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Objective.To explore the smartphone addiction and its impact on quality of sleep and academic performance among the nursing students. Methods. A descriptive cross-sectional study was conducted among the nursing students (n=160) in tertiary care teaching hospital in western Rajasthan (India) by using standardized Smartphone Addiction Scale Short Version (SAS-SV), the quality of sleep was assessed by standardized Pittsburg's Sleep Quality Index scale (PSQI) and academic performance was assessed by self made Academic Performance Scale. Results.In this study 38.1 % students were having moderate smartphone addiction. The smartphone addiction is directly associated with hours daily spend on smartphone (p<0.001), time check smartphone after wake up in the morning (p<0.001), and frequency of smartphone pickups in a day (p=0.003) of students. The quality of sleep is inversely associated with duration of smartphone use (p=0.004), hours daily spend on smartphone (p=0.002), time check smartphone after wake up in morning (p=0.010), of students The academic performance is significantly associated with hours daily spend on smartphone (p=0.003), time check smartphone after wake up in morning (p=0.001), and frequency of smartphone pickups in a day (p=0.015) of students. Conclusion. A high proportion of nursing students have moderate smartphone addiction. This addiction was associated with an increased risk of poor sleep quality and poor academic performance. Educational activities on the healthy use of smartphones are needed in the studied group.
Objetivo. Explorar la adicción a los teléfonos inteligentes y su impacto en la calidad del sueño y el rendimiento académico entre los estudiantes de enfermería. Métodos. Se realizó un estudio descriptivo transversal entre los estudiantes de enfermería (n=160) en el hospital universitario de atención terciaria en el oeste de Rajastán (India). Se empleó la escala estandarizada Smartphone Addiction Scale Short Version (SAS-SV), la calidad del sueño se evaluó mediante el Pittsburg's Sleep Quality Index (PSQI) y el rendimiento académico se evaluó mediante la Escala de Rendimiento Académico de elaboración propia.Resultados. En este estudio, el 38.1% de los estudiantes presentaban adicción moderada a los teléfonos inteligentes. Esta adicción se asoció con las horas diarias dedicadas a los teléfonos inteligentes (p<0.001), el tiempo de revisión de los teléfonos después de despertarse por la mañana (p<0.001), y la frecuencia de uso durante el día (p=0.003). La calidad del sueño se asoció inversamente con los años de uso del teléfono inteligente (p=0.004), las horas diarias de uso (p=0.002) y el tiempo de revisión del teléfono después de despertarse por la mañana (p=0.01). El rendimiento académico también se asoció en forma inversa con las horas diarias de uso del teléfono (p=0.003), el tiempo de revisión del teléfono después de despertarse por la mañana (p=0.001), y la frecuencia de uso del teléfono en un día (p=0.015). Conclusión. Una alta proporción de estudiantes de enfermería tienen adicción moderada a los teléfonos inteligentes. Esta adicción se asoció a un mayor riesgo de mala calidad del sueño y de bajo rendimiento académico. Es necesario llevar a cabo actividades educativas sobre el uso saludable de los teléfonos inteligentes en el grupo estudiado.
