Defensive Medicine in the Context of the Indian Health System

Defensive medicine; although a recent concept, is slowly beginning to cement its place in the Indian health system. An interaction of multiple factors has paved way for this form of practice. Need for certainty of the diagnosis, lack of hierarchy in medical care, exponential growth of micro/super specializations and private/corporate health institutions, incentive-based practice, increasing incidences of violence against health personnel, rising trend of defamation suites against doctors, bad publicity by media, and interference by elected representatives have jeopardized the situation. This has led to decline in practice of clinical medicine, increased burden of investigations, especially in already compromised public facilities, and high out-of-pocket health expenditure. As much as ethical medical practice, standard patient management protocols, strict protection of interest of medical practitioners by law, responsible role of media and elected representatives are the need of the hour; we need to find ways to accept and incorporate defensive medicine into the modern medicine. Different stakeholders are required to come together and take substantial steps to understand the phenomenon and preserve the art and science of practicing medicine in its true form.

Neuro-imaging in severe hypertensive disorders of pregnancy: a study from North Indian tertiary health care institution

Background: Hypertensive disorders of pregnancy comprising of pre-eclampsia and eclampsia are a major cause of adverse pregnancy outcomes. Neurological manifestations of pregnancy induced hypertension are the most common cause of maternal and foetal morbidity and mortality. Cranial neuro-imaging reveals focal regions of symmetric hemispheric oedema; with parietal and occipital regions getting most commonly affected.Methods: The study was conducted among 65 antenatal women diagnosed with pre-eclampsia and eclampsia at gestational age >20 weeks in the department of obstetrics and gynecology, Kamla Nehru State Hospital for Mother and Child IGMC Shimla. Clinical signs and symptoms, neuroimaging findings were recorded for study purpose.Results: About 17.6% of severe pre-eclampsia and 100% of eclampsia had findings observed on cranial MRI. Headache and visual complaints were most frequently recorded. PRES was the predominant neuroradiographic finding in present study and occipital lobe was commonly affected region. No significant difference was observed regarding blood pressure parameters between MRI positive and negative subjects.Conclusions: Neuroimaging in antenatal with severe hypertensive disorders might aid in better understanding of the poorly explained phenomenon. In addition, this would be helpful in better management of the disorders along with their much-dreaded complications. Patients with hypertensive disorders of pregnancy should be subjected routinely to cranial imaging for the better perinatal outcomes.

Predicting pregnancy outcomes from homocysteine level: an evidence from a North Indian study

Background: Hypertensive disorders of pregnancy are a major cause of adverse pregnancy outcomes. Though the etiology of spectrum of vascular disorders of pregnancy is still not understood completely, yet abnormally elevated homocysteine level has been implicated in the causal pathway and pathogenesis. Hyperhomocysteinemia has been significantly associated with increased risk of poor maternal and foetal outcomes in terms of PIH, abruption, IUGR, recurrent pregnancy loss, intrauterine death and prematurity.Methods: The present prospective study was conducted among 180 pregnant women (57 exposed and 123 non exposed) in Kamla Nehru State Hospital for Mother and Child, IGMC Shimla, Himachal Pradesh with an objective of determining association of abnormally elevated homocysteine level in pregnancy and adverse pregnancy outcomes. Socio-demographic, clinical, biochemical including homocysteine level, laboratory, ultrasonographic parameters and foeto-maternal outcomes of pregnancy of all the participants were documented.Results: The mean homocysteine level of exposed group (23.26±10.77 µmol/L) was significantly higher than the unexposed group (8.99±2.47 µmol/L). Among hyperhomocysteinemic subjects, 10.5% had abruption, 15.8% had PRES and 8.7% PPH which was significantly higher than normal subjects. Similarly, patients with homocysteinemia had significantly higher proportion (21.3%) of poor Apgar score, more (41.9%) NICU admissions and higher frequency (4.7%) of meconium aspiration syndrome.Conclusions: The present study generates necessary evidence for associating abnormally elevated homocysteine levels with pregnancy related hypertensive ailments and adverse pregnancy outcomes. It further demands the need of robustly designed studies and trials to further explore the phenomenon. Moreover, it emphasizes on a simple and timely intervention like estimating the much-neglected homocysteine levels during pregnancy which can definitely contribute in predicting and preventing adverse perinatal outcomes.

