A Follow up Study Among Patients on Opioid Substitution Therapy (OST) in Terms of Relapse Rate, Factors Affecting Relapse Rate and HCV Incidence

Background: Many countries are facing a serious problem with opioid dependence. Opioid Substitution Therapy (OST) is prescribed to dependent opioid users to diminish the use and effects of illicitly acquired opioids. The high relapse rate has been affecting the effectiveness of anti-drug work all over the world.Material & Methods:In this study, 200 patients were taken by simple random sampling technique. 100 patient on Buprenorphine substitution therapy and 100 on Methadone maintenance treatment were studied. Patients diagnosed as cases of Opioid dependence as per ICD-10 were selected within the first 3 months and followed up to 1 year at 3, 6 and 9 months. The study was conducted after approval from the institutional ethics and thesis committee. A 14-item questionnaire based on a four-point scale describing the number of times certain events had occurred in the previous week for relapse was used to find factors affecting relapse.Results:The relapse rate among patients in the BPN group at 3, 6 and 9 months relapse was 29.33%, 20.34% and 19.51% while in the Methadone group, it was 24.05%, 15.87% and 12% respectively. The overall HCV Incidence was 75% among patients on Opioid Substitution Therapy. Conclusion:The findings of the study highlight the role of multiple determinants in opioid dependence and relapse. The obtained results showed that HCV infection was an alarming problem among IV opiate drug users in Punjab.

Symptoms and psychosocial effects following hospitalization for Covid-19: A sequential, mixed-methods study from northern India

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.

A rare case report of large bilateral vulval elephantiasis

Elephantiasis, the result of chronic lymphedema, is characterized by gross enlargement of the limbs or genitalia. It occurs because of obstructive diseases of the lymphatic system. Genital elephantiasis is a common result of filariasis. Other causes are lymphogranuloma venereum. granuloma inguinale, carcinomas, lymph node dissection, irradiation and tuberculosis. Filarial elephantiasis of the female genitalia is extremely uncommon, about 1-2% of the total cases of filarial elephantiasis. Mrs. X, 25 years old female, P1L1, resident of a village in Bihar presented to gynaecology OPD of ABVIMS and Dr. RML Hospital on 06th January 2020 with complaint of huge progressively increasing vulval swelling since 3 years. Patient had come from Bihar for treatment. She had been showing in her native place for 2 years but now the lump had made her walking difficult. She did not give history of any drug given for treatment for filariasis. She gave history of being treated for pulmonary Koch 10 years back. On examination, there was a non- ulcerative, polypoidal growth of around 20×14×11 cm arising from bilateral labia majora and minora obstructing the vulval cleft. There was no associated lymphadenopathy or limb oedema. All the investigations were within normal limits. Microfilaria antigen testing done at night was negative. Patient was given diethylcarbamazine and excision of the lump was done on 14th February 2020. Histopathological report showed dilated lymphatics with non-caseating granulomas, consistent with filariasis. In endemic countries like India, filariasis is the commonest cause of elephantiasis; however genital filariasis in woman is very rare. Other cause could be tuberculosis which is still rarer. Early diagnosis and treatment of filariasis can eradicate this neglected tropical disease which causes disfigurement and severe morbidity as its sequelae.

Surgical management of caesarean scar pregnancy: a case report

Caesarean scar ectopic is one of the rarest of all ectopic pregnancies. The incidence of caesarean scar pregnancy (CSP), which was extremely rare till recent times, has been rising steadily. Case have more of such cases being published in medical literature now. It is defined as when a blastocyst implants on a previous caesarean scar. The incidence of caesarean scar ectopic has increased due to increase in number of caesarean deliveries. Early diagnosis of this can be done by using ultrasound. It is very important because a delay can lead to increased maternal morbidity and mortality. Early diagnosis leads to prompt management and improves the outcome by allowing preservation of future fertility. Magnetic resonance imaging (MRI) has important role when sonography is equivocal or inconclusive before therapy or intervention. Case are reporting a rare case of G2P1l1 with previous one caesarean delivery, diagnosed as caesarean scar ectopic pregnancy with the help of sonography. Patient underwent laparotomy and on histopathological examination caesarean scar pregnancy was confirmed. Due to the rarity of this condition, there are no specific guidelines available for its management.

