An Experience in Laboratory Diagnosis of Fungal Infections in COVID-19 Patients

Abstract Introduction Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has cast a gloom spell on healthcare worldwide, infecting millions of people. Objective The aim of the present study is to determine the prevalence and review the contributing comorbidities and the precipitating factors leading to the emergence of the fungal infections in COVID-19-affected patients. To assess the utility of different laboratory techniques for confirmation of fungal infections. To assess the strengths and limitations of the diagnostic methods. Methods We have studied 252 clinical samples obtained from 121 COVID-positive patients. Results Among the 121 patients clinically diagnosed with fungal infections, 88 had diabetes and were given steroids for treatment (p-value = 0.001). Ninety-five patients (78.5%) had a positive laboratory diagnosis (either culture positive, potassium hydroxide [KOH]-positive or positive histopathology report). Fungal culture was positive in 75 (61.9%) patients and histopathology report was positive in 62 (51.2%). Histopathology was positive in 7 (5.8%) patients in whom culture and KOH were negative. Conclusion Aggressive treatment methods, administration of immune suppressants, and antibiotics, with an intention to salvage, have made patients susceptible to the benign fungus, causing it to evade the host immunity, thus leading to invasive infections. Applying different laboratory modalities would not only aid in providing fast and valuable information but also help in understanding the pathology which would assist the clinician in selecting the correct treatment for the patient.

Insulin-Like Growth Factor-1 and Insulin-Like Growth Factor Binding Protein-3 - Biomarkers for Skeletal Maturity Assessment in Class II Malocclusion

ABSTRACT Objective: To estimate the serum levels of non-radiologic biomarkers, Insulin-like Growth Factor-1 (IGF-1), and Insulin-like Growth Factor Binding Protein-3 (IGFBP-3) to potentially identify the pubertal growth spurt in skeletal Class II malocclusion subjects. Material and Methods: Eighty subjects (M-38, F-42) with skeletal Class II malocclusion in the age range of 11-18 years were recruited for the cross-sectional study. Human serum IGF-1 and IGFBP-3 were quantitatively assessed by enzyme-linked immunosorbent assay, and the cervical stage (CS) was evaluated from a lateral cephalogram. Results: Gender-wise comparison of the mean serum IGF-1 levels revealed that the initial peak was detected at CS2 in both genders, [males (87.87 ng/mL), females (78.49 ng/mL)]. However, there was a cognizable difference in the second peak of the mean serum IGF-1 levels between males (CS5, 68.58 ng/mL) and females (CS4, 74.63 ng/mL). Mean IGFBP-3 serum levels in male subjects were high in CS4 (47.24 ng/mL) with a further spike in CS6 (50.54 ng/mL), and in female subjects, it was found to be highest in CS3 (51.95 ng/mL) and then in CS5 (49.68 ng/mL). Conclusion: Mean IGF-1 levels exhibited both sexes' prepubertal and late pubertal spikes. Mean IGFBP-3 levels revealed a pubertal and a late pubertal spike in both sexes, with an earlier growth trend observed specific to females compared to males.

Trans-nasal sphenopalatine ganglion block for post-dural puncture headache management: a meta-analysis of randomized trials

Abstract Objective: To evaluate the efficacy and safety of trans-nasal Sphenopalatine Ganglion (SPG) block over other treatments for Post-Dural Puncture Headache (PDPH) management. Methods: A systematic literature search was conducted on databases for Randomized Controlled Trials (RCTs) comparing trans-nasal SPG blockade for the management of PDPH over other treatment modalities. All outcomes were pooled using the Mantel-Haenszel method and random effect model. Analyses of all outcomes were performed as a subgroup based on the type of control interventions (conservative, intranasal lignocaine puffs, sham, and Greater Occipital Nerve [GON] block). The quality of evidence was assessed using the GRADE approach. Results: After screening 1748 relevant articles, 9 RCTs comparing SPG block with other interventions (6 conservative treatments, 1 sham, 1 GON and 1 intranasal lidocaine puff) were included in this meta-analysis. SPG block demonstrated superiority over conservative treatment in pain reduction at 30 min, 1 h, 2 h, 4 h after interventions and treatment failures with "very low" to "moderate" quality of evidence. The SPG block failed to demonstrate superiority over conservative treatment in pain reduction beyond 6 h, need for rescue treatment, and adverse events. SPG block demonstrated superiority over intranasal lignocaine puff in pain reduction at 30 min, 1 h, 6 h, and 24 h after interventions. SPG block did not show superiority or equivalence in all efficacy and safety outcomes as compared to sham and GON block. Conclusion: Very Low to moderate quality evidence suggests the superiority of SPG block over conservative treatment and lignocaine puff for short-term pain relief from PDPH. PROSPERO Registration: CRD42021291707.

