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   2017| March-April  | Volume 30 | Issue 2  
    Online since August 11, 2017

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Incidents of violence against doctors in India: Can these be prevented?
Neeraj Nagpal
March-April 2017, 30(2):97-100
Violence against doctors is on the rise all over the world. However, India has a unique problem. Meagre government spending on healthcare has resulted in poor infrastructure and human resource crunch in government hospitals. Hence, people are forced to seek private healthcare. Small and medium private healthcare establishments, which provide the bulk of healthcare services, are isolated, disorganized and vulnerable to violence. Violence against health service providers is only a manifestation of this malady. The Prevention of Violence Against Medicare Persons and Institutions Acts, which have been notified in 19 states in the past 10 years, have failed to address the issue. To prevent violence against doctors, government spending on healthcare must be increased and the Indian Penal Code should be changed to provide for a tougher penalty that could act as a deterrent to violence against doctors.
  39,571 2,046 -
Scrub typhus: A prospective, observational study during an outbreak in Rajasthan, India
Rajendra Prasad Takhar, Moti Lal Bunkar, Savita Arya, Nitin Mirdha, Arif Mohd
March-April 2017, 30(2):69-72
Background. Scrub typhus, a potentially fatal rickettsial infection, is common in India. It usually presents with acute febrile illness along with multi-organ involvement caused by Orientia tsutsugamushi. As there was an outbreak of scrub typhus in the Hadoti region of Rajasthan and there is a paucity of data from this region, we studied this entity to describe the diverse epidemiological, clinico-radiological, laboratory parameters and outcome profile of patients with scrub typhus in a tertiary care hospital. Methods. In this descriptive study, we included all patients with an acute febrile illness diagnosed as scrub typhus by positive IgM antibodies against O. tsutsugamushi, over a period of 4 months (July to October 2014). All relevant data were recorded and analysed. Results. A total of 66 (24 males/42 females) patients were enrolled. Fever was the most common presenting symptom (100%), and in 67% its duration was for 7–14 days. Other symptoms were breathlessness (66.7%), haemoptysis (63.6%), oliguria (51.5%) and altered mental status (39.4%). The pathognomonic features such as eschar (12%) and lymphadenopathy (18%) were not so common. The commonest radiological observation was consistent with acute respiratory distress syndrome. Complications noted were respiratory (69.7%), renal (51.5%) and hepatic dysfunction (48.5%). The overall mortality rate was 21.2%. Conclusions. Scrub typhus has emerged as an important cause of febrile illness in the Hadoti region and can present with varying clinical manifestations with or without eschar. A high index of suspicion, early diagnosis and prompt intervention may help in reducing the mortality.
  10,078 990 -
Dietary deficiency of vitamin A among rural children: A community-based survey using a food-frequency questionnaire
Shivali Suri, Dinesh Kumar, Ranjan Das
March-April 2017, 30(2):61-64
Background. Overt vitamin A deficiency has been controlled in most parts of India, but prevalence of subclinical deficiency may still be high, which may enhance susceptibility to infections, reduce growth potential and also lead to higher mortality. We aimed to: (i) assess the consumption pattern of vitamin A-rich foods in children 1–5 years of age in rural Jammu; and (ii) estimate the dietary deficiency of vitamin A leading to risk of subclinical vitamin A deficiency in cluster- villages of the study area. Methods. In 2011, we conducted a survey of 750 children by selecting 50 from each of the 1 5 clusters. The Helen Keller International's Food-Frequency Questionnaire (HKI-FFQ) modified to the local context was used to assess past week's intake for 28 food-items, including vitamin A-rich foods. Results. The study revealed that plant sources such as amaranth, carrots, etc. and animal sources such as eggs and butter were the major sources of vitamin A in the study population. Consumption of amaranth (2.7 days/week) and carrots (1.7 days/week) was moderate but that of animal foods rich in vitamin A was low to negligible (1.1 day/week for eggs and 0.2 day/week for liver and fish combined). The majority (80%) of the cluster-villages manifested inadequate intake of vitamin A-rich foods, thereby making subclinical vitamin A deficiency a public health problem for the whole area. Faulty diets, improper breastfeeding practices, low coverage of vitamin A supplementation and high prevalence of undernutrition could be related to the observed subclinical deficiency. Conclusion. Dietary diversification by including both plant and animal sources of vitamin A in adequate amounts along with improved breastfeeding, better implementation of mega-dose vitamin A supplementation and minimizing undernutrition may help in lowering subclinical vitamin A deficiency. The HKI-FFQ may be used as a proxy indicator of vitamin A intake/status for identifying pockets at risk of subclinical vitamin A deficiency in resource-constrained settings.