A pharmacovigilance study of adverse drug reactions in a tertiary care hospital in Haryana

Background: Adverse drug reaction (ADR) is an inevitable risk associated with all the prescribed medicines. They vary in severity & duration in any population. Thus, ADRs are monitored and assessed on a large scale in our country by the Pharmacovigilance programme of India through adverse drug reaction monitoring centres. This study was taken to assess the pattern of ADR reported in a tertiary care hospital in Haryana.Methods: This study was conducted in the Kalpana Chawla Government Medical College, Karnal, Haryana from January 2018 to June 2019. ADRs were collected from different departments and were analysed according to gender, age, department wise distribution, drugs class involved and ADR that was reported.Results: A total of 233 ADRs were reported in the above mentioned period. Females were affected more than males, maximum number reported in the age group of 21-60 years. The maximum number of ADRs reported was from Dermatology department. Antimicrobials were the class of drugs that were responsible for the maximum number of ADRs reported. Skin manifestations of various types were the most reported ADRs.Conclusions: By keeping a careful and timely watch majority of the ADRS can be prevented by early intervention. There is also a need to ensure timely check on the drugs supplied by the various pharmaceutical companies who get the contract for government supply. This will be a step towards improving patient safety.

Incidental Tuberculoid Granuloma In Bone Marrow Biopsy In 17-Year-Old Male Patient: A Case Report

Granulomas are susceptible to infrequent finding in bone marrow biopsies and may be associated with a broad spectrum of infectious and non-infectious disorders. The incidence of bone marrow granulomas is reported in 0.3% to 3% of bone marrow biopsies with tuberculoid granulomas constituting 6% to 48% of cases. Here, we report the case of a 17-year-old boy with a history of fever (pyrexia of unknown origin). There was no organomegaly and lymphadenopathy with incidental tuberculoid granuloma on bone marrow biopsy

Suprascapular Notch And Its Anatomical Variants

Introduction:The suprascapular notch is situated medial to the root of coracoid and covered by a variable transverse scapular ligament to form a suprascapular foramen, Various shapes of suprascapular notch are observed. Material and Method:The material for the present study comprised of 30 adult scapulae of unknown sex, obtained from the Department of Anatomy, Skims Medical College, Srinagar. Various shapes of suprascapular notch are observed. Result:Suprascapular notches of following shapes were observed: U, V, J. Some scapulae without notches and foramen were also seen. Conclusion:shape of suprascapular notch is important to understand suprascapular nerve entrapment which causes the supraspinatus and infraspinatus muscles to waste.

Synergistic effect of metformin and fenugreek on the lipid profile of type-II diabetic patients

Background: Fenugreek is a traditional herb which has great relevance in the world since time immemorial due to its multifarious uses. Besides being a rich source of nutrition, it also finds place in the cure of certain pathological conditions. One of its highly beneficial effects is have been observed on the lipid profile of the hyperlipidemic patient. This study was thus undertaken to see the hypolipidemic effect of fenugreek seeds in patients of Type 2 Diabetes Mellitus (DM) as add-on therapy with metformin.Methods: An open-labelled comparative study of 12 weeks duration was conducted on patients (randomly divided in 2 groups of 30 each) of Type 2 DM. Group 1 was given metformin 500 mg twice a day while group 2 was given 500 mg of metformin along with fenugreek seed powder capsule, 1gm thrice a day. Evaluation for fasting lipid profile estimation was done at the beginning and at the end of the study. Student’s t-test (paired and unpaired) was applied for statistical analysis.Results: After 12 weeks of treatment, there was significant improvement in the lipid profile of both the groups. However, group 2, that received fenugreek along with metformin showed statistically greater improvement as compared to group 1 which received only metformin.Conclusions: This study shows the beneficial effects of fenugreek seeds on lipid profile in patients of Type 2 DM and can be used as an add-on therapy with metformin in controlling the lipid profile of Type 2 DM.