Modified Pediatric Penile Perception Scale to Evaluate Cosmetic Outcome in Children With Hypospadias Repair

Objectives: To compare the interpretation for cosmesis post-hypospadias repair by child, parents and surgeons using modified Pediatric Penile Perception Scale (PPPS). Methods: This cross-sectional study involving 50 children (aged 2 to 17 years) with hypospadias was conducted at the pediatric surgery department of our public sector tertiary care hospital. Subjects were assessed 6 months after completion of all stages of hypospadias repair. Cosmetic assessment was done using modified PPPS. We clubbed together the variables ‘meatus’ and ‘glans’ as MG (meatus-glans) complex due to their extreme proximity (embedding), while cosmesis of phallus was considered independently. The modified PPPS scoring parameters included phallus, MG complex, shaft skin, and general appearance. Independent assessment by surgeon, patients and parents was compared, and analyzed using SAS 9.2 statistical software. Cosmetic results of single vs staged repair, and different repair types was compared. Results: Assessment using modified PPPS showed that MG complex cosmesis and skin scarring were the most heeded parameters by all three categories of observers. PPPS by surgeons remained least affected by phallic cosmesis and that of the patient by the overall phallic appearance. Tubularized incised plate urethroplasty (TIPU) scored better on cosmesis. Conclusion: Phallic cosmesis should be considered an independent variable for assessing cosmetic outcome of hypospadias, apart from MG cosmesis.

HOME-BASED PULMONARY REHABILITATION: A NARRATIVE REVIEW

Pulmonary rehabilitation is a multidisciplinary, evidence based therapy wherein individually tailored therapies made to improve the physiological and psychological status of chronic respiratory disease patients. We searched 3 databases and term used “home-based pulmonary rehabilitation”. We identified 68 literatures and 8 of them met our inclusion criteria. Our review suggests that home-based pulmonary rehabilitation is effective in chronic respiratory disease patients, further research needed to standardise its quality and benefits.

DIGITAL SEARCH ADVERTISING – THE ROLE OF POST-CLICK FACTORS IN GENERATING PURCHASE CONVERSIONS

A lot of research is available on the effectiveness of search as an advertising channel. Most of these studies tend to treat a click on a search ad as a binary event. All of them study the events leading to the click. This paper goes beyond this to study the post click actions taken by a user subsequent to clicking on a search ad, and refers to those actions as depth of interaction, and testing the variables that have an effect on the nal outcome. We use a prescriptive research design employing binary logistic regression analysis. Results indicate that the duration of time spent, device used, and recency of visit have a very high positive effect on the nal outcome.

Netarsudil monotherapy as the initial treatment for open-angle glaucoma and ocular hypertension in Indian patients: A real-world evaluation of efficacy and safety

Purpose: Glaucoma is the second leading cause of blindness worldwide, affecting more than 64 million people aged 40–80. The best way to manage primary open?angle glaucoma (POAG) is by lowering the intraocular pressure (IOP). Netarsudil is a Rho kinase inhibitor, the only class of antiglaucoma medications that reorganizes the extracellular matrix to improve the aqueous outflow through the trabecular pathway. Methods: An open?label, real?world, multicentric, observation?based 3?month study was performed for assessing the safety and ocular hypotensive efficacy of netarsudil ophthalmic solution (0.02% w/v) in patients with elevated IOP. Patients were given netarsudil ophthalmic solution (0.02% w/v) as a first?line therapy. Diurnal IOP measurements, best?corrected visual acuity, and adverse event assessments were recorded at each of the five visits (Day?1: screening day and first dosing day; subsequent observations were taken at 2 weeks, 4 weeks, 6 weeks, and 3 months). Results: Four hundred and sixty?nine patients from 39 centers throughout India completed the study. The mean IOP at baseline of the affected eyes was 24.84 ± 6.39 mmHg (mean ± standard deviation). After the first dose, the IOP was measured after 2, 4, and 6 weeks, with the final measurement taken at 3 months. The percentage reduction in IOP in glaucoma patients after 3 months of once?daily netarsudil 0.02% w/v solution use was 33.34%. The adverse effects experienced by patients were not severe in the majority of cases. Some adverse effects observed were redness, irritation, itching, and others, but only a small number of patients experienced severe reactions, as reported in a decreasing order: redness > irritation > watering > itching > stinging > blurring. Conclusion: We found that netarsudil 0.02% w/v solution monotherapy when used as the first?line treatment in primary open?angle glaucoma and ocular hypertension was both safe and effective.

