37%), cefazolin (100%), erythromycin (84%), clindamycin (97%), gentamicin (94%) and fusidic acid (95%). No MRSA was found in CA SSTIs whereas 45% of HA S. aureus strains were methicillin-resistant. HA strains demonstrated significantly higher resistance as compared to their CA counterparts (P<0.001). D test was positive in 22% of CA S. aureus tested. Conclusions: In CA SSTIs, methicillin-susceptible S. aureus is the predominant pathogen. Penicillinase-resistant penicillins, clindamycin and erythromycin in that order can be used as suitable antimicrobials for empiric therapy. D test should be carried out routinely. No CA MRSA was detected in the present series.

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TL;DR: Important attributes of fluticasone furoate include low systemic bioavailability, 24-h symptom relief with once-daily dosing, comprehensive coverage of both nasal and ocular symptoms, safety and tolerability with daily use, and availability in a side-actuated device that makes medication delivery simple and consistent.
Abstract: Intranasal corticosteroids are recommended as one of the first-line therapies for the treatment of allergic rhinitis (AR), especially when associated with nasal congestion and recurrent symptoms. Fluticasone furoate is a novel enhanced-affinity glucocorticoid for the treatment of AR approved by the Food and Drug Administration in 2007 and recently introduced in India. Fluticasone furoate nasal spray is indicated for the treatment of the symptoms of seasonal and perennial AR in patients aged two years and older. This review summarizes the clinical data on fluticasone furoate nasal spray and discusses its role in the management of AR. Important attributes of fluticasone furoate include low systemic bioavailability (<0.5%), 24-h symptom relief with once-daily dosing, comprehensive coverage of both nasal and ocular symptoms, safety and tolerability with daily use, and availability in a side-actuated device that makes medication delivery simple and consistent. With these properties, fluticasone furoate nasal spray has the potential to enhance patient satisfaction and compliance, thus making it a good choice amongst available intranasal steroids.

Journal ArticleDOI
TL;DR: The urine testing was found to have 100% sensitivity and 86.33% specificity for the diagnosis of VL and has the potentiality of providing a new, yet simplest non-invasive screening tool for VL in remote rural areas.
Abstract: Background: Diagnosis of visceral leishmaniasis (VL) is a major obstacle in the control of this disease. The rK39 strip-test using patient's blood is a breakthrough; however, it still requires a blood sample, which is a concern for safety in the field. We tried to simplify the test using the patient's urine instead of blood. Aims: To observe the sensitivity and specificity of the urine test in comparison with the blood test. Materials and Methods: We tested active and post-treatment VL patients, Post Kala azar dermal leishmaniasis (PKDL), VL/HIV and control subjects (healthy, disease suspects and diseased other than VL) with the rK39 strip-test using blood and urine samples. Statistical Analysis: The level of agreement between the urine and blood testing was calculated by inter-rater agreement (kappa) statistics. Results: Forty-two active VL, 40 treated VL, six PKDL, three VL/HIV and 139 controls (54 healthy, 21 disease suspects and 64 diseased other than VL) were tested. All VL-related cases showed positive results with urine as well as blood samples (100%). The urine testing was found to have 100% sensitivity and 86.33% specificity for the diagnosis of VL. Kappa statistic between the two methods was 0.916 (P<0.001). Urine testing had more false-positive results in comparison with blood testing (13.67% vs. 9.45%), but the test subjects were from VL-endemic areas and they might be exposed to Leishmania donovani infection. Conclusions: The present study has the potentiality of providing a new, yet simplest non-invasive screening tool for VL in remote rural areas.