Objetivo. Explorar o vício em smartphones e seu impacto na qualidade do sono e no desempenho acadêmico entre estudantes de enfermagem. Métodos. Um estudo transversal descritivo foi realizado entre estudantes de enfermagem (n = 160) em um hospital universitário terciário no Oeste Rajasthan (Índia). Foi utilizada a escala padronizada de dependência de smartphones, Scale Short Version (SAS-SV), a qualidade do sono foi avaliada usando o Pittsburg's Sleep Quality Index (PSQI) e desempenho acadêmico foi avaliado por meio da Escala de Desempenho Acadêmico de nossa própria elaboração. Resultados. Neste estudo, 38.1% dos alunos apresentaram dependência moderada de smartphones. Esse vício foi associado a horas diárias gastas em smartphones (p<0.001), tempo verificando telefones após acordar pela manhã (p<0.001) e frequência de uso durante o dia (p=0.003). A qualidade do sono foi inversamente associada à duração do uso do smartphone (p=0.004), horas diárias de uso (p=0.002) e tempo gasto checando o telefone após acordar pela manhã (p=0.01). O desempenho acadêmico também foi inversamente associado com horas diárias de uso do telefone (p=0.003), tempo gasto verificando o telefone após acordar pela manhã (p=0.001) e frequência de uso do telefone num dia (p=0.015). Conclusão.Uma alta proporção de estudantes de enfermagem tem um vício moderado em smartphones. Esse vício foi associado a um risco aumentado de má qualidade do sono e baixo desempenho acadêmico. É necessária a realização de atividades educativas sobre o uso saudável de smartphones no grupo estudado.
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Humans , Students, Nursing , Smartphone , Sleep QualityABSTRACT
Purpose: To evaluate the efficacy of secondary and salvage intra?arterial chemotherapy (IAC) as a globe salvage treatment modality in advanced and refractory intraocular retinoblastoma. Methods: A retrospective chart review of advanced intraocular retinoblastoma (groups D and E International Classification of Retinoblastoma [ICRB] classification) patients refractory to intravenous chemotherapy (IVC) and undergoing IAC as the secondary and salvage treatment modality between December 2018 and June 2021 was carried out. All patients underwent the IAC procedure by super?selective ophthalmic artery catheterization and with triple?drug chemotherapeutic agents of melphalan, topotecan, and carboplatin. Data were collected about tumor regression, eye salvage, metastasis, and survival outcome at follow?up. Results: Out of 13 patients, 12 patients received secondary IAC after being primarily treated with IVC and focal therapies and one patient received rescue IAC after recurrence following primary IAC. Mean number of IAC cycles administered was 2. Overall, globe salvage rate was 53.84%, with a mean follow?up of 17.53 months (range 6–37 months), three patients had enucleation for residual tumor or tumor recurrence. One patient developed metastasis post enucleation and two patients who were lost to follow?up after enucleation advice for residual tumor developed orbital tumor extension and eventually died of metastasis. Conclusion: Secondary triple?drug IAC following failure of IVC, along with other adjunct treatment modalities might a be a cost?effective option for eye salvage in advanced intraocular retinoblastoma patients who refuse enucleation, with a globe salvage rate of 53.84%. It can also be an effective approach to improve treatment compliance and can help in addressing the barrier of treatment refusal when enucleation is advised.
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This retrospective observational study was aimed at defining the demographic and clinical characteristics as well as severity profile of COVID-19 disease in children admitted to dedicated COVID-19 tertiary care hospital in Mumbai, India, during the second wave. COVID-19 infection detected in children (1 month-12 years) by the rapid antigen test or reverse transcriptase polymerase chain reaction or TRUENAT from March 1 to July 31, 2021 on throat/nasopharyngeal samples were enrolled and their clinical features and outcomes were studied. During the study period, 77 children with COVID-19 infection were admitted, of whom two-third (59.7%) were <5 yr old. The common presenting symptom was fever (77%), followed by respiratory distress. Comorbidities were noted in 34 (44.2%) children. Most of the patients belonged to the mild severity category (41.55%). While 25.97 per cent of patients presented in severe category and 19.48 per cent were asymptomatic. Admission to intensive care was needed in 20 (25.9%) patients, with 13 patients needing invasive ventilation. Nine patients succumbed while 68 were discharged. The results might help understand the course, severity profile and outcomes of the second wave of the COVID-19 pandemic in the paediatric population.
