Showing papers in "Journal of Postgraduate Medicine in 2020"
TL;DR: A comprehensive review of workplace violence against doctors is presented, discussing the prevalence, degree of violence, predictors, impact on physical and psychological health and intervention strategies to devise practical actions against workplace violence.
Abstract: Workplace violence is a major occupational issue concerning doctors that has a significant impact on their physical and psychological well-being. This ultimately affects the health care services of the country. Patient-led episodes of verbal violence are more prevalent in Asian countries, especially in the emergency department, psychiatric wards, and intensive care units, mostly faced by junior doctors and residents. Some common precursors of violence against doctors are patients and their attendants' dissatisfaction and low impulse control, poor administration, miscommunication, infrastructural issues especially differences in services between private and public hospitals, and negative media portrayal of doctors. The assessment of risk factors, development and implementation of workplace violence programs, and addressing underreporting of violent episodes have been suggested as some successful organizational mitigation strategies. Recommendations on the management of workplace violence include the development of participative, gender-based, culture-based, nondiscriminatory, and systematic strategies to deal with issues related to violence. This article aims to present a comprehensive review of workplace violence against doctors, discussing the prevalence, degree of violence, predictors, impact on physical and psychological health and intervention strategies to devise practical actions against workplace violence.
53 citations
TL;DR: A recognized category of O TC medicines by law, patient awareness programs, and support of pharmacists and pharmaceutical companies are required to optimize the use of OTC medicines in India.
Abstract: Patients often approach a pharmacist instead of visiting a doctor for minor ailments such as cough, cold, allergies, pain, fever, acidity, diarrhea, and skin-related conditions. Purchase of specific medicines over the counter is legally recognized in most countries. 'Over-the-Counter (OTC) Medicines' means drugs which are legally allowed to be sold by pharmacists without need for a prescription. The term does not have a legal definition in India. Technically, drugs are OTC unless they are specifically stated as prescription only drugs. OTC drugs allow faster and cheaper access to healthcare; however, their misuse and adverse health effects cause concerns. This article describes concept of OTC medicines and practices in India against the background of globally prevalent regulations and practices. A recognized category of OTC medicines by law, patient awareness programs, and support of pharmacists and pharmaceutical companies are required to optimize the use of OTC medicines in India.
33 citations
TL;DR: There is an urgent need to improve maternity care in India by making it more respectful, dignified, and women-centered by addressing various forms of ill-treatment, determinants, and pooled prevalence of disrespectful maternity care.
Abstract: Background: Respectful maternity care is a rightful expectation of women. However, disrespectful maternity care is prevalent in various settings. Therefore, a systematic review and meta-analysis were conducted to identify various forms of ill-treatment, determinants, and pooled prevalence of disrespectful maternity care in India. Methods: A systematic review was performed in various databases. After quality assessment, seven studies were included. Pooled prevalence was estimated using the inverse variance method and the random-effects model using Review Manager Software. Results: Individual study prevalence ranged from 20.9% to 100%. The overall pooled prevalence of disrespectful maternity care was 71.31% (95% CI 39.84–102.78). Pooled prevalence in community-based studies was 77.32% (95% CI 56.71–97.93), which was higher as compared to studies conducted in health facilities, this being 65.38% (95% CI 15.76–115.01). The highest reported form of ill-treatment was non-consent (49.84%), verbal abuse (25.75%) followed by threats (23.25%), physical abuse (16.96%), and discrimination (14.79%). Besides, other factors identified included lack of dignity, delivery by unqualified personnel, lack of privacy, demand for informal payments, and lack of basic infrastructure, hygiene, and sanitation. The determinants identified for disrespect and abuse were sociocultural factors including age, socioeconomic status, caste, parity, women autonomy, empowerment, comorbidities, and environmental factors including infrastructural issues, overcrowding, ill-equipped health facilities, supply constraints, and healthcare access. Conclusion: The high prevalence of disrespectful maternity care indicates an urgent need to improve maternity care in India by making it more respectful, dignified, and women-centered. Interventions, policies, and programs should be implemented that will protect the fundamental rights of women.
25 citations
TL;DR: CBL aided by WhatsApp helped students acquire knowledge, discuss and learn actively, score more, and retain better than DL, and perceived that CBL enhanced their curiosity; hence, the acquired knowledge through various resources was retained better.
