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   2019| May-June  | Volume 32 | Issue 3  
    Online since February 18, 2020

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Syndromic management of sexually transmitted infections: A critical appraisal and the road ahead
Vishal Gupta, Vinod Kumar Sharma
May-June 2019, 32(3):147-152
DOI:10.4103/0970-258X.278691  PMID:32129308
The syndromic approach has been the cornerstone of management of sexually transmitted infections (STIs) in developing countries. This strategy has had a considerable impact in decreasing the burden of STI in society. It offers the advantages of treating the infection at the first visit itself, reducing the risk of complications, non-reliance on laboratory diagnostics, and easy integration into the primary healthcare system. Nonetheless, it is not without limitations, most often criticized for its inability to treat asymptomatic cases. Syndromic management has been found to be satisfactory for genital ulcer disease and urethral discharge in several settings. However, its performance is not as good in the treatment of vaginal discharge syndrome, as it does not allow a distinction between cervicitis and vaginitis. Diagnostic validation and a review of its performance should be done periodically to keep abreast of the changing aetiology of various syndromes and patterns of drug susceptibility. Supplementing the syndromic approach with point-of-care tests and simple laboratory tests where available can improve its results. Further, healthcare professionals should be imparted training for optimum patient care. This narrative review critically appraises the syndromic approach to STIs, discusses the challenges that it faces, and offers suggestions to improve its performance.
  8,230 687 1
Understanding black magic and other systems of belief
KS Jacob
May-June 2019, 32(3):167-170
DOI:10.4103/0970-258X.278683  PMID:32129313
  6,689 236 1
Making end-of-life and palliative care viable in India: A blueprint for action
Roop Gursahani, Raj K Mani, Srinagesh Simha
May-June 2019, 32(3):129-133
DOI:10.4103/0970-258X.278684  PMID:32129303
  3,361 532 -
Ethics committee registration and re-registration with the regulatory authority in India
Manoja Kumar Das, Deepak Singh
May-June 2019, 32(3):157-160
DOI:10.4103/0970-258X.278682  PMID:32129311
Background. All ethics committees (ECs) that review and monitor clinical trials in India must be registered with the regulatory authority. We ascertained the status of registration and re-registration of ECs till December 2017. Methods. The ECs registered and re-registered with the Indian regulatory authority till December 2017 were extracted. The status of ECs was analysed according to the state, institute category and registration. Results. A total of 1260 ECs were registered, of which 14% were based in medical colleges, 2% in dental colleges, 61.2% in hospitals other than medical colleges and 8% as independent ECs. Of the recognized medical and dental colleges, only 37.3% and 10.9%, respectively, and 45.9% of ECs from teaching hospitals (other than medical and dental colleges) had registered with the regulatory authority. Of the 911 ECs eligible for re-registration, 516 (56.5%) had reregistered. Conclusion. A low proportion of registrations ofECs from eligible academic health institutions raises concern about adherence to regulatory guidelines and conduct of clinical trials in India. The lower re-registration of ECs helps in the identification of factors which should be addressed to facilitate clinical research in India.
  2,939 259 -
D-dimer levels in patients with thromboangiitis obliterans
Angelin Emmanuel, Dheepak Selvaraj, Indrani Sen, Sunil Agarwal, Edwin Stephen, Albert Kota, Sukesh Chandran Nair, Belavendra Antoniswamy
May-June 2019, 32(3):134-136
DOI:10.4103/0970-258X.278685  PMID:32129304
Background. Thromboangiitis obliterans (TAO) or Buerger disease is a recurring progressive segmental vasculopathy that presents with inflammation and thrombosis of small and medium arteries and veins of the hands and feet. The exact cause remains unknown, with tobacco use (primarily smoking but also smokeless tobacco) being highly associated with the disease. The diagnosis is clinical and the lack of a diagnostic gold standard is a deterrent to diagnosing it in patients with atypical presentations. Obliterative endarteritis occurs perhaps due to a mixture of thrombosis and inflammation. The diagnostic sensitivity and specificity of D-dimer as a biomarker for thrombosis is well reported from its use in other areas such as deep vein thrombosis. Identification of a biomarker linked to the causation yields a diagnostic adjunct with a role in therapeutic decision-making, aiding diagnosis in atypical presentation, monitoring disease activity and gauging response to therapy. Methods. Between April 2014 and May 2015, we studied serum D-dimer (a marker of thrombosis) in 62 patients with TAO and compared this to 330 normal age- and sex-matched controls. We included all patients with peripheral arterial disease clinically diagnosed to have TAO according to the Shionoya criteria. There was no history of thrombosis or arterial disease in the control group. The control group was matched for baseline characteristics such as age and sex. All patients underwent a standard diagnostic protocol including blood tests (haemoglobin and creatinine), electrocardiogram, chest X-ray and ankle brachial pressure index. Blood was collected using an evacuated tube system into a citrate anticoagulant tube for testing D-dimer. Results. All the 62 patients diagnosed to have TAO were men with an average age of 40 years (range 18-65 years). They all had a history of tobacco use and did not have other atherogenic risk factors (part of the diagnostic criteria). Medium-vessel involvement was present in 53 patients (85%) and the rest presented with additional involvement of the popliteal and femoral vessels. Upper limb involvement or superficial thrombophlebitis was present in 95% of patients. Laboratory and imaging studies were consistent with TAO. The groups were well matched for age (p = 0.3). The median and interquartile range for D-dimer values were 61 ng/ml and 41-88 ng/ml in controls (n = 330) and 247 ng/ml and 126478 ng/ml in patients (n = 62), respectively (p<0.001). Conclusions. D-dimer levels are considerably elevated in patients with TAO. This indicates an underlying thrombotic process and suggests its potential role as a diagnostic adjunct. It also leads us to hypothesize a potential therapeutic benefit of anticoagulants in this disease.
