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BACKGROUND It is reported that patients who have recovered from Covid-19 continue to experience various symptoms and adverse outcomes. However, this aspect has not been studied well. We aimed to evaluate these variables and the perceived impact of Covid-19 among patients discharged from a Covid hospital in northern India. METHODS We conducted this study among patients discharged from a Covid-19 hospital in northern India in June 2020. As per the official policy at that time, patients detected to have Covid-19 (symptomatically or via contact tracing) were mandatorily admitted. A sequential, mixed-methods design was followed. Patients discharged from the hospital were contacted telephonically, and the cross-sectional prevalence of symptoms, the prevalence of depression and anxiety and the social consequences of admission were assessed. A subgroup of patients was interviewed for qualitative assessment of their experience. RESULTS A total of 274 patients provided consent and were assessed, of which 8 patients underwent detailed interviews. The prevalence of somatic symptoms was 3.4%; 36.2% of the patients had depressive and 12% of the patients had anxiety symptoms. A majority of patients experienced adverse social and economic consequences of hospitalization for Covid-19. These themes were reinforced by a qualitative analysis of in-depth interviews. CONCLUSIONS Our study population experienced a high prevalence of adverse psychosocial consequences of Covid-19. These included depression and anxiety symptoms, stigma and economic and occupational consequences. These deserve more recognition and study.
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Introduction: Cardiopulmonary resuscitation (CPR) is a life saving procedure and adequate knowledge and skills related to CPR are essential for all medical students. This study was undertaken to compare knowledge and practice related to updated CPR guidelines by American Heart Association (AHA) 2020 between junior residents and interns. Methods:This is a questionnaire-based study prepared on Google form consisting of 22 questions on CPR. Total of 124 participants included 41 junior residents and 83 interns. They were advised to read questions carefully and allowed to tick one best response among the options. Results: An average overall correct response from both the group was 14.48 (65.81 %). Among theory knowledge-based questions junior residents had an average of 8.707 correct answers out of 11 (79.15%) which is more correct answers than interns who have average 5.90 correct (53.63%). Similarly, in terms of practical knowledge, junior residents had an average score 9.682 out of 11 (88.026%) compared to interns who had an average of 6.518 out of 11 (59.27%). Conclusion: The study showed poor knowledge about CPR among the interns. More practical based teaching should be employed in MBBS curriculum. Periodical reinforcement and refresher courses should be part of curriculum.
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Purpose@#The purpose of this study is to study the various adverse reactions caused post measles and rubella vaccination done during measles rubella (MR) vaccine campaign in India. @*Materials and Methods@#Prospective, observational study was done in a government tertiary care pediatric intensive care unit. Children aged between 9 months to 15 years, who presented with adverse effects (severe enough to warrant admission) within 7 days of MR vaccine administration. @*Results@#Most common presenting complaint was fever (44.8%), followed by vomiting (34.5%), abdominal pain and dizziness (31%). Abnormal body movements were noted in two children (6.8%) on first day and in one child on fifth day of vaccine administration. Two children (6.8%) presented with generalized macular rashes all over the body on 4th day after vaccination. Altered sensorium on same day of vaccine administration was the presenting symptom of one child. All children improved gradually and were discharged after few days with no mortality or long-term morbidity. Investigations were done according to the protocol of the unit; nothing came significant to be reported. Neither of the children had positive blood culture. @*Conclusion@#MR vaccination programs are scientifically sound, highly recommended and proven effective globally. Causality assessment of adverse events is still an evolving science, and despite taking all the measures and adopting all the available scientific methods, sometimes it is not possible to incontrovertibly prove the causal association of an event with a vaccine. Much more advancement in this area is needed.
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Halophilic bacteria are microorganisms that grow optimally in the presence of the very high concentration of sodium chloride. Halophiles are vital sources of various enzymes including hydrolases, which are very stable and catalytically highly efficient at high salt concentration and other extreme conditions such as high temperature, pH and presence of organic solvents. Several hydrolases such as amylases, proteases, and lipases have been obtained from halophilic bacteria and are commonly used for various industrial applications. We initiated a screening to isolate and characterize the halophilic bacteria from the Red Sea, which is one of the saltiest bodies of water in the world. Water and soil samples, collected from the Red Sea coast, Jeddah, Saudi Arabia, were screened for isolation of halophilic bacteria. Ten bacterial isolates were obtained, which were characterized by biochemical tests and 16S rRNA gene sequencing. Hydrolase producing bacteria among the isolates were screened by plate assay on starch and gelatin agar plates for amylase and protease, respectively. Two bacterial isolates i.e. Bacillus glycinifermentans S3 and Enterobacter cloacae W1were found to possess significant amylase and protease activity.