Abstract: Aims: The present study was carried out for comparative evaluation of case-based learning (CBL) aided with WhatsApp and didactic lectures (DL) while teaching a pathology topic to second-year medical students. In addition, the acceptability of WhatsApp as an aid to CBL was assessed. Material and Methods: After obtaining informed consent, 70 second-year Bachelor of Medicine and Bachelor of Surgery (MBBS) students were exposed to six sessions of CBL aided by case scenarios for one set of topics of anemia posted on WhatsApp groups. This was followed by six sessions of DL for separate set of topics in anemia. The multiple-choice questions (MCQ) test scores obtained pre and postintervention, of CBL and DL sessions, were compared to paired t-test (within the groups) and Student's t-test (between the groups). Categorical data were analyzed using Chi-square (χ2) test. Student's self-administered questionnaires and focus group discussions (FGDs) were used to collect student perceptions and analyzed quantitatively, as well as qualitatively. Results: The mean MCQ scores obtained postintervention in CBL topics were significantly higher compared to DL (22.78 ± 2.99 vs 17.78 ± 3.35; P
23 citations
TL;DR: Enhanced publicizing of anti-tobacco messages through the currently employed media and ensuring that doctors give a brief advice to quit during any contact with a tobacco user could improve the willingness to quit and the consequent quit rate, especially among those tobacco users who are in younger age groups and who have attempted to quit earlier.
Abstract: Background: Willingness to quit in a tobacco user forms the basis for future quit attempts and quitting successfully. Objective: To determine the prevalence and correlates of willingness to quit among tobacco users in India using the Global Adult Tobacco Survey (GATS), India, 2016–2017. Methods: GATS, 2016–17 was a multistage geographically clustered sample survey done among 74,037 individuals aged 15 years and above across all the states and two of the Union Territories of India. Data of all those reported using any form of tobacco were studied for past attempts to quit tobacco, advised to quit by a health care provider, and exposure to anti-tobacco messages delivered through various media and the correlation of these with the willingness to quit using multivariate analysis. Results: Of the 21,085 current tobacco users in the survey, 11,679 (52.2%), were willing to quit all forms of tobacco. Multivariate analysis showed that those in younger age groups (OR: 1.39 [1.23–1.56]), higher education levels (OR 1.15 [1.05–1.18]), time of first tobacco use in the day being more than 60 min after waking up in the morning (OR 1.11 [1.03–1.2]), history of attempts to quit in the past 12 months (OR 1.78 [1.69–1.87]), those advised to quit by health care provider in the past 12 months (OR 1.11 [1.06–1.17]), those using single form of tobacco (OR 1.1 [1.05–1.17]), those exposed to anti-tobacco messages in newspapers/magazines (OR 1.1 [1.05–1.17]), and cinemas (1.14 [1.08–1.20]) were more willing to quit compared to their counterparts. Conclusion: Enhanced publicizing of anti-tobacco messages through the currently employed media, and ensuring that doctors give a brief advice to quit during any contact with a tobacco user could improve the willingness to quit and the consequent quit rate, especially among those tobacco users who are in younger age groups and who have attempted to quit earlier.
14 citations
TL;DR: Alexithymia was found in a relatively high percentage in patients with relapse remitting type of multiple sclerosis and was noticed in older, unemployed, single patients, and those having fewer children.
Abstract: Background: Alexithymia is one's incapacity to identify, comprehend, and describe emotions. There is almost no literature data about the levels of alexithymia among patients with relapse remitting type of multiple sclerosis. Aim: The objective of the present study was to assess the levels of alexithymia in patients with relapse remitting type of multiple sclerosis in relation to their sociodemographic variables and clinical characteristics of the disease. Methods: This cross-sectional study included 106 consecutively assessed patients with relapse remitting type of multiple sclerosis. In addition to the data regarding disease duration, number of demyelinating relapses, and degree of neurological disability, assessed by the expanded disability scale score (EDSS), we used Toronto alexithymia scale (TAS), fatigue severity scale (FSS) and, Hamilton scale for the assessment of anxiety and depression and sociodemographic questionnaire. Results: Study included 74 female and 32 male patients, with a median age of 44 years, median disease duration 90 months, and median EDSS 4. About 29.55% of patients had alexithymia and borderline alexithymia was observed in 31.15% patients. Alexithymia correlated with anxiety and depression (P
8 citations
TL;DR: Abnormal leukocyte count, culture positivity and severe acute malnutrition were significantly associated with progression of SIRS patients to septic shock, and factors associated with mortality were positive blood culture, multiorgan dysfunction, late hospital admissions, severe acutenutrition, and requirement of supportive care.