Journal ArticleDOI
TL;DR: This is a rare presentation of a known condition in an HIV-infected pre-pubertal male child, which did not respond to usual modalities of treatment and had to be treated with antiretroviral therapy.
Abstract: Hidradenitis suppurativa (HS), a painful and chronic condition, commonly occurs in women and coincides with post-pubertal increase in sex hormones. A 13-year-old pre-pubertal HIV-infected male child presented to our clinic with a discharging right axillary lymph node swelling. The biopsy of the lesion showed features of HS. The patient was treated with oral antibiotics, oral steroids, and local antibiotic wash. Though the patient responded to this treatment, the clinical response was not adequate and the lesion recurred. Subsequently, the child was started on antiretroviral therapy (zidovudine, lamivudine, and nevirapine). Following these medications, the lesions healed and had not recurred till we last examined the child. Thus, this is a rare presentation of a known condition in an HIV-infected pre-pubertal male child, which did not respond to usual modalities of treatment and had to be treated with antiretroviral therapy.

Journal ArticleDOI
TL;DR: The recent advances in the development of novel targets of anticoagulants are discussed, including direct thrombin inhibitors and Factor X inhibitors, which are the most clinically advanced.
Abstract: Well-documented drawbacks of traditional anticoagulants have lead to the quest for an ideal anticoagulant resulting in a surge of novel anticoagulant molecules. These newer agents directly target specific steps in coagulation cascade and include newer low molecular weight heparins (adomiparin), ultra low molecular weight heparins (semuloparin, RO-14), inhibitors of activated factor II (dabigatran, AZD0837), X (rivaroxaban, apixaban, edoxaban, betrixaban), IX (REG1,2), XI (antisense oligonucleotides, BMS 262084, clavatadine A), VII/tissue factor (tifacogin, PCI 274836, and BMS 593214), V (recomodulin, solulin), VIII (TB402), dual thrombin/factor X inhibitors (EP21709, tanogitran), and newer vitamin K antagonists (tecarfarin). Direct thrombin inhibitors and Factor X inhibitors are the most clinically advanced. This article discusses the recent advances in the development of novel targets of anticoagulants. Medline, EMBASE, cochrane database, medscape, SCOPUS, and clinicaltrials.gov were searched using terms "anticoagulants", "blood coagulation inhibitors", "anticoagulants and venous thromboembolism", "anticoagulants and atrial fibrillation", and "'antithrombins." Journal articles published from 2007 to 2012 discussing pharmacology and/or clinical trials were screened.

Journal ArticleDOI
TL;DR: This study shows the usefulness of the integration of medical students' reflection-in-learning practices and examination performance in providing descriptive feedback.
Abstract: Background: Feedback provided by integrating students' examination performance and the reflection on learning process may assist medical students to identify the essential learning processes required for better understanding of learning material. Aims: To investigate the relationship between the student's learning process and examination performance and to explore students' perspectives on professional feedback given by integrating the self-reflection on learning process and individual examination performance. Settings and Design: At the end of every medical school block examination, faculty provided descriptive feedback to students regarding individual performance in each subject area. The study had a quasi-experimental design. Materials and Methods: Students' (n=153) self-reflection on learning process was collected using a reflection-in-learning scale. The learning process of the students categorized in fail, pass and first-class categories were compared. Students' self-reflection-in-learning and common mistakes found in answering essay questions were used to offer feedback. Students' perspectives regarding feedback were collected using a validated questionnaire. Statistical Analysis: Kruskal-Wallis test and Mann-Whitney test were used to analyze the data. A P<0.017 was considered as statistically significant. Results: The median score of each item related to reflection was ≤4 (Scale 1-7) in all categories of students (n=153) reflecting a low level of reflection. There was a statistically significant difference in total reflection scores between fail (n=46) and first class category (n=42) students (P=0.002). The majority of students agreed feedback assisted in examination preparation, enhanced individual learning and allowed examinations to be viewed as more objective. Conclusions: This study shows the usefulness of the integration of medical students' reflection-in-learning practices and examination performance in providing descriptive feedback. This modified feedback process may have improved students' awareness leading to acceptance and a conscious practice of self-reflection and enhanced students' examination performance.