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.

Challenges of Second-hand Smoke: Are We Asking the Right Questions?

Second-hand tobacco smoke as defined by WHO is the smoke emitted by a smoker or released from a burnt cigarette or any tobacco product. It is highly prevalent all over the globe but its serious health implications are often neglected by the public and the scientific community alike. Second-hand smoke has everlasting impact on all the body’s major organs, especially among the vulnerable population of children, pregnant ladies, people with chronic diseases and senior citizens. Although India started its war against this menace earlier than other counties, all its efforts remain bootless as its approach and implementation have a wide range of lacunae. This review aims to give a big picture of second-hand smoke, highlighting its pathophysiological changes in the body, socioeconomic impact, various strategies, and the gap that prevents these strategies from finding a favorable result in India. It becomes all the more important to reduce its impact owing to the increase in prevalence among youth reducing their vitality, derailing the society and the nation. It is recommended that the health authorities approach this health problem with utmost seriousness as a laid-back approach could welcome this silent killer’s known and unknown repercussions

POSTPRANDIAL HYPERTRIGLYCERIDEMIA AS A RISK FACTOR FOR MACROVASCULAR COMPLICATIONS IN TYPE 2 DIABETES MELLITUS

Diabetes mellitus is a common endocrine disorder characterized by chronic hyperglycemia, and disturbances of carbohydrate, fat and protein metabolism. The prevalence of diabetes has been increasing widely in India and worldwide. Diabetes is a cause of significant mortality and morbidity due to macro and micro vascular complications. Dyslipidemia accompanying type 2 Diabetes plays an important role in pathogenesis of atherosclerotic vascular disease. Post prandial hypertriglyceridemia, irrespective of fasting triglyceride levels, has emerged as a significant risk factor for symptomatic and asymptomatic macro vascular disease It is a case control study, conducted for a period of 1 year from November 2020 to October 2021, on patients visiting the Out-patient department of NRI institute of Medical Sciences, Sangivalasa, Visakhapatnam. The cases and controls were subjected to clinical and biochemical evaluation to detect presence of macro vascular complications. The cases were subjected to a high fat meal, and plasma triglycerides were measured two and four hours after a fat challenge. It was observed that post prandial hypertriglyceridemia correlated better than fasting triglycerides in patients with macro vascular complications. Persistent and significant post prandial hypertriglyceridemia was observed in diabetic patients with macro vascular complications; and can be used as a marker for predicting vascular complications in type 2 Diabetes mellitus.

Prevalence and Factors Associated With Depression among School Going Adolescents in Bengaluru: A Cross-Sectional Study

Introduction: The period of adolescence involves a lot of emotional changes as it is a period of transition to adulthood demanding independence.Adolescents with depression are more likely to have anxiety, disruptive behavior disorder and substance abuse when compared to those who are not depressed. Objective: To estimate the prevalence of depression among school going adolescents and to assess the factors associated with depression among them. Method: A cross-sectional study was conducted among school going adolescents aged 13-16 years in the urban field practice area of a Medical College. Depression was assessed using Beck's depression inventory (BDI). Total 896 adolescents were included in this study. Single stage cluster sampling method was done in which schools were considered as clusters and students constituted the sampling units. Schools were selected by simple random sampling technique using lottery method. Results: In this study about 45.2% of the adolescents had depressive disorder, out of which mild depression was reported among 22.2% students, 12.4% moderately depressed and 10.6% severe depression. Factors like mother's education, lack of communication by father and mother with their children, lack of needs satisfied by the fathers of the adolescents (61.9%), father's role in adolescents' life (62%) and domestic violence in family (69.7%) were some of the important reasons for developing depression among adolescents. Adolescent whose parents were having conflict (69.2%) were found be depressed when compared to those adolescents whose parents had no conflicts this difference was statistically significant (p<0.05). Conclusion: The prevalence of depression was found to be 45.2%. Finding of the study emphasizes the need for creating awareness about the early identification of behavioral changes leading to depression among adolescents by the parents and teachers. It is also important to emphasize to the parents on how their relationship and behavior towards the family affects the mental wellbeing of the adolescents.