  2,564 569 1
Cross-sectional study on smokeless tobacco use, awareness and expenditure in an urban slum of Bhavnagar, western India
Mihir Prafulbhai Rupani, Khushali Dharmesh Parikh, Mili J Kakadia, Meha M Pathak, Malay R Patel, Manav A Shah
May-June 2019, 32(3):137-140
DOI:10.4103/0970-258X.278686  PMID:32129305
Background. Data are sparse on smokeless tobacco (SLT) use in Bhavnagar. We assessed the prevalence and awareness of and expenditure on SLT use in Bhavnagar. Methods. We conducted a community-based, cross- sectional study in an urban slum of Bhavnagar on a sample of 260 SLT users for a period of three months in 2017. Results. The prevalence of SLT use in Bhavnagar was 27.3% (95% CI 25%-30%). Mawa, a preparation of tobacco flakes mixed with areca nut and lime, was the most commonly chewed form of tobacco; commonly kept in the buccal mucosa. The mean age ofstarting SLT use was 25 years; the mean number of years since chewing was 15 years; the mean time tobacco was kept in the mouth per consumption was 5 minutes and the mean number of packets of tobacco consumed per day was five. The mean expenditure on SLT use per month was ?536. All SLT users were aware that tobacco consumption led to oral cancer. Peer influence was the most common (75%) reason for starting SLT use, and addiction was the most common (74%) reason for its continued use. Among SLT users, 47% had made at least one attempt to quit; of them, 98% had tried self-control for quitting but did not succeed. The most common (72%) reason given by those not able to quit (n=119) was addiction to SLT use. Among the 260 study participants, 72% had read the warnings on packets of tobacco; 59% wished to chew tobacco even after reading the warnings and 62% opined on banning the sale and consumption of tobacco. Ninety-two per cent of SLT users were not comfortable with the idea that imitating them, their children too would start chewing tobacco. Conclusions. Every third person in the urban slum of Bhavnagar was a SLT user. Even though SLT users knew about the harmful effects of tobacco, only a handful were able to quit due to addiction to it. This burden on health services, in addition to the expenditure on purchase of tobacco, requires a comprehensive tobacco cessation programme at the community level.
  2,077 555 -
Public health-oriented healthcare systems: Need for a modified typology
Mathew George
May-June 2019, 32(3):171-174
DOI:10.4103/0970-258X.278689  PMID:32129314
Healthcare systems across the world are dominated by medical care services compared to public health services. Within public health services, individual-oriented interventions dominate compared to population-based interventions perhaps due to the inherent dominance of biomedical approaches within public health. Clarity is needed between diverse approaches, methods and targets of public health as against clinical care services delivered under healthcare systems. Public health has a primary objective of prevention and promotion with the population as the target group with a societal focus, whereas the latter is curative in intent with an individualist orientation and logic and hence reductionist. The implications are important for developing nations such as India, which have a history of neglect towards ensuring public health due to the domination of policies on medical care. The healthcare system should use a modified typology that asserts its differential commitment to address both public health and medical care needs of its citizens.