To Study Nutritional Factors and Postnatal Growth as Predictors of Retinopathy of Prematurity in Neonates Weighing <1750g and/ or Gestation <34 Weeks

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the developing retinal vessels of premature infants. ROP remains one of the leading causes of childhood blindness worldwide. India and other developing countries are facing the third epidemic of ROP. Various risk factors for development of ROP include low gestational age, low birth weight, hyaline membrane disease, sepsis, shock, prolonged oxygen therapy, poor nutrition and weight gain and blood transfusions. Objective: To study nutritional factors and postnatal growth as predictors of ROP in neonates weighing <1750g and/ gestation <34 weeks. Methods: It is a prospective observational study conducted over one year (May 2017 to April 2018) in NICU, Department of Pediatrics, Govt. Medical College Amritsar, in collaboration with Department of Ophthalmology. All antenatal, perinatal and neonatal factors along with nutritional factors and postnatal growth mointoring were recorded. Screening for ROP was done by indirect opthalmoscopy at 4 weeks of postnatal age and followed up till retinal vascularization was complete. Data was analysed using univariate and multivariate regression analysis to evaluate risk factors. Results: Out of 79 babies screened 44 were found to have ROP of which 4 required treatment. Important risk factors found significant on univariate analysis were low birth weight (p=0.023) gestational age (p=0.003), duration of i/v fluid therapy (p=0.004), day of start of feed (p=0.032), day of attainment of full feed (p=0.005), relative weight gain at 4 weeks (p=0.041) and 6 weeks of life (p=0.04). On mutivariate logistic analysis, relative weight gain (g/kg/day) at 4 weeks of life was found to be an independent risk factor. Conclusion: Relative weight gain (g/kg/day) at 4 weeks of life was found to be an independent risk factor for development of ROP. This result may be regarded as providing emphasis on the importance of weight gain at an earlier postnatal age.

Rare breast malignancy subtypes: A cytological, histological, and immunohistochemical correlation

Background: Breast malignancies encompass various subtypes which differ in their clinical presentations, outcomes, and response to the treatment regimens. Thus, a proper histological diagnosis and a special mention of the rare histologic subtypes are required to formulate clear recommendations of their treatment protocols. Materials and Methods: This is a 1-year retrospective study highlighting the rarely encountered subtypes on the mastectomy specimens received. Results: We encountered only 11 rare cases out of the total 153 mastectomy specimens received. The rare subtypes were as follows mucinous cystadenocarcinoma (0.6%), mucinous carcinoma (0.6%), dermatofibrosarcoma protuberans (0.6%), Squamous cell carcinoma (0.6%), papillary carcinoma (2.6%), medullary carcinoma (0.6%), and malignant mesenchymal tumor (1.3%). Conclusion: Our data suggest that these variants are distinct clinicopathological entities with a unique hormonal receptor status. Scant information is available on the rare breast tumor subtypes

Evaluation Of Thrombocytopenia In The Pediatric Patients By Platelet Indices: A Study In A Tertiary Care Hospital.

Background: Evaluation of thrombocytopenia involves a meticulous approach in which complete clinical history, clinical examination, complete hemogram and bone marrow aspiration if indicated, are included. The various platelet indices produced by the automated analysers such as, Mean platelet volume (MPV), Platelet distribution width (PDW), Plateletcrit (PCT) and Large cell ratio (LCR) can be used to distinguish the underlying etiology of thrombocytopenia. Methods: Total of seventy three thrombocytopenic patients <14 years with proper clinic-hematological work up were included in the study. The results were compared by manual examination of the peripheral blood smear. Results: Patients were grouped based on the mechanism- Peripheral destruction 54 (73.9%), Hypoproduction 10 (13.6%), Hypersplenism 9 (12.3%). There was a linear correlation between the platelet count and all the platelet derived indices (MPV, PDW, PCT, LCR) in the patients with peripheral destruction of platelets.The p-value of all the derivatives was statistically significant (level of significance less than 0.05). In patients with hypoproduction and hypersplenism,there was positive correlation between the platelet count and MPV, PDW, PCT & LCR. None of the pvalues were statistically significant. Conclusions: Platelet indices especially MPV and PDW can be used as important initial and supportive tool to differentiate between the hyperdestructive versus hypoprodution and hypersplenism cases.

Dermatofibrosarcoma Protuberans Of Breast - A Case Report

Dermatofibrosarcoma protuberans (DFSP) is best regarded as well differentiated, primary fibrosarcoma of skin. It is an uncommon, slow growing, locally aggressive, and reoccurring but rarely metastasizing tumor of the deep dermis and subcutaneous tissue. Clinically they present as firm solid nodules that arise most frequently on trunk and extremities. DFSP of the breast has been rarely reported. Here, we report a rare case of DFSP of the breast in 47-year-old woman.

