Mental Health Programme in India: Has the tide really turned?

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India’s NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.

Determining PD?L1 expression in head and neck squamous cell carcinoma using immunohistochemistry

Background: Advanced head and neck squamous cell carcinoma (HNSCC) has limited treatment options. Programmed death-ligand1 (PD-L1) expressed by tumor cells interacts with PD-1 receptor on T lymphocytes leading to immune evasive response and survival advantage. Therapy with immune check-point inhibitors target PD-1/PD-L1 blockade inducing tumor regression. Immunohistochemistry (IHC) for PD-L1 expression enables patient selection for immunotherapy and may be considered a potential predictor of clinical response. Methods: A retrospective analysis of IHC for PD-L1 expression using manual laboratory developed technique (LDT) with antibody clone 22C3 (Dako) in 93 cases of HNSCC. PD-L1 expression was correlated with age, gender, tumor site, grade and stage. Results: PD-L1 IHC was performed in 93 cases and immunopositivity was noted in 59 (63.4%) cases. High expression with combined proportion score (CPS) ?50 was seen in 15 (16.1%) cases and low expression with CPS ?1 expression was seen in 44 (47.3%) cases. An almost-perfect interobserver agreement was noted by two pathologists for PD-L1 IHC expression (Cohen’s kappa coefficient = 0.910). No statistically significant correlation was noted between PD-L1 score and patient demographics, tumor site, grade or stage. Conclusion: Detection of PD-L1 status by IHC enables identification of HNSCC patients eligible for future targeted immunotherapy.

Diagnostic utility of FNAC in gouty tophi with review of literature.

Periarticular nodules have the variety of differential diagnosis including inflammatory to neoplastic conditions. Amongst these, gouty tophus is an important differential diagnosis. Fine needle aspiration cytology (FNAC) is a valuable diagnostic tool for the diagnosis of periarticular nodules. We presented here a case of 48 years old male with multiple soft tissue nodules in extremities. Case was evaluated clinically and FNAC was advised. Fine needle aspiration revealed chalky white aspirate. The case was studied and data was collected in month of October 2013. After staining the smear with Hematoxylin and Eosin (H&E), needle shaped crystals were seen in amorphous granular debris. Diagnosis of gouty tophi was made. On further workup, serum uric acid levels were found to be high and a diagnosis of gout was established. FNAC is an easy, minimally invasive and cost effective procedure for diagnosing gouty tophus and is replacing biopsy for the diagnosis of gouty tophus.

Design of DWT Module.

Due to the advancements in information and communication technologies, the electronic transfer of formal documents such as business deals, etc is inevitable. Therefore a DWT based authentication method is proposed in this paper. The formal text document is watermarked by embedding the fingerprint image of the authenticated personnel. DWT is being widely considered in watermarking applications because of its efficient multi-resolution in frequency domain. The lifting based 2D-DWT with two levels of computation is implemented. The 2D-DWT can be implemented by performing 1D DWT row-wise and column wise. Hence with the help of DWT filters both document and the fingerprint image are compressed and it’s divided into sub-bands and the fingerprint is watermarked in the document. The complete system is implemented on FPGA.

MCI’s VISION 2015 and PG medical selection: continuing to produce square pegs for round holes.

The need for better methods of selection for postgraduate (PG) medical seats in different specialties has never been more keenly felt than in the current scenario. Multiple entrance exams, management quota and paid seats, the urgency to get into a PG seat at any cost and the mushrooming of PG entrance exam coaching centres have added to the angst and woes of medical students. Currently the Indian medical education system is one of the largest in the world with around 250 colleges fully recognised by the Medical Council of India (MCI).

Healthcare reform in the USA, 2010: the rocky road ahead.

Historic legislation for healthcare reform in the United States was enacted in March 2010. Reforms in medical practice, payment for services, and access to care and insurance will be introduced by complex processes over time through 2019. The overriding goals of healthcare reform are cost containment and guaranteeing access to all Americans. The contentious political struggle that preceded the legislation is emblematic of the continuous struggle in American society to define who is worthy of services. Understanding the value framework for social and welfare provisions in American society is crucial to making sense of the piecemeal policymaking characteristic of the development of healthcare over the past 50 years. Here some highlights of the reform and the complex organisation of American healthcare are discussed.

Objective standardized clinical assessment with feedback: Adapting the objective structured clinical examination for postgraduate psychiatry training in India.