Bactérias halofílicas são microrganismos que crescem de maneira ideal na presença de uma concentração muito alta de cloreto de sódio. Halófilos são fontes vitais de várias enzimas, incluindo hidrolases, que são muito estáveis e cataliticamente altamente eficientes em alta concentração de sal e outras condições extremas, como alta temperatura, pH e presença de solventes orgânicos. Várias hidrolases como amilases, proteases e lipases foram obtidas a partir de bactérias halofílicas e são comumente usadas para várias aplicações industriais. Iniciamos uma triagem para isolar e caracterizar as bactérias halofílicas do Mar Vermelho, que é um dos corpos de água mais salgados do mundo. Amostras de água e solo, coletadas na costa do Mar Vermelho, Jeddah, na Arábia Saudita, foram examinadas quanto ao isolamento de bactérias halofílicas. Foram obtidos dez isolados bacterianos, caracterizados por testes bioquímicos e seqüenciamento do gene 16S rRNA. As bactérias produtoras de hidrolase entre os isolados foram triadas por ensaio em placa em placas de amido e ágar de gelatina para amilase e protease, respectivamente. Verificou-se que dois isolados bacterianos, isto é, Bacillus glycinifermentans S3 e Enterobacter cloacae W1, possuíam significativa atividade de amilase e protease.
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Peptide Hydrolases , Halobacteriales , Salinity , Amylases , HydrolasesABSTRACT
Background: Neonatal seizures are a major risk factor for neonatal mortality and subsequent neurological disability. The incidence of seizure varies from 1.5-3.7/1000 live birth; while in NICU it can be up to 5/1000 live birth.Methods: This Descriptive type of observational study aimed to study clinical profile, aetiology in neonatal seizures and short term outcome was done in all Neonatal units attached to paediatric Department of SMS Medical College, Jaipur.Results: In the 100 cases Majority of neonates had onset of seizure <3 days (<72 hours) 53% and remaining 47% neonates had onset of seizure >3 days (>72 hours). Most common type of neonatal seizure was subtle(75%), other types were tonic seizure (17.3%), clonic seizure (5.1%) and least common type was myoclonic (2.5%). Most common cause of neonates seizure noted was birth asphyxia (73%) second common cause is pyomeningitis and third common cause is hypoglycaemia. Most common cause of neonatal seizure both in full term (71.17%) and preterm (25%) is birth asphyxia. Second most common cause of neonatal seizure in full term is pyomeningitis (8.70%) and in preterm is pyomeningitis and hypoglycaemia (25%). Most common cause of neonatal seizure both in onset of seizure <3 days (<72 hours) 53% and in onset of seizure >3 days (>72 hours).Conclusions: Out of total 100 cases, neonates with normal birth weight 92% and low birth weight 8%. Majority of neonates had onset of seizure <3 days (<72 hours) 53% and remaining 47% neonates had onset of seizure >3 days (>72 hours). Majority of neonates with seizure delivered by vaginal route (86%) and remaining 14% neonates were delivered by LSCS.
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Methods@#A total of 51 patients with a mean age of 31.75±10.42 years who suffered traumatic SCI were included in this study. Complete neurological examinations (American Spinal Injury Association grading) and magnetic resonance imaging (MRI) were performed at the time of admission and at 3–6 months after injury to study the neurological status and disc and trunk parameters. The type of management (operative or conservative) was decided on the basis of clinical, radiological, and MRI evaluations, and a robust rehabilitation program was initiated. @*Results@#Disc parameters including disc angle, skin angle, cross-sectional area (CSA), and disc height and trunk parameters (mean trunk width, mean trunk depth, and CSA of the lumbar muscles) decreased significantly (p <0.001) during the first 3 months after SCI. However, improvements were observed in disc and muscle parameters at the 6-month follow-up, but these parameters did not return to normal levels. Neither initial neurological status (complete vs. incomplete) nor type of management (operative vs. conservative) had a significant effect on these parameters. @*Conclusions@#Spinal trauma leads to alterations in the morphology of the vertebral column, spinal cord, intervertebral discs, and paraspinal muscles in the initial phase of injury. The extent of these changes may determine the initial neurological deficit and subsequent recovery. Although this study did not identify any statistically significant effect of neurological status or management strategy on these parameters, rehabilitation was found to result in the improvement of these parameters in the later phase of recovery. Future studies are required to evaluate the exact causes of these alterations and the potential benefits of rehabilitation strategies and to minimize these changes.