A Lady with a Broken Heart

Broken-heart syndrome (BHS) is an acute reversible myocardial injury of left or right ventricular myocardium in the absence of coronary occlusion. We, herein, discuss a case of a postmenopausal female presenting with angina equivalent with surface electrocardiogram (ECG) and echocardiography consistent for acute coronary syndrome. The patient was subsequently diagnosed and treated as BHS.

Off-Pump Resection of Giant Intramural Left Ventricular Hydatid Cyst by Pleuropericardial Approach: a Case Report

ABSTRACT Primary cardiac hydatid cyst is a rare and fatal pathology, especially when involving the left ventricular free wall. A 44-year-old male was diagnosed with large intramural left ventricular hydatid cyst with wall thickness of 6 mm at the thinnest point. Cyst was accessed through pleuropericardial approach (left pleura opened, followed by entry into cyst directly through adjacent pericardium without removing the pericardial adhesions) which resulted in easy entry into the cyst, mitigating the risk of mechanical injury. This case report highlights that with detailed evaluation, cardiac hydatidosis can be addressed with off-pump technique, reducing the anaphylaxis risks and cardiopulmonary bypass-related effects.

Isolated external iliac artery aneurysm: a rare case presentation of IgG4-related disease / Aneurisma isolado de artéria ilíaca externa - uma apresentação de caso raro de doença relacionada à IgG4

Abstract Isolated external iliac artery aneurysm is a rare occurrence. These aneurysms have varied presentations depending on size and proximity. Both open surgical and endovascular modalities can be used for treatment depending upon presentation, aneurysmal anatomy, and patient condition. Preservation of at least one internal iliac artery is important to prevent post-repair hypogastric ischemia. There are no previous reports of IgG4-related disease (IgG4-RD) as etiology of these aneurysms. A 32-year-old male patient presented with a left lower abdominal lump and was found to have a left external iliac artery aneurysm on computed tomography angiography. The patient underwent iliofemoral bypass with an 8 mm polyester graft. Histopathological examination of the aneurysm wall suggested IgG4-RD. The patient fulfilled the 2020 Revised Comprehensive Diagnostic Criteria for IgG4-RD. An 18-Fluorodeoxyglucose-Positron Emission Tomography scan performed in the postoperative period showed no active disease, hence medical therapy was not instituted. The patient is doing well at 1 year.

Resumo O aneurisma isolado da artéria ilíaca externa é uma ocorrência rara. Esses aneurismas têm apresentações variadas, dependendo do tamanho e da proximidade. Ambas as modalidades cirúrgicas aberta e endovascular podem ser usadas para o tratamento, dependendo da apresentação, anatomia do aneurisma e condição do paciente. A preservação de pelo menos uma artéria ilíaca interna é importante para prevenir isquemia hipogástrica pós-reparação. A doença relacionada à imunoglobulina G4 (IgG4-RD) nunca havia sido encontrada como etiologia desse aneurisma. Um paciente do sexo masculino de 32 anos que apresentava um nódulo no abdome inferior esquerdo foi diagnosticado com aneurisma da artéria ilíaca externa esquerda na angiotomografia computadorizada. O paciente foi submetido a bypass iliofemoral com enxerto de poliéster de 8 mm. O exame histopatológico da parede do aneurisma era indicativo de IgG4-RD. O paciente cumpriu os Critérios Abrangentes Revisados ​​para IgG4-RD de 2020. A tomografia por emissão de pósitrons com 18-fluorodesoxiglicose no pós-operatório não evidenciou doença ativa, não sendo instituída terapia medicamentosa. Após seguimento de 1 ano, o paciente está bem.

Sex Reversal Syndrome (SRS): A case of SRY-Positive 46,XX Testicular Disorder / Journal of the ASEAN Federation of Endocrine Societies

@#We report a case of an SRY-positive 46,XX Indian male who presented with small testis and phallus, poor beard and mustache development and gynecomastia at the age of 24 years. He was biochemically found to have hypergonadotropic hypogonadism. He had 46,XX karyotype and Quantitative Fluorescence-PCR (QF-PCR) identified the SRY gene on the X chromosome. SRY-positive 46 XX male SRS cases usually present as phenotypically male since birth but develop features of hypogonadism, poor testicular development, and infertility after puberty. Infertility, hypogonadism, external genital development, and psychological distress are the major concerns during the management of the patients. Testosterone therapy for hypogonadism, artificial reproductive technologies for fertility, surgical repair of hypospadias/cryptorchidism/under-virilized genitalia and psychological and genetic counseling are helpful for proper management of the patients.