Abstract: Introduction: There is a paucity of studies on the progression and outcome of Systemic Inflammatory Response Syndrome (SIRS) with its determinants. Aims and Objectives: To determine the predictors of the outcome and progression of pediatric sepsis and septic shock. Materials and Methods: Prospective observational study of children fulfilling criteria of SIRS and their progression to sepsis, severe sepsis, and septic shock (clinically and biochemically) was conducted at a tertiary care center. Results: Totally, 200 children were recruited over a period of 21 months (from February 2016 to October 2017). Most cases (80, 40%) were infants. Of the total, 188 (94%) cases were of an infective etiology (mostly respiratory system). Temperature and heart rate were the two commonest SIRS parameters which were deranged. Blood cultures were positive in only 25 (12.5%) cases. Out of the total 200 children, 108 progressed to sepsis, of which 26 progressed to severe sepsis, of which 22 progressed to septic shock. Abnormal leukocyte count, culture positivity and severe acute malnutrition were significantly associated with progression of SIRS patients to septic shock (P = 0.001, 0.00001 and 0.002, respectively). Factors associated with mortality were positive blood culture, multiorgan dysfunction, late hospital admissions, severe acute malnutrition, and requirement of supportive care (P values-
8 citations
TL;DR: The study concludes that anthropometric determinants can be used effectively as risk markers for suicidality and severity of illness in women with postnatal depression.
Abstract: Context: Studies have shown nutrition to play a role in etiology of postnatal depression, but few risk markers have been developed for the same. Anthropometric determinants have not been sufficiently researched in relation to suicidality and severity of illness in women with postnatal depression. Aim: The present study assesses the efficacy of anthropometric determinants as risk markers of severity of illness and suicidal ideations in postnatal depression. Methods and Materials: 100 women were screened at 6 weeks postnatal for the presence of postnatal depression and suicidal ideation using the Edinburgh Postnatal Depression Scale. Anthropometric determinants assessed were height, weight, weight gain in pregnancy, weight at first antenatal visit, body mass index and waist-to-hip ratio. Univariate and multivariate analysis were done for risk estimation using Spearman's rank correlation and multiple regression analysis, respectively. Results: In total, 39% of the women showed the presence of postnatal depression. Out of these 39 women, 31% had suicidal ideations. The waist-to-hip ratio was the most significant factor in all the models, having a negative correlation with suicidality and severity of depression (P
8 citations
TL;DR: The importance of subjective Assessment in competency-based assessment and ways and means of improving the rigor of subjective assessment are highlighted, with particular emphasis on the development and use of rubrics.
Abstract: With the introduction of competency-based undergraduate curriculum in India, a paradigm shift in the assessment methods and tools will be the need of the hour. Competencies are complex combinations of various attributes, many of which being not assessable by objective methods. Assessment of affective and communication domains has always been neglected for want of objective methods. Areas like professionalism, ethics, altruism, and communication-so vital for being an Indian Medical Graduate, can be assessed longitudinally applying subjective means only. Though subjectivity has often been questioned as being biased, it has been proven time and again that a subjective assessment in expert hands gives comparable results as that of any objective assessment. By insisting on objectivity, we may compromise the validity of the assessment and deprive the students of enriched subjective feedback and judgement also. This review highlights the importance of subjective assessment in competency-based assessment and ways and means of improving the rigor of subjective assessment, with particular emphasis on the development and use of rubrics.
7 citations
TL;DR: The educational scenario in India is undergoing a paradigm shift with the introduction of competency-based medical education (CBME), and this approach encourages learners to take responsibility for their progress towards competence, and hence is termed learner-led approach.