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Methods@#A total of 51 patients with a mean age of 31.75±10.42 years who suffered traumatic SCI were included in this study. Complete neurological examinations (American Spinal Injury Association grading) and magnetic resonance imaging (MRI) were performed at the time of admission and at 3–6 months after injury to study the neurological status and disc and trunk parameters. The type of management (operative or conservative) was decided on the basis of clinical, radiological, and MRI evaluations, and a robust rehabilitation program was initiated. @*Results@#Disc parameters including disc angle, skin angle, cross-sectional area (CSA), and disc height and trunk parameters (mean trunk width, mean trunk depth, and CSA of the lumbar muscles) decreased significantly (p <0.001) during the first 3 months after SCI. However, improvements were observed in disc and muscle parameters at the 6-month follow-up, but these parameters did not return to normal levels. Neither initial neurological status (complete vs. incomplete) nor type of management (operative vs. conservative) had a significant effect on these parameters. @*Conclusions@#Spinal trauma leads to alterations in the morphology of the vertebral column, spinal cord, intervertebral discs, and paraspinal muscles in the initial phase of injury. The extent of these changes may determine the initial neurological deficit and subsequent recovery. Although this study did not identify any statistically significant effect of neurological status or management strategy on these parameters, rehabilitation was found to result in the improvement of these parameters in the later phase of recovery. Future studies are required to evaluate the exact causes of these alterations and the potential benefits of rehabilitation strategies and to minimize these changes.
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@#The number of mental health problems among the young people in Malaysia is increasing, and this is worrying. Prompt action is needed as the young generation especially university students are the future leaders of the country. This study aimed to evaluate the level of stigma and attitudes of university students towards mental health disorders since limited study regarding this issue conducted in Malaysia. This is a cross-sectional study design whereby 496 students from MAHSA University were asked to complete a pre-validated questionnaire. The questionnaire consisted of three main sections which were demographic, measures of knowledge and attitudes of respondents towards mental health disorders. The findings showed that there was a significant difference between knowledge score of the different age groups, ethnicity, faculty and current education level of respondents. Besides that, significant differences were reported between attitude score of the different age groups, faculty and current education level of the respondents. It was also found that there was a statistically significant positive correlation between mental health knowledge and attitudes towards mental health disorders. Overall, the respondents displayed good knowledge and attitude towards mental health disorders.
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The elderly people are more prone to develop psychiatric disorders due to a number of factors like changes in the brain, other illnesses etc. They represent the most vulnerable group as they are most sensitive to the effects of drugs and are at increased risk of developing adverse drug reactions. This warrants the need to make the prescribers cautious about rational prescribing of antipsychotics to the Elderly. The study included elderly inpatients and outpatients visiting psychiatry ward with psychiatric disorders. Descriptive weighed analysis was performed to determine the prescribing practices of atypical antipsychotics. Among the 70 patients who were involved in the study, 36 patients were diagnosed with neurotic disorders and 30 patients were diagnosed with psychotic disorders and 4 were diagnosed with degenerative disorders (dementia). In our study neurotic disorders (51%) were the major diagnosis. 6 different atypical antipsychotic drugs were prescribed to the patients suffering from different psychiatric disorders. Among them olanzapine (43%) was the most commonly prescribed drug, followed by quetiapine (30%), risperidone (21%), clozapine (3.2%), lurasidone (1%), and aripiprazole (1%). This study has concluded that atypical antipsychotics are preferred over typical antipsychotics and Olanzapine is the most commonly prescribed drug for the elderly patients suffering from psychiatric disorders. On comparison of the prescribed daily doses with the maximum daily dose we have observed that the prescribed daily doses for the elderly patients were well within the maximum daily dose of the drugs and in our study no adverse drug reactions were reported in the study subjects that were involved.