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Purpose: To assess and analyze the visual outcomes of patients with retinal vein occlusions in a real?world setting with a long?term follow?up of more than 5 years. Methods: Retrospective analysis of 56 patients having retinal vein occlusions from a tertiary eye center, with a mean follow?up of 7 years was performed. Primary outcome measures were mean change in best?corrected visual acuity (BCVA) from baseline at 6 months, 1 year, 2 years, 3 years, and final visit (?5 years), proportion of patients having BCVA better than 20/40 and worse than 20/200, and mean number of injections. Secondary outcome measures were change in central macular thickness (CMT), development of subsequent retinal vein occlusion (RVO) in same eye or the other eye, and development of neovascular complications. Results: The mean change in letter score was + 11.84 in branch RVO (BRVO), +7.14 in non?ischemic central RVO (CRVO), and ?9.5 in ischemic CRVO at 1 year, which changed to + 8.57, ?5 and ? 24, respectively, at the end of follow?up. CMT had improved from 506 ± 98.8 ?m, 576.44 ± 149 ?m, and 618 ± 178.27 ?m, respectively, at baseline to 267 ± 94 ?m, 345.20 ± 122.61 ?m, and 265.50 ± 107.75 ?m, respectively, in BRVO, non?ischemic, and ischemic hemi RVO (HRVO)/CRVO groups. The total mean number of injections given in BRVO, non?ischemic CRVO, and ischemic CRVO groups were 4.6, 6.6, and 4.1, respectively. None of the patients with BRVO developed neovascular glaucoma (NVG). Non?ischemic to ischemic HRVO/CRVO conversion was noted in 4/11 eyes at a mean duration of 12.6 months. NVG was noted in 7/9 eyes (77.8%) in initial ischemic CRVO/HRVO group and 3/4 (75%) converted eyes. Conclusion: Patients with BRVO have good visual outcomes with anti?VEGF, while in CRVO results may vary considerably owing to patient compliance and treatment burden on long?term follow?up in a real?world setting
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Background: Prostate is fibromusculoglandular organ encircling the neck of the urinary bladder, Benign prostate hyperplasia, prostate carcinoma and prostatitis are three pathologic processes which frequently affect the prostate gland. Prostatic enlargement causes urinary symptoms of static (hesitancy, retention) and dynamic (urgency, dribbling) nature. PSA is a glycoprotein which is expressed by both normal and neoplastic prostate tissue. PSA is used widely as a screening tool for carcinoma prostate. Gleason's microscopic grading is a paramount feature and with PSA are important for diagnosis, management, and prognosis of carcinoma. The purpose of this study is to frame evidence based PSA levels for various prostatic lesions. This prospective study was done on total 50 samples. The samples taken were bothMethod: transurethral resection of prostate and prostatic biopsies. All were grossed, sectioned, stained using H & E, viewed under microscope and graded by Gleason's scoring. Total 50 samples were studied, out of which 46 were benign and 4Result: malignant. Mean age of the cases was 63.13 years. 8% patients had PSA values more than 20 ng/ml. PSA isConclusion: specific for prostate and is one of the best screening tools available for early detection of prostate cancer as it is a well accepted, simple, safe and cost effective method. The early diagnosis of clinically significant cancer obtained by evaluation of PSA levels helps in immediate and effective treatment
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Background: Non-Hodgkin抯 Lymphoma is a common hematological malignancy. Its incidence and distribution in India are slightly different from developed nations. The study was initiated to obtain the epidemiological, clinical and histopathological spectrum of lymphoma in a single tertiary care hospital of North India. Methods: 104 eligible consecutive cases of lymphoma were retrospectively analyzed from January 2016 to March 2020. Morphology and immunohistochemistry were performed and clinical details were captured from hospital information system. Cases were reclassified according to WHO classification of Tumors of Hematopoietic and Lymphoid Tissue 2017 and also clinically as nodal and extra nodal lymphomas and analyzed. Results: Among the included patients 14.4% patients are diagnosed as Hodgkin抯 lymphoma (HL) while 85.5% belonged to non-Hodgkin抯 lymphoma (NHL). Median age for NHL is 52.5 years. Male outnumbered females in both NHL and HL with ratio of 1.87 and 1.5. Majority of NHL are mature B-cell neoplasm (83.1%), while mature T-cell and NK cell neoplasm are less (14.6%). Most common subtype found is Diffuse large B-cell lymphoma (52.8%) followed by Primary diffuse large B cell lymphoma of CNS (15.7%). Primarily nodal Vs extranodal involvement is seen in 51.9% and 48% of cases. Most common extranodal site is CNS followed by GIT and spine. Conclusion: In the present study DLBL is the most common subtype seen in 52.8% of cases in concordance with other studies but the sticking difference here is low incidence of follicular lymphoma and CLL/SLL and a much higher incidence of Primary DLBCL of CNS. There is an Inherited selection bias because the cases are collected from single institution; however, causes and reasons should be more extensively investigated.