  3,817 670 -
Continuing professional development of doctors
Anshu , Tejinder Singh
March-April 2017, 30(2):89-92
After graduating from medical school, all doctors need to undertake some training activities lifelong to maintain, update or develop their knowledge, skills and attitudes towards their professional practice. Continuing professional development (CPD) refers to continuing development of medical and non- medical competencies including professionalism, and interpersonal, managerial and communication skills. There is no single correct way of doing CPD. Most learning in CPD is self-directed and based on one's own learning needs. Effective CPD is characterized by the presence of three factors: a clear reason why a particular CPD needs to be undertaken, learning activities appropriate to identified needs and follow- up on learning. There are several models for CPD. However, the onus is on doctors to show that they continue to maintain appropriate professional standards after training. Here, regulation becomes essential for revalidation, monitoring and to provide the necessary impetus to make CPD mandatory. In India, the credit point system is followed by some states, but the policy to link credit hours with renewal of registration thereafter is not uniform. While the present system is able to monitor time devoted to CPD, it encourages people to gather certificates of attendance at sessions without relevance to or real interest in the subject. The quality and relevance of CPD activities matter more than the quantity of hours. Eventually, we need to move away from credit point counting towards a process of self-accreditation and reflection. Each individual will have to find appropriate methods, learn, document and present evidence that learning has happened, and show that it has been applied in practice. As a profession, we need to encourage a culture where doctors do not view CPD and recertification as a threat. Doctors will need to understand that they are accountable to their patients, and should prioritize and build CPD into their practice.
  3,009 529 -
Multispecialty consensus statement for primary care management of diabetic foot disease in India
Arun Bal, Charudatta Chaudhari, Vijay Langer, Dipak Vyas, G Thulasikumar, Milind Ruke, Madhuri A Gore, Pinjala Ramakrishna, Rakesh K Khazanchi, SR Subrammaniyan, S Raja Sabapathy, Sanjay Desai, Sanjay Vaidya, Srikanth Vijayasimha, Sudhir Jain, Sunil Chaudhary, Sunil Kari, Tushar Rege
March-April 2017, 30(2):82-88
  2,271 350 -
A study of events between the onset of symptoms and hospital admission in patients with acute abdomen
Shubhada Khanapure, Sanjay Nagral, Aditya J Nanavati
March-April 2017, 30(2):65-68
Background. Acute abdomen is a common surgical emergency. Prompt investigation and treatment, including surgical intervention, is critical in reducing morbidity and mortality. Methods. We carried out a prospective observational study at a large urban secondary healthcare centre in India. Patients with surgical acute abdomen were consecutively enrolled in the study over a period of 2 years. Data were collected regarding the onset of symptoms, time of presentation to the hospital and events in the intervening period. Results. Analysis showed that misdiagnosis by medical personnel was significantly associated with delay in admission to the hospital. Unfamiliarity with the medical facilities, ignorance, low education and illiteracy and public holiday were the contributing factors for delayed presentation. Even though we detected some trends, the delay was not significantly associated with age, sex, educational level or socioeconomic status of the patient. The delay resulted in an increased mortality and morbidity especially in patients who needed emergency operative management. Conclusion. Delayed presentation of acute abdomen is often not due to a single reason. The causes are distributed over various levels starting from the patient, family, medical personnel, administrative deficiencies, socioeconomic and sociocultural status of the country.
  1,892 359 -
Primary or specialist medical care: Which is more equitable? A policy brief
Prasanta Mahapatra, Sanjeev Upadhyaya, G Surendra
March-April 2017, 30(2):93-96
Background. Equity in health and equitable access to healthcare has been at the core of health policy in India. The key policy challenge has been how to make that possible? Various health insurance schemes such as the Rashtriya Swasthya Bima Yojana and Arogyasri seek to improve poor people's access to specialist medical care in the public and private sectors. On the other hand, access to primary medical care has been left to the supply side interventions. Methods. We did a focused review of evidence on equity aspects of primary medical care versus specialist medical care. We selected relevant publications from the Cochrane Library, PubMed and Google Scholar searches and articles snowballing out of them. Results. Higher primary care physician-to-population ratio is invariably associated with better health outcomes. Primary care may partly protect the poor from adverse effects of income inequality on health status. On the other hand, populations do not necessarily benefit from an overabundance of specialists in a geographical area. Conclusions. Three key policy lessons emerge from this review. First, states should strengthen primary medical care by upgrading health centres. Second, a family health protection plan should be introduced as a demand side intervention to deliver primary care through health centres, non-profit and for-profit clinics. Third, postgraduate courses in family medicine should be introduced for a balanced development of the specialty of primary care pari passu other specialties.
  1,890 237 -
Treatment of primary angle-closure glaucoma: Does early lens extraction help?