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A patient, being a moderate myope with an axial length of 24.71 mm, presented to us with a fresh rhegmatogenous retinal detachment and marked peripheral chorioretinal degeneration. Difficulty in maneuvering with the standard 23 gauge vitrectomy cutter, inability to identify the break due to poor peripheral contrast, inadequate laser uptake, and an unusual large silicon oil fill (7.3 ml) were a few findings raising suspicion. Postoperative ocular ultrasonography showed an oblate eyeball with a relatively longer oblique axis (26.1 mm) as compared to the axial length confirming our suspicion. Oblateness should be suspected when the chorioretinal degenerations are more marked in the periphery as compared to the posterior pole. Intraoperative difficulties should be kept in mind while operating such cases.
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A 45-year-old diabetic male, with diabetic retinopathy and medically uncontrolled neovascular glaucoma (NVG) underwent intracameral bevacizumab followed by trabeculectomy, with controlled intraocular pressures (IOP) post-operatively, OD: 12 mmHg; OS: 14 mmHg. Patient was referred to hematology, where he was diagnosed as chronic myeloid leukemia (CML) and started on imatinib mesylate. Thereafter, he presented with recurrence of neovascularization and vascularization of the bleb along with OS vitreous hemorrhage at 6 weeks follow-up. While he was planned for OS vitreo-retinal surgery, he presented with OD spontaneous hyphema with raised IOP (OD: 38 mmHg, OS: 16 mmHg). He had maintained a tight glycemic control. Following imatinib therapy, there was a rapid progression and recurrence of neovascularization, eventually leading to failure of trabeculectomy OD and bilateral severe loss of vision. Imatinib may be implicated in the worsening of NVG in CML patients, especially with co-existing diabetes and thus, such patients should receive regular thorough ophthalmic evaluation as long as imatinib continues.
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Purpose:@#Distal femoral fracture is one of the most common lower limb injuries and accounts for less than 1% of all fractures. Open fracture takes 5%-10% of the all distal femoral fractures, which is at an increased risk of complications. There were limited studies which documented the outcomes of such cases. The present study aims to evaluate the outcome and complications in these fractures using primary definitive fixation with condylar locking plate and antibiotic impregnated collagen sheet secondary to aggressive debridement.@*Methods:@#This is a prospective study conducted in a tertiary care orthopaedic hospital in northern India. Thirty patients of open distal femoral fractures were managed by primary definitive fixation with condylar locking plate and antibiotic impregnated collagen sheet secondary to aggressive debridement. They were followed for minimum of six months. Patients were followed up monthly for first four months, at six months and one year after surgery. Clinical and radiological signs of healing, any complications, time to union, and functional outcome were assessed.@*Results:@#The mean age of patients was 44.33 years (range 20-82 years) with male predominance of 66.7%. According to Gustilo-Anderson classification, there were 5, 15 and 10 patients with open grade I, II and IIIA distal femoral fractures respectively. According to orthopaedic trauma association (OTA) classification, majority of patients in our study were of C3 type. The mean time to bony union was 5.6 months (range 4-9 months). Average postoperative knee range of motion (ROM) at the latest follow-up was 98° (range 70°-120°). Lysholm knee scoring scale showed excellent score in 11 patients, good in 9 patients, fair and poor in 5 patients each; however, there was no significant correlation with fracture pattern types (p < 0.05). Knee stiffness was the major complications encountered in the study. The knee ROM was <90° in 5 patients and 90°-120° in rest of the patients, while 1 patient had extensor lag of 10°. One patient had implant failure and lost to follow-up; 3 patients had deep infection.@*Conclusion:@#An approach of primary definitive fixation with condylar locking plate and antibiotic impregnated collagen sheet secondary to early aggressive debridement in open distal femur fractures shows significant results in terms of functional and radiological outcomes with minimal complications.
