Improving the Availability of Adequately Iodized Salt by Mobilizing the Network of Salt Traders in Uttar Pradesh, India.

Objectives: Uttar Pradesh (UP) is a non-salt producing state in India. Most of the salt is imported and traded in 18 of the 75 districts in the state. In 2009, the household coverage of adequately iodized salt in UP was 43%. This presentation features the important initiative taken by the state government with support by UNICEF to increase the availability of adequately iodized salt by mobilizing the network of salt wholesalers and retailers in UP. Methods: A total of 204 wholesalers and retailers were mapped across the 18 salt unloading districts. Four titration laboratories in the state medical colleges were revitalized. Salt samples were collected from shops and storage points on a monthly basis and sent to the laboratories to test the samples' iodine content. Reports on the iodization adequacy of salt were issued, shared with the wholesalers and retailers and used to monitor the iodization quality of salt. Monthly dialogue with salt wholesalers and retailers was carried out to sensitize and motivate them to procure and sell only adequately iodized salt. The salt testing results were also used by the Salt Department and the Department of Food and Drug Administration to take punitive actions against manufacturers producing inadequately iodized salt. Results: The availability of non-iodized salt decreased by 2.5% and availability of adequately iodized salt increased by 10% over a one-year period. Conclusions: Mapping, sensitization and using a combination of punitive and non punitive approach with the wholesalers and retailers proves to be an effective strategy to ensure adequate availability of appropriately iodized salt.

Management Information Systems (HMIS): A Method for Strengthening HMIS in Uttar Pradesh, India.

Objectives: Estimates from robust cross sectional surveys have brought into question the accuracy of HMIS of VAS in India, including potential errors as HMIS data is rolled up at various levels from health worker- to state-level, limiting the usefulness of these data for program feedback and improvement. In response, we sought to identify errors in monitoring data at different levels, suggest corrective action and establish coverage by a cross sectional survey triangulated with HMIS data. Methods: This exercise was conducted in 16 districts where 48 primary health centers (PHCs) were selected randomly. Data on Vitamin A coverage recorded at districts, PHCs, sub-health centers (SHCs) and health worker/volunteer level were cross-verified with coverage figures recorded at their respective constituent units. Discrepancies between coverage data recorded at health facilities and that aggregated from their constituent units were computed. A 30X7 cluster survey was also undertaken in each of these centers to establish population-based coverage. Results: Overall, there was a 7% discrepancy between figures reported by PHCs and that aggregated from their SHCs. In some PHCs the discrepancy was as large as 40%. The cross-sectional household survey identified 10% higher coverage than that reported by the state government (52% vs 42%). District specific findings were used to identify and facilitate systemic changes in reporting and data compilation. Conclusions: This is a cost-effective method and useful exercise for improving internal data quality and minimizing reporting error. The involvement of government functionaries in the process increased the ownership of study results and facilitated corrective actions.

Continuous professional development for physicians / Desarrollo profesional continuo para médicos

Maintenance of professional competence remains an exercise of permament learning and an essential requirement for evidence–based medical practice. Physicians attend continuing professional development (CPD) programs to acquire new knowledge. Often CPD programs remain the main source for updates of information. CPD organizers have a considerable responsibility in determining appropriate curriculum for their conferences. Organizing an effective CPD activity often requires understanding of the principles of adult education. Prior to deciding on the curriculum for a CPD, course organizers should conduct needs assessment of physicians. CPD planners should create activities that would consistently improve physician competence. CPD sessions that are interactive, using multiple methods of instructions for small groups of physicians from a single specialty are more likely to change physician knowledge and behavior. The effectiveness of a CPD program should be evaluated at a level beyond measuring physician satisfaction. CPD planners should incorporate methods to determine the course attendees' improvement of knowledge, skills and attitudes during the CPD activities. Pre and post conference evaluations of physicians using multiple choice questions may form a useful method of assessment. [Ghosh, AK. Continuous professional development for physicians.

Mantener la competencia profesional sigue siendo un ejercicio de aprendizaje permanente y un requisito esencial para la práctica de la medicina basada en la evidencia. Los médicos asisten a programas de educación médica continua o desarrollo profesional continuo continuing profesional development (CPD) para la adquisición de nuevos conocimientos. Amenudo los programas CPD siguen siendo la principal fuente de actualización. Los organizadores de la educación médica continua (CPD) tienen una gran responsabilidad en la determinación de contenidos apropiados para sus conferencias. Organizar una actividad de educación continua (CPD) efectiva requiere a menudo la comprensión de los principios de la educación de adultos. Antes de decidir sobre los contenidos de la (CPD) los organizadores del curso deben llevar a cabo la evaluación de las necesidades de los médicos. Los planificadores de (CPD) deben crear actividades que mejoren constantemente la competencia médica. Sesiones de (CPD) interactivas y el uso de múltiples métodos de instrucción para pequeños grupos de médicos de una sola especialidad son más propensos a cambiar el conocimiento y la conducta de los médicos. La eficacia de un (CPD) debe ser evaluada en un nivel más allá de la medición de la satisfacción del médico. Planificadores de (CPD) deben incorporar métodos para determinar la mejora de los asistentes al curso de conocimientos, habilidades y actitudes en las actividades de (CPD). Las evaluaciones pre y post conferencia con preguntas de opción múltiple puede formar un método útil para la evaluación. [Ghosh, AK. Desarrollo profesional continuo para los médicos.