Rising Burden of Psychiatric and Behavioral Disorders and Their Adverse Impact on Health Care Expenditure in Hospitalized Pediatric Patients with Inflammatory Bowel Disease / 대한소아소화기영양학회지

Purpose@#The incidence and prevalence of inflammatory bowel disease (IBD) are increasing along with an increasing number of patients with comorbid conditions like psychiatric and behavioral disorders, which are independent predictors of quality of life. @*Methods@#Non-overlapping years (2003-2016) of National Inpatient Sample and Kids Inpatient Database were analyzed to include all IBD-related hospitalizations of patients less than 21 years of age. Patients were analyzed for a concomitant diagnosis of psychiatric/ behavioral disorders and were compared with IBD patients without psychiatric/behavioral disorder diagnoses for outcome variables: IBD severity, length of stay and inflation-adjusted hospitalization charges. @*Results@#Total of 161,294 IBD-related hospitalizations were analyzed and the overall prevalence rate of any psychiatric and behavioral disorders was 15.7%. Prevalence rate increased from 11.3% (2003) to 20.6% (2016), p<0.001. Depression, substance use, and anxiety were the predominant psychiatric disorders. Regression analysis showed patients with severe IBD (odds ratio [OR], 1.57; confidence interval [CI], 1.47–1.67; p<0.001) and intermediate IBD (OR, 1.14; CI, 1.10–1.28, p<0.001) had increased risk of associated psychiatric and behavioral disorders than patients with a low severity IBD. Multivariate analysis showed that psychiatric and behavioral disorders had 1.17 (CI, 1.07–1.28; p<0.001) mean additional days of hospitalization and incurred additional $8473 (CI, 7,520–9,425; p<0.001) of mean hospitalization charges, independent of IBD severity. @*Conclusion@#Prevalence of psychiatric and behavioral disorders in hospitalized pediatric IBD patients has been significantly increasing over the last two decades, and these disorders were independently associated with prolonged hospital stay, and higher total hospitalization charges.

Dexmedetomidine versus clonidine as an adjuvant to local anaesthetic in brachial plexus blocks: a metaanalysis of randomised controlled trials

Abstract Objective: This meta-analysis aimed to compare the efficacy and safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. Methods: Two investigators independently searched databases to identify all RCTs comparing the efficacy and/or safety of dexmedetomidine and Clonidine as an adjuvant to local anesthetics in BPBs. All outcomes were pooled using the inverse variance method with a random-effect model. An I2 test was used to assess heterogeneity. The source of heterogeneity was explored through meta-regression. The quality of the evidence was assessed using the GRADE approach. Results: Out of 123 full texts assessed, 24 studies (1448 patients) were included in the analysis. As compared to Clonidine, dexmedetomidine groups showed significantly longer sensory block duration (MD = 173.31; 95% CI 138.02-208.59; I2 = 99%; GRADE approach evidence: high); motor block duration (MD = 158.35; 95% CI 131.55-185.16; I2 = 98%; GRADE approach evidence: high), duration of analgesia (MD = 203.92; 95% CI 169.25-238.58; I2 = 99%; GRADE approach evidence-high), and provided higher grade quality of block (RR = 1.97; 95% CI 1.60-2.41 ; I2 = 0%; GRADE approach evidence: moderate). The block positioning technique (regression coefficient: 51.45, p = 0.005) was observed as a significant predictor of the heterogeneity in the case of sensory block duration. No significant difference was observed for the risk of hypotension (RR = 2.59; 95% CI 0.63-10.66; I2 = %). Conclusion: Moderate to high-quality evidence suggests dexmedetomidine is a more efficacious adjuvant to local anesthetic in BPBs than Clonidine.