Abstract: The educational scenario in India is undergoing a paradigm shift with the introduction of competency-based medical education (CBME).[1] CBME approach is organized around competencies, or predefined abilities, as outcomes of the curriculum. This approach encourages learners to take responsibility for their progress towards competence,[2] and hence is termed learner-led approach. The students are expected to identify and negotiate activities to meet their learning needs, which increase their accountability.[3] It also demands that the students should work in team, focus on active learning, have self-reflection, and develop selfdirected learning skills.[4]
5 citations
TL;DR: MRI and magnetic resonance imaging showed multiple variably sized osseo‐cartilaginous masses within the ankle joint space and similar intensity outgrowth from epiphysis of lower end of tibia, suggestive of synovial osteochondromatosis.
Abstract: A n 8‐year‐old boy presented to the outpatient department with pain and slowly growing swelling on the medial aspect of the right ankle since 7 months. History of trauma while playing was present for which patient had taken alternative medicine. On examination, the swelling was over the anterior aspect of the right medial malleolus. There was restriction of dorsiflexion movement of the foot along with crepitus. All other joints were normal. Hematological investigations were normal. Serum vitamin D and calcium were 26.6 ng/ml (N‐30–100 ng/mL) and 9.2 mg/dL (N‐ 8.6–10.6 mg/dL), respectively. Roentgenogram of the right foot revealed variable size calcific foci in the periarticular region and tibiotalar joint space. The differential diagnosis was synovial chondromatosis and calcified hematoma (in view of trauma). Magnetic resonance imaging (MRI) showed multiple variably sized osseo‐cartilaginous masses within the ankle joint space and similar intensity outgrowth from epiphysis of lower end of tibia, suggestive of synovial osteochondromatosis [Figure 1a]. The lesion was excised and sent for histopathology examination.
TL;DR: More focus needs to be given for allocating resources and developing workplace interventions for prevention and control of hypertension, as more than one-third of drivers have hypertension globally which is in excess of the general population.
Abstract: Background: Hypertension is one of the leading causes of premature deaths worldwide. Drivers have an additional risk of hypertension when compared to the general population because of the nature of their profession. Hence, the current review was done to estimate the global burden of hypertension among professional drivers. Methods: We conducted a systematic search for articles on the prevalence of hypertension among drivers published from 2000 to 2017 in Medline and Embase. Meta-analysis was performed using the random-effects model and pooled prevalence of hypertension was reported. Heterogeneity was assessed using the likelihood ratio (LR) test and publication bias was assessed using Egger's test. Results: In total, 26 studies with 15,702 drivers were included. The pooled prevalence of hypertension among the drivers worldwide was 34% (95% confidence interval [CI]: 27–40%). World Health Organization (WHO) region-wise estimates showed that prevalence was highest among the drivers in the Western Pacific region (56%) and lowest in the Eastern Mediterranean and African region (21%). Studies showed significant evidence of heterogeneity (χ2 = 1816.1,P
TL;DR: By and large similar pattern of morbidities were recorded in the two strata suggesting that the communities, irrespective of the distance of their residences from UCIL plant or sources of their drinking water, are equally vulnerable to various morbidities.
Abstract: Objective: A cross-sectional study was undertaken to assess the prevalence of morbidities in communities residing at variable distances from the closed down insecticide manufacturing plant premises of Union Carbide India Limited (UCIL), Bhopal, India and to determine association of morbidities, if any, with their drinking water usage pattern and distance of localities from the UCIL plant. Materials and Methods: A total of 10,827 individuals belonging to 2,184 families, residing within 0-1 km (Stratum I) and 2.5-5.0 km (Stratum II) radial distances from UCIL plant were surveyed and 9,306 of them (86%) were clinically examined. Data were analyzed to examine the association between the groups of morbidities, likely due to biological and chemical water contamination, and the distance of locality from the UCIL plant. Multiple logistic regression was used to explore the risk factors for morbidities. Results: Nearly similar prevalence (25.3% in stratum I, 25.8% in stratum II) and the trend of all-cause morbidities were recorded in the two strata. While morbidities related to gastrointestinal tract system (P 0.05) was observed between the prevalence of morbidities, likely due to the consumption of biologically or chemically contaminated drinking water, and the distance of locality/stratum from the UCIL plant. Discussion and Conclusion: By and large similar pattern of morbidities were recorded in the two strata suggesting that the communities, irrespective of the distance of their residences from UCIL plant or sources of their drinking water, are equally vulnerable to various morbidities.