Background: The objective structured clinical examination (OSCE) is used commonly for assessment of psychiatry trainees but has been used less for teaching. Aim and Setting: This study describes the adaptation of the OSCE method for training purposes in a postgraduate psychiatry training center in India and the initial findings with regard to trainee performance. Materials and Methods : The adapted method was called the objective structured clinical assessment with feedback (OSCAF). The adaptation included several steps - modifying existing OSCE patterns for language and cultural appropriateness, using supervised roleplaying instead of standardized or simulated patients and evolving an assessment method (14-item checklist) that would generate feedback. This exercise was conducted in front of a group of multidisciplinary peers and supervisors. Statistical Analysis: Descriptive statistics and ANOVA were used. Results: Analysis of the performance based on the 14-item checklist assessing common elements of any patient-related interaction in 34 different OSCAF tasks indicated the following: less-than-satisfactory (<75%) performances in the following areas - assuring confidentiality (73.5%), assessing comfort (62%), summarizing (60%), closure (62%) and checking whether the 'patient' had understood what was being communicated (42%). Based on the nature of clinical situations, performances on some specific and difficult OSCAF situations were found to be inadequate and indicated need for further training. Conclusions: We have been able to demonstrate OSCAF to be a convenient, cost-effective training method in psychiatry, with limited demands on resources; however, further refinements in ratings and feedback methods and studies on effectiveness may enhance its utility.

Should mental health assessments be integral to domestic violence research?

Research on sensitive issues such as abuse and violence in vulnerable populations poses several ethical dilemmas. An important aspect is the impact of such enquiries on one's mental health. This paper discusses specific ethical issues related to mental health based on violence research conducted and reviewed by the authors. Research on violence among women includes the possibility that some revelations are occurring for the first time and are likely to be emotionally charged. Further, the very act of disclosure may involve emotional risks for the respondent. Psychological distress may be present prior to, during, or following the study. Hence assessing mental health parameters becomes essential and integral to research of this nature. Several issues in methodology are also important in mitigating the level of distress. Research on sensitive issues should either use measures developed in the same culture or those with adequate adaptation. The order of questions, language and method of termination of the interview may often make a difference to its psychological impact. While focus group discussions and semi structured interview schedules are most suited, questionnaires with a less structured and rigid approach may also be used. Preludes may be introduced to facilitate transition between different sections of an interview schedule and to provide a rationale for further enquiry. Obtaining informed consent in violence research should be a process rather than a one-time formality. Reports of adverse events are likely in violence research and hence such studies must include mental health intervention, ongoing follow up, documentation and appropriate referral services. Finally, since the researcher and the subject of the research are both affected in a study of this nature, adequate sensitisation, ongoing training and supervision of research staff are essential. Based on findings from ongoing research on violence and from review of other studies done in India, the paper will focus on best practices in addressing mental health issues in domestic violence research.

Existence of proviral porcine endogenous retrovirus in fresh and decellularised porcine tissues.

PURPOSE: Swine are expected to be utilized as xenograft donors for both whole organ and cellular transplantation. A major concern in using porcine organs for transplantation is the potential of transmission of porcine endogenous retrovirus (PERV). Tissue-engineered or decellularised heart valves have already been implanted in humans and have been marketed by certain companies after Food and Drug Administration (FDA) approval. The aim of this study was to examine the existence of porcine endogenous retrovirus (PERV) in fresh and decellularised porcine tissues. METHODS: Porcine tissues (both fresh and decellularised) were analysed using validated assays specific for PERV: polymerase chain reaction (PCR), reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: PERV specific GAG sequences were found in the porcine heart tissue samples using PCR for DNA and RT- PCR for RNA. All tissue samples (both fresh and treated tissues) like aortic valve, pulmonary valve and heart muscle showed the presence of PERV DNA. RT PCR for PERV was positive in all fresh tissues and was found to be negative in decellularised treated tissues. CONCLUSIONS: PCR is a rapid, specific test for the detection of PERV virus in xenografts. These findings have demonstrated that the presence of proviral DNA form of PERV in porcine tissues needs to be carefully considered when the infectious disease potential of xenotransplantation is being assessed.

A review of the ethics in research on child abuse.

Research on violence and abuse, particularly involving vulnerable groups such as women and children, has many ethical ramifications. There are few published reports in India on ethical guidelines and standards in this area. This paper reviews Child Abuse: India 2007, a study conducted by the ministry of women and child development, government of India. The review highlights the need for conducting an ethical inquiry in this area. Certain concerns about the conduct of the study are raised. Core ethical issues pertaining to consent and refusal, risk and benefit, effects of the study process on the researcher and the researched and the reporting of adverse events are discussed. The ethical implications of the study and ethical responsibilities of the researcher are emphasised.

Reconstrução microcirúrgica em cirurgia de cabeça e pescoço. Opções e soluções para defeitos complexos / Head and neck microsurgical reconstruction options and solutions for complex defects

Câncer em cabeça e pescoço é entidade muito comum nos países em desenvolvimento. Nos defeitos pe- quenos ou não complexos, podemos utilizar da várias opções para reconstrução, como retalhos locais ou pedículadosadistância,masquandonosdeparamoscom defeitos grandes ou complexos, microcirurgia torna-se necessária.