Occult Follicular Variant of Papillary Thyroid Carcinoma Presenting as Scalp Metastasis: A Case Report.

The skin metastasis of follicular variant of papillary carcinoma thyroid (FVPTC) is a rare condition and the lesions should be differentiated from primary skin tumors. The scalp is the most frequent site which is involved in skin metastasis of FVPTC. It shows the poor outcome and aggressive nature of the disease. In this report, we aim to present a case report of a 65 year –old female with scalp metastasis of FVPTC highlighting the fact that a solitary cutaneous lesion may be the first evidence of disseminated malignancy in a patient with occult papillary thyroid carcinoma.

Impact of referral transport system on institutional deliveries in Haryana, India.

Background & objectives: Creation of a strong referral transport network across the country is necessary for improving physical access to public sector health facilities. In this study we evaluated the referral transport services in Haryana, i.e. Haryana Swasthya Vaahan Sewa (HSVS), now known as National Ambulance Service (NAS), to assess the extent and pattern of utilization, and to ascertain its effect on public sector institutional deliveries. Methods: Secondary data on 116,562 patients transported during April to July 2011 in Haryana state were analysed to assess extent and pattern of NAS utilization. Exit interviews were conducted with 270 consecutively selected users and non- users of referral services respectively in Ambala (High NAS utilization), Hisar (medium utilization) and Narnaul (low utilization) districts. Month-wise data on institutional deliveries in public facilities during 2005-2012 were collected in these three districts, and analysed using interrupted time series analysis to assess the impact of NAS on institutional deliveries. Results: Female gender (OR = 77.7), rural place of residence (OR = 5.96) and poor socio-economic status (poorest wealth quintile OR = 2.64) were significantly associated with NAS ambulance service usage. Institutional deliveries in Haryana rose significantly after the introduction of NAS service in Ambala (OR=137.4, 95% CI=22.4-252.4) and Hisar (OR=215, 95% CI=88.5-341.3) districts. No significant increase was observed in Narnaul (OR=4.5, 95% CI= -137.4 to 146.4) district. Interpretation & conclusions: The findings of the present study showed a positive effect of referral transport service on increasing institutional deliveries. However, this needs to be backed up with adequate supply of basic and emergency obstetric care at hospitals and health centres.

Cost & efficiency evaluation of a publicly financed & publicly delivered referral transport service model in three districts of Haryana State, India.

Background & objectives: Various models of referral transport services have been introduced in different States in India with an aim to reduce maternal and infant mortality. Most of the research on referral transport has focussed on coverage, quality and timeliness of the service with not much information on cost and efficiency. This study was undertaken to analyze the cost of a publicly financed and managed referral transport service model in three districts of Haryana State, and to assess its cost and technical efficiency. Methods: Data on all resources spent for delivering referral transport service, during 2010, were collected from three districts of Haryana State. Costs incurred at State level were apportioned using appropriate methods. Data Envelopment Analysis (DEA) technique was used to assess the technical efficiency of ambulances. To estimate the efficient scale of operation for ambulance service, the average cost was regressed on kilometres travelled for each ambulance station using a quadratic regression equation. Results: The cost of referral transport per year varied from `5.2 million in Narnaul to `9.8 million in Ambala. Salaries (36-50%) constituted the major cost. Referral transport was found to be operating at an average efficiency level of 76.8 per cent. Operating an ambulance with a patient load of 137 per month was found to reduce unit costs from an average ` 15.5 per km to ` 9.57 per km. Interpretation & conclusions: Our results showed that the publicly delivered referral transport services in Haryana were operating at an efficient level. Increasing the demand for referral transport services among the target population represents an opportunity for further improving the efficiency of the underutilized ambulances.

Gender differences in health care seeking behaviour of tuberculosis patients in Chandigarh.