TL;DR: Two cases with varied presentation of Pancreatic-pleural fistula, a rare sequela of pancreatitis, presented with acute on chronic pancreatitis with bilateral (predominantly right) pleural effusion and effectively managed with endoscopic pancreatic duct stenting.
Abstract: Pancreatic-pleural fistula (PPF) is a rare sequela of pancreatitis. High degree of clinical suspicion is required to diagnose a PPF. Confirmation is done by high amylase content in pleural fluid analysis. Here, we present two cases with varied presentation of PPF. A 43-year-old man presented with acute on chronic pancreatitis with bilateral (predominantly right) pleural effusion. Another 57-year-old man, previously diagnosed with chronic calcific pancreatitis, presented with left pleural effusion. Both cases were effectively managed with endoscopic pancreatic duct stenting.
TL;DR: Concise and follows guidelines to authors stated by the journal, usually structured‐ Background/introduction, aims, methods, results, conclusions (or similar subsections).
Abstract: Concise and follows guidelines to authors stated by the journal. Usually structured‐ Background/introduction, aims, methods, results, conclusions (or similar subsections). Whether it is independent, complete and stand‐alone (i.e., give a fair idea of the contents of the paper without reading the complete manuscript). Reflects the content of the article accurately (especially after a revision). Is it consistent with the content of the main text? Word limit stated by the journal is adhered to (usually about 250 words).
TL;DR: This case highlights the critical importance of both a general awareness of common imaging findings after navigated THA surgery (whereby tracker pins have been employed) and the value of 'hands on' clinical assessment of patients to allow correlation with suspicious imaging findings.
Abstract: Once purely the domain of knee surgery, the use of computer-navigated techniques in total hip arthroplasty (THA) is becoming progressively more commonplace. As with the adoption of any new technology-assisted approach, the uptake of navigated THA utilization has heralded a new suite of technique-specific potential complications. One such example – not usually seen with conventional instrumented THA – pertains to complications related to the insertion and use of fixed pelvic array trackers. This case report describes the unusual circumstance of retained local bony debris generated through application of self-drilling, self-tapping iliac crest pins (for rigid navigation tracker placement) being mis-interpreted on advanced imaging - at a hospital site remote from the index surgery - as an aggressive, early-stage, chondrosarcomatous lesion. This case highlights the critical importance of both a general awareness of common imaging findings after navigated THA surgery (whereby tracker pins have been employed) and the value of 'hands on' clinical assessment of patients to allow correlation with suspicious imaging findings.
TL;DR: A case of ileocecal mucormycosis following intracardiac repair of congenital heart disease in a 17-year-old boy is described here who lacked the typical risk-factors for mucormYcosis.
Abstract: Gastrointestinal mucormycosis is a rare form of invasive mucormycosis with high fatality rate due to difficulty in establishing its diagnosis. The classic risk-factors include immunosuppression and metabolic derangement. A case of ileocecal mucormycosis following intracardiac repair of congenital heart disease in a 17-year-old boy is described here who lacked the typical risk-factors for mucormycosis. Ileocecal mucormycosis affecting an individual without the classic risk-factors is uncommon.
TL;DR: A case of multiple widespread fixed drug eruption caused by rabeprazole is reported in patients with cutaneous adverse drug reactions at routine check-up.
Abstract: Fixed drug eruption is one of the most common forms of cutaneous adverse drug reactions. Analgesics and antibiotics are the most common drugs causing fixed drug eruption. Here, we report a case of multiple widespread fixed drug eruption caused by rabeprazole.
TL;DR: In a country where the prevalence of tuberculosis is high, the pre-employment chest radiograph may still have a role in detecting tuberculosis in the post-exposure group.