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Background: The difficulties faced during early childhood can be cushioned against by psychological factors. The aim of the study was to find out the relationship between resilience and self-compassion among young adults and to find out gender difference on the two variables. Methodology: Data was collected from 62 early adults and data was analysed using Mann Whitney-U test and Spearman correlation statistical techniques. Result: According to the results, no gender difference existed on either of the variables. Along with this self- compassion and resilience were found to have a positive correlation among early adults. However, this correlation was not found in males alone but was found among females. Conclusion: Based on the results of this study, if young adults are taught about these traits, their transition can be made easier and smoother.
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Objective To systematically identify and critically appraise the methodological quality of pediatric guidelines applicable to management of COVID-19 in India. Methods Pediatric COVID-19 guidelines applicable to India, published until 30 April 2021, were identifed through a systematic search across ten databases. Each was critically appraised for methodological quality using the AGREE-II tool, by at least two appraisers. Median (interquartile range) of the total score and domain-wise scores were calculated, and compared for Indian vs. foreign guidelines, updated vs. original versions of guidelines, and those developed earlier vs. later in the pandemic. Results A total of 62 guidelines was identifed. Only 8 (12.9%) were published in India. The overall AGREE-II score ranged from 4.7% to 72.8%; with median (IQR) 37.9% (29.4, 48.6). This suggested overall low(er) methodological quality. The median (IQR) domain-wise scores were as follows: Scope and Purpose 66.7% (58.3, 83.3), Stakeholder Involvement 41.7% (30.6, 83.3), Rigor of Development 23.4% (14.8, 37.5), Clarity of Presentation 59.7% (50.0, 75.0), Applicability 27.1% (18.8, 33.3), and Editorial Independence 8.3% (0.0, 45.8). This suggested diversity in quality of diferent aspects of the guidelines, with very low quality in the critical domain of methodological rigor. There were no statistically signifcant diferences in the overall scores of Indian vs. foreign guidelines, updated versions vs. original versions, and those developed earlier vs. later in the pandemic. Conclusion The currently available pediatric COVID-19 guidelines have low methodological quality, adversely afecting their credibility, validity, and applicability. Urgent corrective strategies are presented for consideration.
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Background : Gall Bladder Polyps are mucosal lesions that project from the Gall Bladder wall into the Gallbladder lumen. They form morphologically distinct lesion/s with internal characteristics different than that of neighboring structures as verified by microscopic examination. About 4-6% are picked up clinically, 2-12% in Cholecystectomy specimens and 4% on Ultrasound. Materias and Methods : A three calendar year retrospective single surgical unit study compromised of 1442 cholecystectomies performed for benign Gall Bladder Disease. The patient were subjected to Ultrasound of abdomen for diagnosis and routine clinic work up. The Gall Bladders Harboring Polyps were examined grossly for site ,number, and microscopy for histological details. Results : In a total number of 40 cases of Gall Bladder Polyp, females outnumbered males. This series spreads over age groups of 3rd decade - 9th decade, most of the patients were seen in 6th decade of life. Youngest patients were 27 years old and oldest one was 85 years old. Incidentally, none of the old patients had evidence of malignancy on histopathology in their Gall Badder Polyp, only 2% were necessitated for a pre-operative diagnosis of Gall Bladder Polyps alone. Rest required it for presence of Gallstones with or without Polyp. None of >10mm size showed any malignant change on histopathological examination. On the Contrary, among the polypoid lesions <10mm size, one polypid lesion (7mm) showed a malignant change (Carcinoma in situ) Conclusion : A predictive model for neoplastic potential of Gall Bladder Polyp may support clinical decision to achieve an ideal therapeutic outcome. Hence a need for reappraisal of management guidelines.