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STUDY DESIGN: Prospective clinical study. PURPOSE: We evaluated the challenges faced during diagnosis and management of patients with subacute pyogenic discitis and discussed various clues in clinical history, radiologic and hematologic parameters of these patients that helped in establishing their diagnosis. OVERVIEW OF LITERATURE: Present literature available shows that in patients with subacute spondylodiscitis and infection with less virulent organisms, the clinical picture often is confusing and the initial radiologic and hematologic studies do not contribute much toward establishing the diagnosis. METHODS: Demographic pattern, predisposing factors, clinical presentation, comorbidities, microbiology, treatment, neurologic recovery, and complications of 11 patients were prospectively reviewed regarding their contribution toward the conformation of diagnosis of subacute pyogenic discitis. RESULTS: Mean age at presentation was 46.0 years with average preoperative Oswestry Disability Index and Visual Analog Scale scores of 83.4 and 7.18, respectively. Mean follow-up duration was 12.0 months. The most common site of infection was the lumbar spine, followed by the thoracic spine (n=1). Infective organisms were isolated in only 45% of cases. Staphylococcus aureus was the most common causative organism isolated. CONCLUSIONS: Diagnosing subacute spondylodiscitis in a patient presenting with subacute low backache poses a diagnostic challenge. Clinical and radiologic picture are deceiving, and bacteriologic results often are negative, further complicating the picture. A detailed medical history along with clinical, radiologic, and biochemical parameters prevents missing the diagnosis. Serial serum C-reactive protein and alkaline phosphatases were more reliable blood parameters in cases of subacute presentation.
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Humans , Alkaline Phosphatase , C-Reactive Protein , Causality , Clinical Study , Comorbidity , Diagnosis , Discitis , Follow-Up Studies , Low Back Pain , Lumbar Vertebrae , Phosphoric Monoester Hydrolases , Prospective Studies , Spine , Staphylococcal Infections , Staphylococcus aureus , Tertiary Care Centers , Tertiary Healthcare , Visual Analog ScaleABSTRACT
Background: Gall bladder stones are one of the commonest abdominal disorder requiring hospitalization and surgery in India. In Europian countries more than 10% prevalence of gall bladder stone has been recorded. Different studies suggested that sluggish movement of bile during hypothyroidism may induce formation of stone in gall bladder. Moreover, use of thyroxine for dissolving gall bladder stone has been suggested in studies. However, relation of thyroid hormones and gall bladder stone is still unclear. Therefore, present study was designed to assess if there is any relation between thyroid hormones disorders and gall bladder stones. Methods: It was cross sectional type of study which was conducted in departments of general surgery of TMMC & RC, Moradabad. This study was carried out from April 2017 to December 2017. Study population included 100 patients of cholelithiasis undergoing for cholecystectomy. Surgical profile along with full history including name, age, sex etc was recorded in the study. Similarly, full history of control group subjects was taken. Thyroid hormones in serum total tri iodothyronine (T3), free thyroxine (FT4), and TSH were measured by Enzyme Linked Immunosorbent Assay (ELISA) method. Results: Gall bladder stone were more common in female patients (60) in comparison of male patients (40). Hypothyroid disorder was found in 20% male gall bladder patients. Whereas, 7.5% hyperthyroid disease in male cholelethiais patients. Euthyroid status was observed in 72.5% male gall bladder patients. Hypothyroid disorder was found in 14% female gall bladder patients. Whereas, 7% hyperthyroid disease in female cholelethiais patients. Euthyroid status was observed in 65% female gall bladder patients. Conclusion: Findings of the current study suggest that female population suffers more in comparison of male population. Further, prevalence of gall bladder stones were more in 51 to 60 years age group population. Further, no definite relation was observed between thyroid hormones disorders either hypothyroid or hyperthyroid and gall bladder stones. However, more studies of on larger populations are required to assess if there is any relation between thyroid disorders and gall bladder stones
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Ricinus communis L. (R. communis), commonly known as castor oil plant, is used as a traditional natural remedy or folkloric herb for the control and treatment of a wide range of diseases around the globe. Various studies have revealed the presence of diverse phytochemicals such as alkaloids, flavonoids, terpenes, saponins, phenolic compounds such as kaempferol, gallic acid, ricin, rutin, lupeol, ricinoleic acid, pinene, thujone and gentisic acid. These phytochemicals have been responsible for pharmacological and therapeutic effects, including anticancer, antimicrobial, insecticidal, antioxidant, anti-diabetic, antinociceptive, anti-inflammatory, bone regenerative, analgesic, and anticonvulsant activity. R. communis harbours phytochemicals which have been shown to target peroxisome proliferator activated receptor (PPAR), nuclear factor NF- κ -B, cytochrome p450, P38 mitogen-activated protein kinases kinase (p38 MAPK), tumor protein P53, B-cell lymphoma-extra-large (Bcl-xL) and vascular endothelial growth factor receptor-2 (VEGFR-2). Considering its wide variety of phytochemicals, its pharmacological activity and the subsequent clinical trials, R. communis could be a good candidate for discovering novel complementary drugs. Further experimental and advanced clinical studies are required to explore the pharmaceutical, beneficial therapeutic and safety prospects of R. communis with its phytochemicals as a herbal and complementary medicine for combating various diseases and disorders.