Ramanjit Sihota
March-April 2017, 30(2):78-79
  1,735 346 -
Association of presenile cataract with galactose-1-phosphate uridyl transferase gene mutations
Nitin Nema, Ravindra Kumar, Abha Verma, Sonam Verma, Kiran Chaturvedi
March-April 2017, 30(2):73-75
Background. Presenile cataract is commonly idiopathic in origin. However, patients with presenile cataract could have an underlying genetic abnormality of galactose metabolism. We studied the association, if any, between idiopathic presenile cataract and galactose-1 -phosphate uridyl transferase (GALT) gene mutation. Methods. We selected 50 patients with idiopathic presenile cataract, <45 years of age, and 50 age- and sex-matched controls for the study. Mutations in the GALT gene were determined by polymerase chain reaction restriction fragment length polymorphism. The classical galactosaemia was characterized by Q188R and K285N mutations, whereas Duarte galactosaemia by N314D mutations (Duarte-2: N314D with IVS5-24G >A and Duarte-1: N314D without IVS5- 24G>A). Results. The most common mutation observed was the N314D (Duarte) mutation. The frequencies of classical and N31 4D alleles in patients with presenile cataract (16%) and controls (26%) were not statistically different (p=0.32, OR 0.54, 95% CI 0.20–1.45). Similarly, there was no statistically significant difference in the frequency distribution of Duarte-1 (p=0.77, OR 0.77, 95% CI 0.23–0.24) and Duarte-2 (p=0.44, OR 0.38, 95% CI 0.07–2.03) galactosaemia mutations in patients and controls. Conclusion. Duarte galactosaemia, a milder form of the disease, is more common than classical galactosaemia in the Indian population. Duarte galactosaemia is unlikely to be a causative factor in presenile cataract.
  1,560 310 -
Why India needs video-assisted thoracic surgery (VATS)
Sai Yendamuri
March-April 2017, 30(2):101-102
  1,645 173 -
An outlier in public health history in India: A.T.W. Simeons's scheme for rural medical relief, Kolhapur, 1943-47
Shubhada Pandya
March-April 2017, 30(2):103-107
It is customary to date provision of health services in rural India to the Report of the Bhore Committee (1946) and its descendants. It is presumed that in pre-Bhore India (the last half-century of the British era) the rural public health scenario was devoid of discerning commentators and practical effort. The presumption is misleading. Historical material shows that attempts, official and non-official, to improve rural environments and attend to the health problems of villagers were not wanting. Such efforts followed two main, sometimes intersecting, streams, namely sanitation and medical relief. I examine a little-known, yet noteworthy effort in the latter category, connected with Bombay Province, which incorporated in fledgling form modern practice in rural healthcare delivery. The central character was a medical expatriate of German ancestry (but contested nationality), whose connection with Bombay spanned almost two decades including the period of the Second World War. Albert Theodore William Simeons (1900–70) was a specialist in tropical medicine whose intellectual interests and facile pen ranged wide. Providence and the paranoia of the war-time Government of British India saw him in 1943 as Director of Public Health in the princely state of Kolhapur. Here he set up and supervised a novel scheme for ‘Rural Medical Relief’ centred on trained villagers as first-line providers of medical treatment. The scheme endured after Simeons's departure from India, and worked well enough to be remembered post-1947 by senior medical personnel of the time and also (but without crediting him) in official publications. The Kolhapur experience also inspired a first-of-its kind fictional work by this multi-faceted personality. Archival material available in India relating to Simeons's years at Kolhapur is trifling. Other primary sources have therefore been utilized to rescue the history.
  1,544 185 -
Hepatitis C Virus: Discovery to epitaph in a life-time
Rakesh Aggarwal
March-April 2017, 30(2):57-60
  1,357 313 -
Late presentation of retinal detachment in India: A comparison between developing nations
Brijesh Takkar, Shorya Vardhan Azad, Indrish Bhatia, Raj Vardhan Azad
March-April 2017, 30(2):116-116
  1,428 172 -
Synchronous malignancies of thyroglossal duct cyst and thyroid gland
Chinna Naik, Sandip Basu
March-April 2017, 30(2):76-77
Malignant involvement of thyroglossal duct cyst is rare, still rarer is the synchronous malignant involvement of the thyroid gland. Although the Sistrunk procedure is often regarded as adequate, controversy exists of the need for an additional total thyroidectomy and radioiodine ablative therapy, the decision of which depends upon the presence of (i) suspicious thyroid gland nodule; (ii) presence of lymphadenopathy; or (iii) a previous history of neck irradiation. We report a 47-year-old woman diagnosed with papillary carcinoma within a recurrent thyroglossal duct cyst with infiltration into surrounding soft tissues and a suspicious thyroid nodule of the left thyroid lobe with no regional lymph node involvement. On final histopathology, the left thyroid nodule had a follicular variant of papillary carcinoma thyroid without regional nodal involvement. The patient underwent total thyroidectomy with radioactive iodine postoperatively.
  1,077 240 -
The promise and challenges of buprenorphine implant for treatment of opioid dependence
Debasish Basu, Swapnajeet Sahoo, Abhishek Ghosh
March-April 2017, 30(2):80-81
  983 239 -
Thomas Earl Starzl (11 March 1926–4 March 2017)
Vinay Kumaran
March-April 2017, 30(2):108-109
  745 262 -
Letter from Chennai
MK Mani
March-April 2017, 30(2):110-111
  809 121 -
Chronicles from Central India: An atlas of rural health
Sunil K Pandya
March-April 2017, 30(2):114-115
  688 104 -
Letter from Glasgow
HS Kohli
March-April 2017, 30(2):112-112
  661 130 -
Vivek Arya
March-April 2017, 30(2):119-119
  644 124 -
War Neurology
Roop Gursahani
March-April 2017, 30(2):113-114
  593 89 -
News from here and there

March-April 2017, 30(2):117-118
  562 105 -