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Background & objectives: The World Health Organization (WHO) document released on the World No Tobacco Day, 2020, mentions that tobacco kills over 22,000 people worldwide every day either from its use or second-hand smoke exposure, which is one person every 4 sec. In 2003, the Cigarettes and Other Tobacco Products Act (COTPA) was enacted by the Indian government to control/regulate use of tobacco and tobacco products. Despite various amendments to this law, there has not been any appreciable decrease in tobacco use. The objective of this study was to assess the compliance level with sections 4-10 of COTPA in urban Puducherry in South India. Methods: Random sample survey of 13 wards was carried out in selected parts of the city of Puducherry. The estimated sample size was minimum 160 public places and point of sales (PoS) each. A pre-tested checklist was used to obtain information on compliance with COTPA. Statistical and spatial analysis was performed using STATA v12.0 and QGIS v2.14.21, respectively. Results: Eight per cent of public places, 0 per cent of PoS, 1.7 per cent of educational institutions and 48 per cent of tobacco packages were found compliant with COTPA specifications. The compliance in public places varied from 0 (bus stops) to 55 per cent (religious places). Interpretation & conclusions: The overall compliance with COTPA was found to be very low in urban Puducherry. In order to ensure proper implementation of the laws, effective enforcement with periodic monitoring of various sections of COTPA are needed.
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Purpose: To evaluate the association of daily screen time and quality of sleep with the prevalence of dry eye among college?going women. Methods: This study was a cross?sectional, comparative questionnaire?based study of 547 college?going women in northern India. A 10?item Mini Sleep Questionnaire was used to check the quality of sleep, and the Standard Patient Evaluation of Eye Dryness (SPEED) scale was used to examine the prevalence of dry eye among college?going women. Results: Multinomial logistic regression showed a significant association between dry eye with daily screen time spent (P < 0.05) and the quality of sleep (P < 0.05) among college?going girls. Using Latent Class Analysis, two latent classes were selected based on the Bayesian Information Criteria. It was found that the majority population falls in class two and was having Severe Sleep?Wake difficulty. It was seen that the participants in class two belonged to the age bracket of 18–21 years, were from stream Humanities, education of father and mother equal to graduation, father working only, belonging to the nuclear family, having one sibling, hailing from the urban locality, spending more than 6 h daily on?screen, a majority of them using mobile phones, not using eye lubricants, and reported an increase in screen time during COVID?19. Conclusion: Dry eye and sleep quality are essential global health issues, and coupled with increased screen time, may pose a challenge in the present era. Preventive strategies need to be incorporated in school and college curriculums to promote physical, social, and psychological well?being and quality of life
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Schmincke described lymphoepithelioma as an undifferentiated carcinoma with abundant lymphoid stroma in the nasopharynx. Tumors with a similar histomorphology in extrapharyngeal areas have been referred to as lymphoepithelioma-like carcinoma (LELC). The association of an Ebstein-Barr virus (EBV) infection with lymphoepithelioma is well established in the nasopharynx but not so well at the extrapharyngeal sites. Only four cases of LELC have been reported in the gall bladder, of which all were negative for the EBV. This paper reports the first case of an EBV-associated mixed gall bladder carcinoma exhibiting a distinct phenotype of LELC and adenocarcinoma with mucinous differentiation. The EBV was confirmed by the strong granular membranous and cytoplasmic expression of LMP-1 (latent membrane protein-1) on immunohistochemistry and nuclear EBER RNA on chromogen in-situ hybridization in the tumor. This is the first case of LELC positive for EBV in the gall bladder. LELC has a more favorable prognosis than conventional adenocarcinoma or squamous cell carcinoma, irrespective of the site. Although a higher T stage and nodal metastasis were exceptional in the present case in contrast to the previous cases, the EBV-associated lymphocytic response might limit the disease spread and confer better overall survival and prognosis in these patients. Nevertheless, more prospective studies with a larger cohort will be needed to understand the pathogenesis, biological behavior, and prognosis of this rare entity.