Introduction: head and neck cancer are very common entities of developing countries. In small or non complex defects we have a lot of options for reconstruction, like local or pedicle flaps, but when we consider big or complex defects microsurgery is necessary. Methods: in our casuistic, we have used radial forearm free flap for oral cavity, tongue and faryngeal defects, free anterolateral thigh flap with vastus lateralis muscle for maxilla defects and free fibula flap for mandible defects, between 20 patients. All flaps were done in the same institution and by the same surgical team. Results: the most common complications observed in microsurgical flaps like venous thrombosis and hematoma were not observed in this casuistic of 20 cases. Conclusion: microsurgical flaps for head and neck reconstruction represent an excellent alternative for big and complex defects, with low complication rates.

Nutraceutical effects of garlic oil, its nonpolar fraction and a Ficus flavonoid as compared to vitamin E in CCl4 induced liver damage in rats.

Carbon tetrachloride feeding (3.2g/kg/72hr) for one month increased significantly the serum and tissue lipid profile and deranged the enzyme levels viz; alkaline phosphatase, alanine transaminase, aspartate transaminase, glutathionze reductase, HMGCoA reductase, catalase, gluc.6.PDH and malic enzyme in rats. Simultaneously the lipid peroxidation level in liver was also raised. On administration of garlic oil and its major nonpolar fraction (NPFGO) and a flavonoid isolated from the bark of Ficus bengalensis Linn, viz; leucopelargonin derivative respectively to different groups(100mg/kg/day) the deleterious effects of CCl4 were significantly ameliorated. The liver damage by CCl4 was satisfactorily prevented by these samples as effectively as Vit. E (50 mg/kg/day). The results prove that important nutraceuticals (phytonutrients) like bioflavonoids and theols i.e. allylic sulphide rich fractions give protection from toxins like CCl4. The order of beneficial effects of the drugs are Leucopelargonin > NPFGO > Garlic oil and their effects are comparable to that of vitamin E used at a minimal dose.

HIV & psychiatric disorders.

HIV infection and psychiatric disorders have a complex relationship. Being HIV infected could result in psychiatric disorders as a psychological consequence of the infection or because of the effect of the HIV virus on the brain. Disorders may be as varied as depression, post-traumatic stress disorders, AIDS phobias, grief and the whole gamut of cognitive disorders. In addition, several psychiatric conditions may predispose individuals to acquiring HIV infection as a consequence of their influence on behaviour. There is also strong evidence of the relationship of substance use disorders and severe mental illnesses with HIV infection. HIV related psychiatric disorders also offer a challenge to clinicians in issues of differential diagnosis and management. Majority of the work in India has focused on substance use and HIV, and to a lesser extent on the psychiatric effects of HIV infection. Given the magnitude of the problem in the country and the multiple physical and psychological stressors that persons with HIV face in India, more research is needed.

Transplacental transfer of measles antibody in Delhi.

OBJECTIVE: To find out the patterns of and the factors, if any, affecting the transplacental transfer of measles antibody. DESIGN: Comparison of measles antibody titres in mothers with titres in cord blood samples. METHODS: Maternal and cord blood samples from 174 full-term pregnant women of middle socio-economic status were tested for hemagglutination inhibition (HI) antibody against measles in Delhi during October 1993 to January 1995. None of the mothers had been immunized against measles. RESULTS: Antibody were undetectable in both maternal and cord samples in only 4 (2.3%) pairs. Mean maternal titre was found to be 2.94 Log2. Transplacental concentration and dilution were respectively observed in 34% and 26% of the samples. Cord titres were more often higher than the maternal values only if the maternal values were low. Overall, cord/maternal ratio of mean titre (Log2) was found to be 1.06. Although the age of the mother and parity had had no significant bearing on the transplacental transfer of measles antibody, cord titres were significantly more often higher than the maternal values as the birth weight increased (Chi-square for linear trend = 5.4; p = 0.02). CONCLUSIONS: The study failed to show appreciable concentration of measles antibodies across the placenta.

Immunity to diphtheria in women of childbearing age in Delhi in 1994: evidence of continued Corynebacterium diphtheriae circulation.

Blood samples from 171 full-term pregnant women (aged 18-38 years) of middle socioeconomic status from Delhi were tested for diphtheria antitoxins by indirect hemagglutination (IHA) test. History of primary immunization/clinical diphtheria during childhood was not ascertainable, but none had been revaccinated against diphtheria at any time. About 94% women had very high antitoxin titers (> or = 0.125 IU/ ml); none had antitoxin titer less than 0.015 IU/ml, the minimum protective level. The titers were uniformly high in all age groups. However, women having 2 or more children had significantly higher antitoxin titers than those having no or one child (p < 0.01). The results from this study and historical data on diphtheria in Delhi are compatible with continued transmission of C. diphtheriae in recent times in Delhi which is of sufficient magnitude to boost the antitoxin levels in adults, especially mothers having two or more children. The study highlights the need of increasing the immunization coverage with DPT among children to reduce the transmission of Corynebacterium diphtheriae.