Drug utilization study of co-administration of nonsteroidal anti-inflammatory drugs and gastroprotective agents in an orthopaedics outpatients department of a tertiary care hospital in West Bengal.

Background: Non steroidal anti-inflammatory drugs (NSAIDs) are the commonly prescribed analgesic in the orthopaedics department. NSAIDs are prescribed for a long period in both acute condition (like fracture of bones, muscle injury, postoperative procedures etc) or chronic conditions (osteoarthritis etc). However, they have many adverse effects, especially gastrointestinal toxicity when use regularly. For this reason NSAIDs are frequently co-prescribed with gastro protective agents. Common gastroprotective agents are proton pump inhibitors (PPI), H2 blockers, sucralfate, antacids and misoprostol (prostaglandin analogue). Methods: A cross-sectional, unicentric drug utilization study was conducted. Prescriptions were collected from patients attending the orthopaedic outpatients department. The prescription pattern of NSAIDs, gastroprotective agents or co-administration of NSAIDS and gastroprotective agents were analyzed. Results: A total of 977 prescriptions were studied; in which 928 prescriptions contained NSAIDs with gastroprotective agents (97.92%). The most common gastroprotective agents combined with NSAIDs was H2 receptor blockers (60.56%), followed by proton pump inhibitors (PPIs) (21.65%), while antacids are prescribed least (17.78%). Misoprostol or sucralfate were not used at all. Conclusions: NSAIDs are commonly co-prescribed with gastroprotective agents in high percentage.

Antimicrobials & cholera: are we stranded.

Antimicrobial resistance poses a major threat in the treatment of infectious diseases. Though significant progress in the management of diarrhoeal diseases has been achieved by improved hygiene, development of new antimicrobials and vaccines, the burden remains the same, especially in children below 5 yr of age. In the case of cholera, though oral rehydration treatment is the mainstay, antimicrobial therapy is mandatory at times to reduce the volume of stool and shorten the duration of the disease. Though for many pathogens, antimicrobial resistance emerged soon after the introduction of antibiotics, Vibrio cholerae remained sensitive to most of the antibiotics for quite a long period. However, the scenario changed over the years and today, V. cholerae strains isolated world over are resistant to multiple antibiotics. A myriad number of mechanisms underlie this phenomenon. These include production of extended-spectrum beta-lactamases, enhanced multi-drug efflux pump activity, plasmid-mediated quinolone and fluoroquinolone resistance, and chromosomal mutations. Horizontal transfer of resistance determinants with mobile genetic elements like integrons and the integrating conjugative elements (ICEs), SXTs help in the dissemination of drug resistance. Though all strains isolated are not resistant to all antibiotics and we are not as yet “stranded”, expanding spectrum of drug resistance is a definite cause for concern. Pipelines of discovery of new antibiotics are drying up as major pharmaceutical companies are losing interest in investing money in this endeavour, mainly due to the short shelf-life of the antibiotics and also due to the fast emergence of drug resistance. To address this issue, attempts are now being made to discover drugs which are pathogen specific and target their “virulence mechanisms”. It is expected that development of resistance against such antibiotics would take much longer. This review briefly focuses on all these issues.

Disorders of potassium homeostasis: pathophysiology and management.

Disorders of potassium homeostasis are common electrolyte abnormalities encountered in hospitalized patients. Hypokalemia and hyperkalemia have been estimated to occur in about 21% and 3% of hospitalized patients, respectively; though the morbidity and mortality associated with the latter is significantly higher. Potassium is a predominantly intracellular ion and the understanding of its dynamics between intra- and extracellular fluid milieus, along with its handling by the kidneys, is important in the diagnosis and treatment of potassium disorders. This article aims to provide a clinically relevant update on management of potassium disorders for internists.

Disorders of calcium, phosphorus and magnesium metabolism.

Abnormalities of calcium, magnesium and phosphorus are common in hospitalized patients. Infrequently patients might present in the outpatient settings with non-specific symptoms that might be due to abnormalities of divalent cation (magnesium, calcium) or phosphorous metabolism. Several inherited disorders have been identified that result in renal or intestinal wasting of these elements. Physicians need to have a thorough understanding of the mechanism of calcium, magnesium and phosphorous metabolism and diagnoses disorders due to excess or deficiency of these elements. Prompt identification and treatment of the underlying disorders result in prevention of serious morbidity and mortality.

Structural organization of cholera toxin gene and its expression in an environmental non-pathogenic strain of Vibrio cholerae.

Non-pathogenic, environmental strain of Vibrio cholerae, ELTOR Ogawa EW6 carries a copy of the cholera toxin gene in its chromosome. Restriction enzyme digestion followed by Southern blot analysis revealed that the structure of the cholera toxin gene in this organism is different from that found in the virulent strains. The xbaI site which has been found to be conserved in the cholera toxin of the virulent strains examined so far, is absent here. Results of the RNA dot blot analysis indicated that the cholera toxin gene in EW6 is transcribed much less efficiently compared to the cholera toxin gene present in the virulent strain Vibrio cholerae classical Inaba 569B.