  2,069 362 -
Novel mutation in the nuclear receptor subfamily 0, group B, member 1 (NR0B1) gene associated with intrafamilial heterogeneity in three boys with X-linked adrenal hypoplasia congenita and hypogonadotropic hypogonadism from India
Sony Mohan, Sumita Danda, Sarah Mathai, Anna Simon
May-June 2019, 32(3):141-143
DOI:10.4103/0970-258X.278692  PMID:32129306
Background. Nuclear receptor subfamily 0, group B, member 1 (NR0B1) gene previously known as DAX1 is a transcription factor that plays a key role in the development of hypothalamo-pituitary-gonadal and adrenal axis. Primary adrenal failure may result from metabolic, infection, autoimmune or developmental causes resulting in a life-threatening condition needing immediate intervention. This study aimed to analyse NR0B1 (DAX1) gene mutation resulting in adrenal hypoplasia congenita (AHC) in three brothers presenting with hypogonadotropic hypogonadism and primary adrenal failure either in infancy or in early childhood. Methods. We studied three boys with primary adrenal failure and hypogonadotropic hypogonadism presenting at different ages at the Paediatric Endocrinology Clinic. Muta- tional analysis of NR0B1 gene was carried out by bidirectional sequencing. Results. All the three boys had deletion of G in exon 1 at position 189 (c.189_189delG) of the gene resulting in frame shift mutation (Y64Tfs*21). Conclusion. Novel mutation in NR0B1 detected by this study explained the cause ofhypogonadotropic hypogonadism with primary adrenal failure in this Indian family. Intrafamilial variability was seen in this family. Early diagnosis by genetic testing, genetic counselling and family screening can help to manage this life-threatening condition.
  2,073 344 -
The MAHSA University, Malaysia's medical student oath and a comparison of various oaths
Ravindran Jegasothy, Madhumita Sen
May-June 2019, 32(3):161-166
DOI:10.4103/0970-258X.278687  PMID:32129312
When students enrol in a medical school, they are not introduced to any ethical issues until later in the curriculum. The Hippocratic/physician’s oath is taken upon graduation. A student oath is important to introduce students to the solemnity of the education they are dedicating themselves to. This oath is analysed and compared with the doctor’s oath upon graduation and a few other oaths.
  1,511 181 1
Indian healthcare at crossroads (part 3): Quo vadis?
AC Anand
May-June 2019, 32(3):175-180
DOI:10.4103/0970-258X.278696  PMID:32129315
  1,253 198 1
Assessing functional capacity before major non-cardiac surgery
Kanil Ranjith Kumar, Lokesh Kashyap
May-June 2019, 32(3):155-156
DOI:10.4103/0970-258X.278688  PMID:32129310
  1,074 157 -
An unusual case of isolated right-sided infective endocarditis masquerading as non-resolving pneumonia
Akshyaya Pradhan, Sharath P Sanganagoudar, Pravesh Vishwakarma, Rishi Sethi
May-June 2019, 32(3):144-146
DOI:10.4103/0970-258X.278694  PMID:32129307
Right-sided infective endocarditis in non-intravenous drug abusers and non-immunocompromised patients is rare. The diagnosis is difficult as it can present as a respiratory illness leading to delays in diagnosis and development of complications, which can be fatal. The standard Duke criteria may not be adequate for diagnosis. We present a patient with isolated right-sided infective endocarditis mimicking right lower lobe non-resolving pneumonia who did not respond to antitubercular therapy.
  954 224 -
Epidemiological investigation and containment of a measles outbreak in New York: Critical appraisal and public health implications for India
Joseph L Mathew
May-June 2019, 32(3):153-155
DOI:10.4103/0970-258X.278690  PMID:32129309
  1,002 170 -
Brain vessel anomalies in autosomal dominant polycystic kidney disease
Maria Ejma, Pawel Urbanowski, Miroslaw Brodowski, Konstanty Guranski, Barbara Hendrich, Magdalena Krajewska
May-June 2019, 32(3):189-189
DOI:10.4103/0970-258X.278698  PMID:32129319
  896 175 -
How to conduct interactive case discussions
Vishnu Moleyar Sharma
May-June 2019, 32(3):181-182
DOI:10.4103/0970-258X.278695  PMID:32129316
Interactive case discussion (ICD) is a modified form of clinicopathological conference. ICD is a learning process and with active participation from the audience. The case is selected with specific pre-defined learning points and presented by a person who knows the full details. Differential diagnosis and approach to diagnosis, investigations and interpretation of data are discussed after each step using multiple-choice questions (MCQs). The audience participates in each step of the discussion by using an electronic voting system for MCQs. Each MCQ is discussed by the presenter. In the end, the diagnosis and management are briefly discussed. ICD is also used as an activity for continuing medical education.
  880 169 2
Can radiotherapy for breast cancer increase breast arterial calcification?
Yasemin Benderli Cihan
May-June 2019, 32(3):190-190
DOI:10.4103/0970-258X.278680  PMID:32129320
  861 158 -
Text Book of Cardiology (two volumes)
Rajiv Agarwal
May-June 2019, 32(3):188-188
  811 151 -
Letter from Ganiyari
Anissa Mary Thomas Thattil, Sobin Sunny, S Sakthi Arasu, Bobby Joseph
May-June 2019, 32(3):186-187
DOI:10.4103/0970-258X.278681  PMID:32129318
  750 151 -
Letter from Mumbai
Sunil K Pandya
May-June 2019, 32(3):183-185
DOI:10.4103/0970-258X.278697  PMID:32129317
  757 136 -
News from Here and There
Anika Sulania
May-June 2019, 32(3):191-192
  494 113 -