Abstract: Context: Chest radiographs have been used worldwide as a screening tool before employment and training, by various healthcare and other government and nongovernment institutions. Many studies done in the past have demonstrated a relatively low yield for tuberculosis detection and therefore, the authors have questioned this practice. Aims: To compare the value of the preadmission/employment chest radiograph in two groups, namely, those who have been previously exposed to a healthcare setting (post-exposure group) and those who have not been exposed (pre-exposure group) and to determine if there is a significant difference in tuberculosis detection between these two groups. Settings and Design: A retrospective review of the reports of the chest radiographs of all candidates appearing for admission to various undergraduate and postgraduate courses in our institute between 2014 and 2017 was performed. Materials and Methods: The various abnormalities detected were recorded and the findings in the two groups were compared. Statistical Analysis Used: Chi-square test was used to compare between two group proportions. Results: Thirty out of 4333 (0.69%) candidates in the pre-exposure group and 53 out of 3379 (1.57%) candidates in the post-exposure group showed abnormalities on chest radiographs involving the lung parenchyma, mediastinum, heart, or pleura. In the pre-exposure group, six (0.14%) were found to have underlying cardiac disease and one (0.02%) had tuberculosis. Among the six candidates in the post-exposure group who underwent further investigations in our institute, five (0.15%) were diagnosed to have tuberculosis. Although there was no statistically significant difference in tuberculosis detection between the groups (P = 0.051), there is a trend towards higher detection of tuberculosis in the post-exposure group. Conclusions: In a country where the prevalence of tuberculosis is high, the pre-employment chest radiograph may still have a role in detecting tuberculosis in the post-exposure group.
TL;DR: An 11-month-old boy who presented with inconsolable crying, swelling, and decreased use of left lower limb since the age of 8 months is referred to institute with differential diagnosis of osteomyelitis or Ewing tumor as per MRI report.
Abstract: W e report an 11-month-old boy who presented with inconsolable crying, swelling, and decreased use of left lower limb since the age of 8 months. Child was apparently well until the age of 8 month when the parents noticed crying due to pain. Initially pain was intermittent and mild: however, it increased progressively in intensity and frequency. At the time of presentation pain was so severe that he had to be given analgesic at least twice to have a proper sleep. Apart from this problem his history was unremarkable since birth. Parent had sought treatment at nearby hospital where analgesics were given, but as the child did not improve radiographs followed by magnetic resonance imaging (MRI) of affected extremity were done [Figure 1a and b]. Despite extensive work-up the diagnosis was not clear and he was referred to our institute with differential diagnosis of osteomyelitis or Ewing tumor as per MRI report.
TL;DR: A 9-year-old right handed girl, who presented to the authors' hospital with acute onset right faciobrachial monoplegia, was treated symptomatically for dengue fever, clinically became a febrile, thrombocytopenia improved and discharged home after 7 days.
Abstract: W e report a 9-year-old right handed girl, who presented to our hospital with acute onset right faciobrachial monoplegia. She was being treated in a local hospital one week back with history of fever and myalgia. She was then evaluated to have thrombocytopenia with dengue NS1 antigen positivity. She was treated symptomatically for dengue fever, clinically became a febrile, thrombocytopenia improved and discharged home after 7 days. On the day of discharge, child developed acute onset right faciobrachial monoplegia and was referred to our hospital. On examination she had right upper motor neuron facial weakness with right upper limb grade 3/5 power. Left upper limb and lower limb powers were normal. Her blood reports showed thrombocytopenia with positive dengue IgM antibody. MRI brain showed left basal ganglia infarct [Figures 1 and 2a, b]. MR Angiography done showed left middle cerebral artery M1 segment narrowing [Figure 3]. There was no previous history of stroke and recent varicella infection in this child. Evaluation for pediatric arterial stroke was done. Investigations for primary thrombophilia like CBC, prothrombin time, activated partial thromboplastin time, factor V leiden mutation, homocysteine, and anti phospholipid lipid antibody work up, Protein C, Protein S, and Antithrombin III were negative. Lumbar puncture with CSF study done, showed normal study. Cardiology work up done, ECG, echocardiogram were normal. Imaging of brain and neck vessels ruled out dissection or Moya Moya disease. A 9-year-old child presented with the clinical picture of stroke, right faciobrachial monoplegia following dengue fever and MRI brain with MR angiogram showing left basal ganglia infarct with stenosis of left M1 segment of middle cerebral artery, a diagnosis of pediatric stroke due to transient focal cerebral arteriopathy of childhood following dengue fever was made. She was treated with pulse methyl prednisolone for 3 days along with daily aspirin to continue. Her follow-up MRI brain with MR angiography after 6 months showed resolution of left MCA M1 stenosis which confirmed transient focal cerebral arteriopathy.