Creation of a Smoke-free Environment for Children: An Assessment of Compliance to COTPA 2003 Legislation in an Urban Area

Objective: To ascertain the compliance to Cigarette and Other Tobacco Products Act(COTPA) 2003 which ensures the protection of children from the adverse health effects ofsecond hand smoke. Methods: This cross-sectional study assessed the compliance of 32educational institutions and 157 points of sale of Shimla city. Results: About 88% of theeducational institutions and mere 7.6% points of sale were found having good compliance tothe key indicators. No point of sale was found within the premises of educational institutions;however, 26% were found selling tobacco products within 100 metres radius of aneducational institution. 7.6% points of sale were found selling a tobacco product to children.Conclusion: Despite having the status of a smoke-free city, lapses were observed incompliance to the Act. Strict adherence to the provisions of the Act would ultimately lead to asmoke-free environment for our children

Can serum homocysteine predict hypertensive disorders of pregnancy?: an evidence from a case control study in a North Indian tertiary health care institution

Background: Hypertensive disorders of pregnancy are a major cause of both maternal and foetal morbidity and mortality. Although pregnancy induced hypertension (PIH) is still regarded as a disease of theories and unknown etiology, elevated homocysteine level has been hypothesized as a key risk factor. Abnormally raised homocysteine has been significantly associated with increased risk of PIH, abruption, intrauterine growth restriction, recurrent pregnancy loss, intrauterine death and prematurity.Methods: The present case control study was conducted among 180 pregnant women (90 cases and 90 controls) in Kamla Nehru State Hospital for Mother and Child, IGMC Shimla, Himachal Pradesh with an objective of ascertaining the role of homocysteine in pregnancy related hypertensive disorders. Socio-demographic, clinical, biochemical including homocysteine level, laboratory and ultrasonographic parameters of all the participants were documented.Results: The mean homocysteine level of cases (18.30±10.81) was significantly higher than the controls (8.70±2.64).  About 62.2% cases had abnormally raised homocysteine level (>15 µmol/L), while only 1.1% controls had such level. The odds of a case having abnormally elevated homocysteine level were 146.6 (CI: 19.52-1101) times to that of controls. Eclamptics had the highest homocysteine level followed by preeclamptics and controls.Conclusions: The present study significantly associates the abnormally elevated homocysteine levels with pregnancy related hypertensive ailments and demands much needed robustly designed studies to further explore the phenomenon. A simple intervention like estimating the much neglected homocysteine levels prior to pregnancy can definitely aid in predicting and preventing perinatal outcomes.

A descriptive study to quantify severity in patients with severe scrub typhus in hilly city of Northern India

Background: Himachal Pradesh is an endemic area for scrub typhus. If not treated early, it can lead to life threatening complications. Therefore, more emphasis needs to be laid on the diagnosis and prompt treatment, so that mortality due to severe scrub typhus can be prevented. So, this study was done with an objective to study the clinical profile of patients diagnosed with severe scrub typhus and assess their severity using APACHE II score in IGMC, Shimla.Methods: Authors conducted a descriptive cross-sectional study in Indira Gandhi Medical College, Shimla over one year (June 2016-May 2017). Out of 538 confirmed scrub typhus cases, 58 severe cases were reported, and their severity was assessed with predefined criteria of sepsis and APACHE II score.Results: Mean age of males (50.18±18.6 yrs) was found to be more than that of females (45.52±14.5 yrs), the difference being statistically insignificant t(56)= -1.01, (P=0.32). Fever (100%), headache (84.5%), vomiting (79.3%) were the major presenting symptoms and tachycardia (96.5%), hypotension (87.9%), tachypnoea (94.8%) were the main clinical signs. The mean APACHE II score on admission was 16.25±5.0 with a predicted mortality of 23.5%, that was found to be less than actual reported hospital mortality (25.8%).Conclusions: APACHE II score was found reliable tool for risk stratification. Case fatality in diagnosed cases of severe scrub typhus was found high. Early diagnosis and prompt treatment according to guidelines would help in decreasing the mortality, financial burden on patient, society and health system.