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TL;DR: The occurrence of the exonic variants of FST gene seems to be dependent on the ethnic background of the subjects under study and its role in the PCOS pathophysiology cannot be established with hitherto available evidence.
Abstract: Background: Out of a panel of 37 candidate genes tested for linkage with polycystic ovary syndrome (PCOS), the strongest evidence of linkage was reported in the follistatin (FST) gene region. Subsequently, a couple of studies outside India investigated the FST gene for the presence of any mutations and its association with PCOS and the results were found to be largely inconsistent probably due to differences in the ethnic backgrounds and small sample sizes. Aims: To screen the FST gene for mutations and to establish their association pattern with PCOS among a large cohort of South Indian women. Settings and Design: Case-control study. Materials and Methods: PCOS cases were recruited according to the 2003 Rotterdam diagnostic criteria. All the exons of the FST gene were amplified and analyzed in all the cases and controls for the presence of mutations using polymerase chain reaction (PCR) and direct DNA sequencing. Results: A total of 549 women consisting of 250 PCOS cases and 299 controls were recruited for the study. No mutations were found in any of the exons of the FST gene in our Indian sample which is consistent with an earlier finding among the Asian women from Singapore. Although three of the four cohorts of Caucasian background studied earlier reported variants, none of them could establish a strong association with PCOS. Conclusions: The occurrence of the exonic variants of FST gene seems to be dependent on the ethnic background of the subjects under study and its role in the PCOS pathophysiology cannot be established with hitherto available evidence.

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TL;DR: Although there was a slight transient cognitive impairment detected with the screening tests following acute OP ingestion, no long-term cognitive defects was detected.
Abstract: Background : Chronic damage to the central nervous system resulting in cognitive impairment has been shown with repeated, low doses of organophosphorus (OP) exposure over month or years. Aim: The study aimed to find out whether there is any cognitive impairment following acute OP exposure that could be detected by a simple screening instrument, the Mini Mental State Examination (MMSE), in clinical settings. Settings and Design: A cohort study. Materials and Methods: The study was conducted with matched controls. Consecutive patients admitted to the hospital with acute ingestion of OP were recruited. Cognitive function was assessed with the MMSE, digit span test, test of long-term memory function and concentration. Patients were assessed twice: at 1 and 6 weeks of exposure. Statistical Analysis: Continuous variables were analyzed with the paired and unpaired T-tests. Non-normally distributed data were analyzed with the Mann-Whitney U test and Wilcoxon Signed Rank test. Discrete variables were analyzed with the Chi-square test. Results: There were 60 patients and 61 controls. The mean age (SD) of the patients and controls was 31.5 (11.6) and 31.3 (11.8) years, respectively. Forty-two patients turned up for the second assessment. Significant impairment of cognitive function was seen in the total score of MMSE (95% CI -2.5 to -0.3), orientation (95% CI -1 to -0.2) and language (95% CI -0.9 to -0.1) domains of MMSE, digit span test (95% CI 0.1-1.7) and test of long-term memory function (95% CI 0.3-2.3) in the first assessment compared with the controls. When the results of the second assessment were compared with the controls, no significant differences were seen. Conclusion: Although there was a slight transient cognitive impairment detected with the screening tests following acute OP ingestion, no long-term cognitive defects was detected.

Journal ArticleDOI
TL;DR: The present study indicates that, despite comparable surgical trauma, the OPCAB significantly reduces tissue injury and may contribute to improved organ function, and improved postoperative recovery.
Abstract: Background: Coronary artery bypass grafting (CABG) is done either using cardiopulmonary bypass (CPB) or without using CPB (OPCAB). But, recently, reports have shown that CPB is associated with increased postoperative morbidity because of the involvement of many systems. Aims: The aim of this prospective study was to evaluate the influence of the technique of surgery on various tissue injury markers and the extent of endothelial activation in patients undergoing CABG and OPCAB coronary revascularization. Settings and Design: This study was conducted at a tertiary healthcare center during the period May 2008 to December 2009. Materials and Methods: This was a prospective nonrandomized blinded study. The activities of Creatine Phosphokinase (CK) and its isoenzyme CK-MB, Lactate dehydrogenase (LDH), levels of cardiac Troponin I, soluble vascular cell adhesion molecule-1 (sVCAM-I) and systemic nitric oxide production were assessed. Statistical analysis: All the results were expressed as Mean±SD. P value ≤0.05 was considered significant. The statistical analysis was carried out using SPSS Version 11.5-computer software (SPSS Inc., Chicago, IL, USA). Results: The surgical trauma had elevated CK, CK-MB and Troponin I in both the groups and further elevation was seen in the CABG group in comparison to OPCAB (P<0.001). The Troponin I concentrations showed an increase from 0.11±0.02 preoperatively to 6.59±0.59 (ng/ml) at 24 h (P<0.001) compared to the OPCAB group. Mean serum levels of sVCAM-1 increased significantly after surgery in both the groups (P<0.02). To determine serum nitric oxide (NO) production, NO2− and NO3− (stable end products of NO oxidation) were analyzed which also increased significantly at 24 h in both the groups. But the increase was not significant at 48 h in both the groups compared to the preoperative value in our study. Conclusion: The present study indicates that, despite comparable surgical trauma, the OPCAB significantly reduces tissue injury. The overall pattern of endothelial activation after OPCAB is significantly lower than that after CABG. This may contribute to improved organ function, and improved postoperative recovery.