TL;DR: These findings should make anyone to sit down and take notice as Indian health care system has traditionally developed and designed for maternal and child healthcare services, which are more commonly available than health services for any other sub-group of population of disease condition.
Abstract: {Figure 1} One of the first and most widely used framework on responsiveness was proposed by the World Health Organization (WHO) and comprises of elements such as dignity, autonomy, confidentiality, prompt attention, quality of amenities, access to social support networks and choice of service provider [13] These findings should make anyone to sit down and take notice as Indian health care system has traditionally developed and designed for maternal and child healthcare services, which are more commonly available than health services for any other sub-group of population of disease condition [ ]if this is the situation in maternity care, there is a little reason to believe that other health services would be any better in responsiveness Health care for poor should not end up becoming poor health care [ ]developing mechanism to capture their expectations and non-medical needs from health services and use of this information for corrective measures, should be given due importance in policy-making and program design [ ]all health system strengthening activities need to be done in parallel, without waiting for one to be completed and then doing next
TL;DR: This article highlights aleatory and epistemic uncertainties and shows with the help of an example how apparently valid and reliable findings can completely derail due to these uncertainties.
Abstract: Aleatory uncertainties are generated by intrinsic factors such as studying a sample rather than the whole population and the source of epistemic uncertainties is extraneous such as limitations of knowledge. These uncertainties inflict all the findings in empirical medical research, but they are rarely appreciated. This article highlights these uncertainties and shows with the help of an example how apparently valid and reliable findings can completely derail due to these uncertainties. We conclude that aleatory and epistemic uncertainties should get due consideration while drawing conclusions and before the results are put into practice. Methods to reduce their impact on results are also presented.
TL;DR: The cause of death was related to adenoviral interstitial pneumonitis with superadded confluent bronchopneumonia and diffuse alveolar damage.
Abstract: A 3‐month‐old male child was referred to our tertiary‐care center for respiratory distress. He was in very poor general condition and expired within 2 hours of admission. Before this referral, the child had been hospitalized twice in the recent past for similar complaint and had been administered antibiotics and inotropes. There were 3 two‐dimensional echocardiographic reports which had suggested ostium secundum atrial septal defect (ASD) and large muscular ventricular septal defect in a setting of transposition of great arteries. There was an additional finding of left atrio‐ventricular valvular atresia with a discrepancy in the type of ventricular looping (d‐loop versus l‐loop). A complete autopsy was requested. All organs were in situs solitus with normal bronchial morphology (eparterial right bronchus and hyparterial left bronchus). The cause of death was related to adenoviral interstitial pneumonitis with superadded confluent bronchopneumonia and diffuse alveolar damage. Detailed cardiac examination showed a single ventricle of right ventricular morphology with a double outlet [Figures 1 and 2], along with a large ostium secundum ASD and mitral valvular atresia. The aorta and pulmonary trunk were situated side‐by‐side with a right and left positions, respectively. The pulmonary trunk was larger than the ascending aorta. A hypoplastic left ventricle was not demonstrated. Interestingly, the left atrial appendage (LAA) was absent [Figure 1].
TL;DR: Two cases of invasive amebiasis which developed a fulminant course in the immediate postoperative period after abdominal surgeries for visceral malignancies are reported.
Abstract: Amebiasis caused by protozoa Entamoeba histolytica (EH) is the third leading parasitic cause of human mortality. Although amebiasis is endemic in India, only about 10% of the infected individuals manifest disease. Clinical spectrum of amebiasis ranges from asymptomatic colonization to amebic colitis to hemorrhagic and fulminant colitis. Factors causing an invasive infection are not completely understood. Pathogen virulence, host immunity, and ability of the pathogen to evade host immune response play vital role in determining the disease course. Host factors such as immunocompromised states may make an individual susceptible to develop symptomatic infection. Malignancies usually result in chronic debilitation which may make the individual prone to develop invasive amebiasis with rapid progression. We report two cases of invasive amebiasis which developed a fulminant course in the immediate postoperative period after abdominal surgeries for visceral malignancies.