Epidemiological profile of animal bite patients attending emergency department at a tertiary care health facility in a northern hilly Indian city

Background: Rabies is a highly infectious zoonotic disease with a high case fatality rate. In India, approximately 20,000 deaths among 17.4 million exposed people occur every year. The data on animal bites is scarce and unreliable due to poor surveillance and hence, the projected figures are far less from the actual numbers. The present study was conducted to describe epidemiological characteristics of animal bite patients attending casualty department at a tertiary care Government health facility in Shimla, Himachal Pradesh.Methods: It was a retrospective study based on secondary data received from animal bite register for year 2017 at casualty department of the Indira Gandhi Medical College and Hospital, Shimla, Data of 1512 patients attending the casualty department with history of animal bite was included for the study purpose.Results: About 58% of victims were males and the maximum (22.6%) animal bites were seen in 21-30 years age group. Majority (51.6%) of patients were exposed to dog bites, followed by monkey bites (42.85%) and cat bite 49 (3.2%). About 69.9% of animal bites were in the lower limbs, followed by upper limbs (22.1%), abdomen (4.4%) and head and neck region (3.6%). Maximum bites were category III bites (74.6%) followed by of category II bites (12.9%).Conclusions: Study highlights the neglected but significant picture of animal bite in the Shimla city. Timely and correct post exposure prophylaxis for the animal bite victims is necessary to prevent rabies. This should be supplemented with a robust surveillance and reporting system. With the global aim of zero rabies deaths by 2030; it is time to strengthen the anti-rabies activities at every level.

Clinical and biochemical profile of patients hospitalized with jaundice: Experience from a teaching hospital in north India

Background: Jaundice is a common problem in both medical and surgical practice. For best line of management, it is very essential to differentiate all types of jaundice. The cause can often be correctly anticipated clinically but usually biochemical and radiological imaging investigations are required for confirmation. Here we present a study on clinical and biochemical profile of jaundice patients admitted in a tertiary care hospital.Methods: It was an observational study and all patients admitted with jaundice in the department of medicine meeting inclusion/exclusion criteria were enrolled. Data was collected on a self-designed, pretested and structured format.Results: Out of 100 patients, 77 were males, and median age of 47.5 years. Apart from jaundice, anorexia was the most common presenting complaint (90%), while ascites was the most common finding. Cirrhosis (60%) was the most common cause of jaundice. The mean total bilirubin was 7.9 mg%. Mean Hemoglobin in patients with cirrhosis was 9.7gm/dL. 78% patients of cirrhosis revealed esophageal varices. Majority (80%) showed hypoproteinemia. PT was prolonged >3sec in 87% of cases. On USG shrunken liver was noted in all patients with cirrhosis, enlarged liver was found in two patients of liver abscess while altered echotexture was seen in 66% cases. 90 patients improved, 9 died and only one was referred.Conclusions: Alcoholic liver disease was the leading cause of cirrhosis (92%). Jaundice in general and alcoholic cirrhosis in particular affects mostly the productive age group of the male population and has a high economic burden on our society.

COTPA 2003 compliance assessment of tobacco vendors and products: current status of an earliest smoke free Indian city

Background: Tobacco smoking is a global phenomenon, associated not only with health but also with other issues like employment, trade and revenue. However, the ill aspects of tobacco outweigh any productivity related to it. Various regulatory measures have been devised to control this menace at national as well as international level. In India, COTPA-2003 legislation intends to control and regulate tobacco consumption, advertisement and trade. Methods: The present study assessed the compliance of 157 points of sale and 59 tobacco products to the Sections 5,7,8,9 and 10 of the smoke free legislation using a structured observational checklist. Results: In total (41%) POS were advertising tobacco in one or other form with product showcasing (64%) being the most common modality of advertisement. Actual advertisement boards were seen at only 14.6% of POS. About 87% of the advertisement boards carried a health warning. Loose cigarettes were being sold at about 77% of the POS. All tobacco products available in the city were observed to display good compliance; however none of the smoke product displayed nicotine and tar content on the pack. Conclusions: Negligible number of PoS was seen to display an actual advertisement. Almost all tobacco products displayed good compliance to the Act. The striking shortcoming was the absence of nicotine and tar content on the package of the product even after 16 years of enactment. Discrepancies need to be addressed appropriately supplemented with aggressive monitoring of adherence to the Act in order to sustain the smoke free status of the city.