Background: Gender is a social determinant of health. In view of the substantial burden of tuberculosis (TB), it is important to look into the gender issues related to utilization of services. Aims: To find out gender differences in health care seeking behaviour of tuberculosis patients. Methods: A cross sectional study, using integrated mixed method, was conducted in Chandigarh (India). Systematic random sample was used to interview 109 TB patients (54 men and 55 women) from eight randomly selected health institutions. Results: More women (40%) resorted to home remedies or medicines without prescription at the onset of symptoms compared to men (13%). More men (87%) consulted qualified medical practitioners compared to the women (60%). Consultations from private doctors were more common among men. Mean delay in diagnosis was more in men (60 days) than women (33 days). Main reasons for delay, in men and women respectively, were late referral by doctor (37% vs 26%), long distance to health institution (29% vs 28% ), prolonged use of self-medication (30% vs 26%), and financial constraints (7% vs 17%). More women (20.8%) reported missing a prescribed dose of treatment as compared to men (11.1%). However, 10% men were on re-treatment compared to none of the women. Conclusions: Delay in diagnosis was more in men than women. More delay occurred due to delayed referral by doctors among men and due to financial constraints among women. Hence, gender differences in health care seeking behaviour should be kept in mind while selecting programme strategies.

Decentralization of health services in India: barriers and facilitating factors

Background: In India, the process of decentralization of health services started taking shape in the mid-1990s. Systemic reforms envisaged delegation of administrative and financial responsibilities at district level for management of health-care institutions in 23 states of India in 1999. Subsequently, some of these reforms became part of the National Rural Health Mission (NRHM) launched in 2005. This study aims to document the process of decentralization in health services with special reference to the barriers and facilitating factors encountered during formulation and implementation of reform policies. Methods: Secondary data were reviewed, health facilities were observed, and semi-structured interviews of the key actors involved in decentralization were carried out in Haryana (India). Results: Political and bureaucratic commitment to reforms was found to be the most important facilitating factor. Orientation training on decentralized administrative structures and performancebased resource distribution were the other important facilitators. Structural changes in administrative procedures led to improvement in the financial management system. Significant improvement in the public health infrastructure was observed. From 2004 to 2008, the state government increased the budget of health sector by nearly 60%. Frequent changes in the top administration at the state level hampered the decentralization process. Districts having a dynamic administrative leadership implemented decentralization more effectively than the rest. Conclusions: Decentralization of financial resources has improved the functioning of health services to some extent. Major policy decisions on decentralization of human resource management, increase in financial allocation, and greater involvement of community in decisionmaking are required.

Root coverage using epithelial embossed connective tissue graft.

In periodontal practice, root coverage after marginal soft tissue recession requires daily clinical decisions. Numerous longitudinal human studies have been presented to support the efficacy and predictability of different mucogingival surgical techniques for root coverage. Over the years, root coverage procedure using the subepithelial connective tissue graft with variations has emerged as the favorite surgical technique. In the case presented in this report, subepithelial connective tissue graft with embossed epithelium was used to cover Miller's class II gingival recession in the upper right canine. The design is such that embossed epithelium exactly fits the recession site and the connective tissue portion is tucked below the gingival margin of the recipient site. In this technique, coronal advancement of flap is not needed. Wider zone of attached gingiva at the recipient site was achieved by this technique.

Epidemiology to public health intervention for preventing cardiovascular diseases: The role of translational research.

Despite significant progress in medical research, cardiovascular diseases (CVDs) continue to be the largest contributors of morbidity and mortality both in developed and developing countries. The status of public health interventions related to CVDs prevention was reviewed to identify actions that are required to bridge the existing gap between the evidence and the policy. We used a framework comprising two steps - “bench to bedside” and from “bedside to community” to evaluate translational research. Available literature was reviewed to document the current status of CVD prevention and control at national level in India. Case studies of risk factor surveillance, tobacco control and blood pressure measurement were used to understand different aspects of translational research. National level initiatives in non-communicable diseases surveillance, prevention and control are a recent phenomena in India. The delay in translation of research to policy has occurred primarily at the second level, i.e., from ‘bedside to community’. The possible reasons for this were: inappropriate perception of the problem by policy makers and programme managers, lack of global public health guidelines and tools, and inadequate nationally relevant research related to operationalization and cost of public health interventions. Public health fraternity, both nationally and internationally, needs to establish institutional mechanisms to strengthen human resource capacity to initiate and monitor the process of translational research in India. Larger public interest demands that focus should shift to overcoming the barriers at community level translation. Only this will ensure that the extraordinary scientific advances of this century are rapidly translated for the benefit of more than one billion Indians.