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<p><b>PURPOSE</b>New research is focusing on the use of autologous growth factors to increase the effect of bone fracture healing while decreasing the amount of healing time for the patient. Platelets have been demonstrated to be the natural storage vessel for several growth factors and cytokines that promote blood coagulation, tissue repair, and the process of bone mineralization. The present study aims to evaluate the role of platelet-rich plasma (PRP) in healing of acute femoral shaft fractures radiologically. We hypothesize that it provides artificial hematoma and releases various growth factors.</p><p><b>METHODS</b>This prospective randomized study was carried out in 72 patients of traumatic fracture of the femoral shaft operated with interlocking nails (closed or open). Patients were divided into two groups: study group A (n = 33) treated with intramedullary nailing & PRP injection/gel application in the same setting; and control group B (n = 39) treated with intramedullary nailing without PRP application. Both groups were further divided into two subgroups. Study group included subgroup A1 (n = 14) operated with closed intramedullary nailing and PRP injection at the fracture site under radiological control, and subgroup A2 (n = 19) operated with open intramedullary nailing and PRP gel along with fibrin membrane application at the fracture site; while control group included subgroup B1 (n = 16) operated with closed intramedullary nailing, and subgroup B2 (n = 23) operated with open intramedullary nailing. Radiological assessment of fracture healing was done by measuring the cortex to callus ratio every month till union at 6 months.</p><p><b>RESULTS</b>Measurements of mean cortex to callus ratio revealed significant difference between the groups A & B at third and fourth months. Measurements of mean cortex to callus ratio did not reveal significant difference between the subgroups at first and sixth months. A statistically significant difference was observed between subgroups A1 & B2 and B1 & B2 at the second month; between subgroups A1 & B2, A2 & B2 and B1 & B2 at the third month; and between subgroups A1 & B2 at fourth and fifth months.</p><p><b>CONCLUSION</b>PRP has no effect on femoral shaft fracture healing treated with closed intramedullary nailing. However, PRP and matrix scaffold provided by fibrin membrane may provide an artificial hematoma effect in the initial phase of healing in open or failed closed intramedullary nailing.</p>
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Adolescent , Adult , Humans , Male , Middle Aged , Acute Disease , Femoral Fractures , Diagnostic Imaging , General Surgery , Fracture Fixation, Intramedullary , Fracture Healing , Platelet-Rich Plasma , Prospective StudiesABSTRACT
This commentary addresses the issue of disproportionate medical interventions for end-of-life patients. A complex mix of sociocultural and medical factors, against the backdrop of the legal milieu, has an impact on the quality of death. The barriers to appropriate end-of-life and palliative care in India are multilayered and not easy to dismantle. To raise the level of care for the dying in India, currently rated among the worst in the world, it would require no less than a nationwide movement. This paper attempts to bring into the open the areas of concern for discussion, and proposes appropriate legislation for a realistic solution.
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Globally, the expanding issues over the extent of substandard or spurious medicines remain a challenge. It is operated largely by encompassing wrong therapeutic doses or adulterated formulations that necessitates routine monitoring to avoid any potential public health adversity. This study was aimed to determine the diclofenac sodium content in generic products available in northern Indian market. Therefore, 32 commercially available generic products of diclofenac sodium tablet were procured from the open market and subjected to assay evaluation using in-house developed and validated high performance liquid chromatography (HPLC) method. Product identification was confirmed by thin layer chromatography (TLC) method; and the quantitative results by validated in-house HPLC method showed 34.37% (11/32) products as out of Indian Pharmacopoeia specification including 15.62% (5/32) substandard products. This makes the health situation miserable for public and their trust. On comparing the assay with price of each tablet, it was noticed that quality of products was irrespective of price. People rely completely on manufacturer quality promises and on regulatory process. However, such substandard products which still exist in the market for use by the patient; unfortunately not identified yet, poses a serious issue and require some interventions to stop them in entering into market. So there is an urgent need to carry out the quality evaluation on regular and large scale by the state and national drug authorities to ensure better quality medicines.