Assessment of compliance to the COTPA 2003 legislation in tertiary healthcare institutes of Shimla: a smoke free city in India

Background: Tobacco smoking is a pandemic affecting populations and contributing to global morbidity and mortality. It is well known that the second hand smoke is equally hazardous like first hand smoke. Cigarette and other tobacco products act 2003 is an effort put forth by Government of India in order to curb this menace and protect people from ill effects of second hand smoke.Methods: The present study was conducted to assess the compliance to smoke free act in tertiary healthcare institutes in Shimla city, Himachal Pradesh. A total of 57 public places and 8 shops in five Tertiary healthcare institutes were evaluated for various provisions of the act. Compliance to different sections of the act was assessed using a structured observational checklist.Results: Signage indicating ban on smoking was seen at 71.9% places. Active smoking was absent at 77.2% places. About 25% shops around the institutes were found selling tobacco products. Signage displaying ban on sale within 100 m of educational institution and sale to minors was not observed at any shop. Tobacco product vendor was seen around 80% of educational buildings. Tobacco free institution signage was seen at 60% of educational premises.Conclusions: The study highlights that the level of compliance did not meet the standards laid down for a smoke free city. Timely and periodic assessment of the compliance must be conducted by the administrative authorities of the institutes for ensuring the adherence and strict implementation of the provisions of the act.

HPV infection: in need of timely intervention

Persistent infection with human papilloma virus (HPV) has been proved beyond doubt to be associated with the development of cervical cancer. One woman dies of cervical cancer every 8 minutes in India. As per estimations for the year 2018, about 96922 new cervical cancer cases are diagnosed annually in India and it ranks as the second most common female cancer in all age groups. But being an infectious cause it is possible to contain its development and transmission. Coupled with this, we have a potent vaccine to fight this infection. A well documented account of positive impact of HPV vaccination has been published in numerous studies around the globe. By 2013, its vaccination had been introduced in about fifty countries around the globe. In India also, recently, two HPV vaccination projects for operational feasibility were launched in Andhra Pradesh and Gujarat. In November 2016, Punjab becamethe first state in the country to include the vaccine in its universal immunization program. This era belongs to women empowerment and we cannot deny them the opportunity of good health. Hence it’s high time India introduces an effective HPV vaccination program.

Comprehensive review on world herb trade and most utilized medicinal plant.

Herbal medicine is plant derived material or preparations with therapeutic or other human health benefits, which contain either raw or processed ingredients from one or more plants. Allopathic medicine are said to be more successful in acute conditions of diseases, but due to its side effects plant based medicines are preferred. In the end of 18th century herbal medicines started popularizing in healthcare area. The utilization of medicinal herbs became 60% in most of the countries and 70 -80% of Chiniese, Indian, African and Germany people used from 19th century up to now. Some of the medicinal plants have higest trade in world herb market consistently through past years. These plants are Panax ginseng, Sylibum marianum, Zingiber officinalis, Allium sativum, Glycyrrhiza glabra, Ginkgo biloba, Echinicea indica, Rodeala rosea, Hypericum perforatum and Curcuma longa have shown highest trade in world herb market and these are the top plants which are used in the herbal preparation.

Estimation of valsartan and hydrochlorothiazide in pharmaceutical dosage forms by absorption ratio method.

A new absorption ratio method was developed and validated for the determination of valsartan and hydrochlorothiazide in tablets. Calibration curves for valsartan and hydrochlorothiazide over concentration range of 2-20 μg/ml were plotted and molar absorptivity for both the drugs were calculated at both the wavelengths of 270.5 nm (l-max of hydrochlorothiazide) and 231.5 nm (iso- absorptive point). The results of analysis have been validated statistically and by recovery studies. The value of standard deviation was satisfactory and recovery studies ranging from 99.05-102.23% for valsartan and 97.42-100.22% for hydrochlorothiazide were indicative of the accuracy and precision of the proposed method. The results of the assay are in good agreement with the label amount. The method was found to be simple, rapid, and accurate and can be adopted in routine analysis of these drugs in formulations. Due to these attributes, the proposed method could be used for routine analysis of these drugs in combined dosage forms.