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Schmincke described lymphoepithelioma as an undifferentiated carcinoma with abundant lymphoid stroma in the nasopharynx. Tumors with a similar histomorphology in extrapharyngeal areas have been referred to as lymphoepithelioma-like carcinoma (LELC). The association of an Ebstein-Barr virus (EBV) infection with lymphoepithelioma is well established in the nasopharynx but not so well at the extrapharyngeal sites. Only four cases of LELC have been reported in the gall bladder, of which all were negative for the EBV. This paper reports the first case of an EBV-associated mixed gall bladder carcinoma exhibiting a distinct phenotype of LELC and adenocarcinoma with mucinous differentiation. The EBV was confirmed by the strong granular membranous and cytoplasmic expression of LMP-1 (latent membrane protein-1) on immunohistochemistry and nuclear EBER RNA on chromogen in-situ hybridization in the tumor. This is the first case of LELC positive for EBV in the gall bladder. LELC has a more favorable prognosis than conventional adenocarcinoma or squamous cell carcinoma, irrespective of the site. Although a higher T stage and nodal metastasis were exceptional in the present case in contrast to the previous cases, the EBV-associated lymphocytic response might limit the disease spread and confer better overall survival and prognosis in these patients. Nevertheless, more prospective studies with a larger cohort will be needed to understand the pathogenesis, biological behavior, and prognosis of this rare entity.
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This systematic review (SR) synthesises recent evidence and assesses the methodological quality of published SRs in the Differential diagnosis of temporomandibular disorders (TMD). A systematic literature search was conducted in the PubMed, Cochrane Library, and Bandolier databases for 1987 to September 2019. Three investigators evaluated the methodological quality of each identified SR using two measurement tools: The assessment of multiple systematic reviews (AMSTAR) and level of research design scoring. Thirty-one SRs met inclusion criteria and 28 were analysed: 20 qualitative SRs and eight meta-analysis.The main aim of this article is to Differential diagnose the pain which is not related to any dental disease. Most of dental clinician have problem to diagnose TMD (Temporomandibular Disorders) and Orofacial Muscle pain. The approach of this article is to simplify the differential diagnosis for better and fast treatment of the respective disease by classifying various TMJ related and muscle related problems
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Depression and anxiety are the most common mental disorder affecting individuals with human immunodeficiency virus (HIV) infection. Anxiety is highly prevalent in HIV infected individuals in clinical studies. Early identification and treatment of depression and anxiety in patients may improve better outcome of ART Therapy. We wanted to evaluate the prevalence of depression and anxiety among HIV patients taking antiretroviral therapy and examine the predicting effect of depression and anxiety with demographics on CD4 count. MethodsThis study was conducted in the ART Plus center in Department of Medicine, PT JNM Medical college, Raipur, Chhattisgarh and Dr. Bhim Rao Ambedkar Memorial Hospital between July 2018 and June 2019. A total of 300 patients who were enrolled in the ART plus center, gave consent to participate in study. Participants were selected in systematic random sampling method irrespective of their age, gender, ethnicity, socio-economic status, occupation, education, and present CD4 count. Starting CD4 count was assessed on enrolment to ART center and present CD4 count repeated at the time of recruitment to our study. Depression was evaluated using Hamilton Depression Rating Scale and anxiety was measured by Hamilton Anxiety Rating Scale by a Psychiatrist. ResultsThe first model showed 8.8% of total variance (R= .297, R2=.088; F (5, 298) = 5.683; p<0.01) for starting CD4 count and second model showed 6.7% of total variance (R=.259, R2=.067; F (5, 298) = 4.221; p<0.01) for present CD4 count with five predictor variables (depression, treatment year, gender, age, anxiety). Depression of the patients was negatively associated with starting CD4 count (-.085, p<0.01) before starting ART Regimen. Treatment year of the patients was positively associated with present CD4 count (-.085, p<0.01). ConclusionsThe study demonstrates high prevalence of anxiety and depression among HIV positive patients taking antiretroviral therapy (ART) and strong correlation of depression and anxiety and its associated factors among HIV positive patients taking ART. High depression reported lower level of CD4 count before starting ART regimen.