Demographic profile of patients seeking teleophthalmology consultations through e-Sanjeevani: Retrospective analysis of 5138 patients from North India

Purpose: To report the demographic profile of patients registered through e?Sanjeevani OPD seeking teleophthalmology services. Methods: This was a cross?sectional data analysis of patients with ocular complaints registered through the e?Sanjeevani platform at a tertiary care center. It was a doctor?to?doctor consultation, where teleophthalmology consultants provided teleconsultation services at subcenters (SCs), primary health centers (PHCs), and community health centers (CHCs). Data regarding the patient’s age, gender, residential address, provisional diagnosis, and treatment prescribed were recorded from May 2021 to February 2022 (9 months). Results: In total, 5138 patients were teleconsulted from the mean age of the patients was 37.64 ± 19.34 years. Among these patients, 44% were males and 56% were females. Most of the teleconsultation calls were made from Palwal district (19.8%), followed by Hisar (14.5%) and Sonipat. The most common provisional diagnosis was dry eyes (21%), followed by allergic conjunctivitis (18%), refractive error (15%), and cataract (14%). These constituted approximately 70% of the diagnosis made through teleconsultations. The rest of the eye problems were diagnosed as stye, blepharitis, nasolacrimal duct obstruction, pterygium, subconjunctival hemorrhage, etc., The majority of the patients were managed medically (56.6%) and approximately 11.6% of the patients were referred for surgical intervention. Conclusion: e?Sanjeevani is an effective way to provide teleconsultations to patients in remote locations. The majority of the patients seeking ophthalmology consultations can be managed conservatively. Patients requiring surgical intervention can be referred timely, thus avoiding any delay in treatment

Comparative Evaluation of Efficacy of Three Single File Retreatment Systems for Removal of Gutta Percha and Assessment of Root Canal Transportation - An In Vitro Study

Background: In comparison to multiple file systems, recent advancements in single file retreatment systems had reduced the working time and ease of operation for clinicians. Aim: To compare the efficacy of retreatment systems compared with hand instrumentation, by evaluating their removal efficacy, time required for retreatment and assessment of canal transportation. Methods and Material: Forty premolars were instrumented using ProTaper Gold gold files. Post instrumentation, scan was taken, obturated using warm vertical compaction technique, and stored in artificial saliva for three months and randomly divided into four groups for retreatment. Hand instrumentation (Hi), Neoniti (Nn), Mtwo R (Mt), WaveOne Gold (Wg). Post retreatment, scan was taken. Teeth were sectioned longitudinally and photographed under the stereomicroscope. Retreatment time was recorded, and canal transportation was calculated. Statistical Analysis: The results were analyzed using one?way analysis of variance (ANOVA) followed by Tukey’s post hoc test at 95% confidence level. Results: The retreatment time was significantly longer in the Hi group. Within the test groups, a significantly longer time has been taken by Wg (p < 0.05) compared to Mt and Nn. There was no difference in the canal transportation between the single file systems at 3 mm, 6 mm and 9 mm from the apex, there was statistically significant higher transportation for the Hi group at 9 mm from the apex (p < 0.05). Conclusions: All techniques were effective in removal of filling material with minimal canal transportation. Wg system was shown to increased time compared to Nn and Mt systems. Hi group was slowest with maximum canal transportation at 9 mm from the apex.

Essential medicines for cardiovascular diseases in India: Rapid appraisal of policies and processes at the subnational level

BACKGROUND The burden of cardiovascular diseases (CVDs) and response to health systems vary widely at the subnational level in India. Our study aimed to assess the variation in state-level access to medicines for CVDs by comparing the essential medicines lists (EMLs) at the national and subnational levels in India and by rapid appraisal of the existing policies and processes of drug procurement. METHODS We assessed the inclusion of six classes of medicines for CVDs in the recent and publicly available national and subnational EMLs from July to September 2018 in the states of Telangana and Madhya Pradesh. We examined the drug procurement and distribution policies and processes using documentary review and five key informant interviews between March and June 2018. RESULTS The WHO’s EML, India’s national EML, and 21 of 28 publicly available (75%) Indian state and Union Territory EMLs included all six classes of essential medicines for CVDs. However, some medicines were not included in the policy packages of essential medicines meant for primary health centres. Both the states used centralized tendering and decentralized distribution as part of the public sector drug procurement process. The requirement was based on the previous year’s consumption. The approximate time between procurement planning and distribution was 7–8 months in both the states. CONCLUSION Substantial variation exists in the selection of drugs for CVDs in EMLs at the subnational level in India. Improving forecasting techniques for requirement of medicines and reducing time lags between forecasting and distribution to health facilities may allow for better access to essential medicines.