Journal ArticleDOI
TL;DR: The relative commonness of reduced-activity CYP2B6 alleles in this study called for attention in terms of dosage requirements for MMT and ARV in Malaysia.
Abstract: Background: Drugs with complex pharmacology are used in the management of drug use disorder (DUD) and HIV/AIDS in Malaysia and in parts of South-East Asia. Their multiethnic populations suggest complexity due to the genetic polymorphism, such as CYP2B6 that metabolizes methadone and anti-retroviral. Aims: Our aim was to explore the genetic polymorphism of CYP2B6 among Malays, Chinese, Indians, and opiate-dependent individuals in Malaysia. Settings and Design: The study utilized DNA from our previous studies on CYPs and new recruitments from opiate-dependent individuals. Materials and Methods: For the new recruitment, after obtaining consent and baseline demography, 5 ml blood was obtained from patients attending methadone maintenance therapy (MMT) Clinics. Genomic DNA was extracted using standard methods. 10 nucleotide changes associated with CYP2B6*10, CYP2B6*2, CYP2B6*17, CYP2B6*11, CYP2B6*8, CYP2B6*14, CYP2B6*9, CYP2B6*4, CYP2B6*6, CYP2B6*27, and CYP2B6*20 were determined using multiplex nested allele-specific PCR. Statistical Analysis: Descriptive statistics were used to summarize demographic data. Differences in allele frequencies between populations were tested using Chi-squared test and were corrected using the Bonferroni test. Results: CYP2B6 polymorphism in Malaysia is variable with trends that suggest an ethnic difference. Reduced activity CYP2B6*6 occurred in 13% to 26% among Malays, Chinese, Indians and opiate-dependent individuals. Another 'reduced activity', CYP2B6*2 allele, was found at much lower percentages in the groups. Conclusions: The relative commonness of reduced-activity CYP2B6 alleles in our study called for attention in terms of dosage requirements for MMT and ARV in Malaysia. It also implored follow-up association studies to determine its relevance and consequences in personalized medicine for drug use disorder and HIV/AIDS.

Journal ArticleDOI
TL;DR: A case of scrub typhus with a rare ophthalmic manifestation that highlights the increasingly complex presentation of common diseases and indicates there is much to be discovered about the immunopathogenesis of this infectious disease.
Abstract: Scrub typhus is a mite borne infectious disease caused by Orientia tsutsugamushi. It is a common cause of undifferentiated febrile illness in the Indian subcontinent. We present a case of scrub typhus with a rare ophthalmic manifestation.Our patient presented with fever and opsoclonus, was diagnosed to have scrub typhus and completely improved upon treatment. Opsoclonus complicates various medical diseases, including viral infections, toxin, encephalitis, brain tumors, and paraneoplastic syndromes. There has been only one previously reported case of opsoclonus in scrub typhus. This phenomenon highlights the increasingly complex presentation of common diseases. It also indicates there is much to be discovered about the immunopathogenesis of this infectious disease.