TL;DR: A 29-year-old male patient who had severe ulcerative colitis with low level CD4+ count of 254 cells/mm3, and had no evidence of HIV or Human T cell Lymphotrophic virus type I or II infections is reported.
Abstract: Idiopathic CD4+ T lymphocytopenia (ICL) is a very rare immunodeficiency syndrome with an unexplained depletion of CD4+ T lymphocytes and no evidence of Human Immunodeficiency Virus (HIV) infection. Here we report a 29-year-old male patient who had severe ulcerative colitis with low level CD4+ count of 254 cells/mm3, and had no evidence of HIV or Human T cell Lymphotrophic virus type I or II infections. He had recurrent Candidiasis infection and his CD4 count was just 53 cells/mm3 after 3 months. The cause for the decline of CD4 T lymphocytes was unknown.
TL;DR: A case highlighting the difficulties and possible solutions in ablation in atrioventricular-nodal-reentrant-tachycardia is presented, making it difficult to produce transmural lesions and increasing risk of producing AV block.
Abstract: Atrioventricular (AV)-nodal-reentrant-tachycardia is a rare association in a patient with persistent left-sided superior vena cava and dilated coronary sinus. There are a few inherent difficulties in ablation in this condition, viz., difficulty in localization of good site for ablation and difficulty in stabilization of the ablation catheter at the designated site, making it difficult to produce transmural lesions and increasing risk of producing AV block. We hereby present a case highlighting the difficulties and possible solutions for them.
TL;DR: Clinicians ought to use their discretion to screen those truly at risk for vitamin D deficiency on a case to case basis and avoid indiscriminate testing of the same to ensure a rational approach to vitamin D testing.
Abstract: Objective: Vitamin D deficiency is widely prevalent worldwide. This has led to a significant surge in referrals for vitamin D assessment in recent years. The cost-effectiveness and rationalization of this practice is uncertain. This study aimed to evaluate the referral pattern for vitamin D testing from a tertiary center in southern India. Materials and Methods: This was a cross-sectional study done over a period of one year (2017). A total of 95,750 individuals, referred for vitamin D screening were included in this study. Details regarding referring departments and indications for referral were obtained from the computerized hospital information processing system (CHIPS). Results: The study population exhibited a female preponderance (54.1%) with mean (SD) age of 40.3 (18.5) years. Overall, 44% were found to have vitamin D deficiency. Most of the referrals were from nephrology (15.4%), neurology (10.1%), and orthopedics (9.1%). Nevertheless, dermatology, the staff-clinic, and hematology which contributed to 3.3%, 1.7%, and 1.7% of referrals, had a higher proportion of vitamin D deficiency of 59.1%, 57.7%, and 64.6%, respectively. Although the most common indications for referral were generalized body aches (20.5%) and degenerative bone disorders (20.1%), the proportion of subjects with vitamin D deficiency referred for these indications were 46.1% and 41.6%, respectively. In contrast, chronic steroid use that accounted for 3.3% of the referrals had 59.1% of subjects who were deficient in vitamin D. Conclusion: To ensure a rational approach to vitamin D testing, clinicians ought to use their discretion to screen those truly at risk for vitamin D deficiency on a case to case basis and avoid indiscriminate testing of the same.
TL;DR: In all societies, the general expectations from physicians have remained universal and the physicians should be trustworthy, respect patients, give appropriate advice, and communicate effectively with patients, their families, and members of the community.
Abstract: There will be no two opinions if I say that a health care practitioner has to be competent to provide health care and should also provide it with compassion. In all societies, the general expectations from physicians have remained universal. The physicians should be trustworthy, respect patients, give appropriate advice, and communicate effectively with patients, their families, and members of the community. They should remain abreast with newer developments in the field and use them judiciously for improving quality of care. They should be an ethical, responsible, and accountable professionals.[1,2] These and many more attributes have emerged since ancient times and are mentioned in various systems of Medicine. For example, the ancient granthas of Ayurveda, Charaksamhita, and Sushrutsmahita have a detailed elaboration about “vaidyagunas”,[3,4] which are not different than what we expect today.