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Altered glucose uptake and metabolism is the key characteristic of cancer cells including hepatocellularcarcinoma (HCC). However, role of glucose availability in chemotherapeutic outcome of HCC is unclear. Thepresent study investigates the effect of glucose facilitated sensitization of HCC cells towards doxorubicin(DOX) and sorafenib (SORA). In HCC cells, we observed that hyperglycemic culture condition (HG) isassociated with increased sensitivity towards DOX and SORA. P-glycoprotein (P-gp), a transporter involved indrug efflux, was elevated in HCC cells in NG, rendering them less susceptible to DOX and SORA. Further, thisstudy demonstrated that knockdown of dickkopf protein 4 (DKK4), a Wnt antagonist protein, causes enhancedglucose uptake and reduction in P-gp level rendering HCC cells in NG sensitive to DOX and SORA.Moreover, HG elevates the level of intracellular reactive oxygen species (ROS), which regulates P-gp.Alteration in intracellular ROS did not directly affect regulation of DKK4 in HCC cells. Functional assayssuggest that alterations in DKK4 and P-gp level in HCC cells are dependent on glucose availability andchanges in ROS level because of enhanced glucose utilization, respectively. Collectively, the present studyhighlights direct involvement of glucose-induced ROS, DKK4 and P-gp in altering the sensitivity of HCC cellstowards DOX and SORA.
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Ectopic pregnancy is defined as pregnancy outside uterine cavity. Of all ectopic pregnancy, tubal ectopic is most common. Most cases today are diagnosed early and hence timely treatment is possible. In stable patients, medical line of management with methotrexate can be used. With early diagnosis and medical line of treatment, use of injectable methotrexate is on rise. Being aware of characteristics of methotrexate like mechanism, dosage, side effects and contraindications, appropriate patient selection and watchful monitoring will help reduce methotrexate induced toxicity.
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Total Quality Management (TQM) is a managerial and managemental approach of an organization focused on quality, based on participation of all of its members and while aiming at long term benefits to the organization and consumers health. It is focused on continuous improvement of all processes approached with combined fundamental management techniques and specialized tools under quality systems. TQM is a process of managing the whole organization so that it progress in all the dimensions of products and services that are important to the consumers. It roots from the belief that mistake can be avoided or mininimised and defects can be prevented, with sole objective being the continuous process improvement. The introduction of Hazard Analysis Critical Control Point (HACCP) has signaled a shift in emphasis from resource intensive end product inspection and testing to preventive control of hazards at all the stages of food supply chain. It also identifies and controls hazards that are fundamentals for food safety. The integrated approach to implementation of ISO standards and HACCP concept is vital for management of quality and safety of dairy products hence safeguarding the customer’s requirements, ensuring that certified products conform to minimum standards set internationally. These standards ensure and enhance transparency in the development of food quality and safety procedures, thus helping to upgrade and update food safety systems. ISO laid down guidelines, codes, specifications and requirements to evolve effective TQM system.