A Case for Horizontal Distribution of Activities between General Surgery and Surgical Super Specialties

Under the current practice in organizing surgical services, proportionate representation of disciplines is provided in the curricular planning and in corresponding clinical functions. This is based on the level of competence expected by the end of training period. The disciplines as a “whole” are placed in general surgery or super specialty. The system of vertical arrangement has some serious concerns. Paradoxically, patients with diseases of simple and routine nature of discipline categorized as super specialty are neglected. Super specialist is unable to attend on account of preoccupation with serious challenging problems. The general surgeon hesitates because of privileging issues, fear of allegations of negligence and litigation. The system of vertical division is based on premise that some disciplines deal with complex procedures and others with only simple and routine nature. This premise is incorrect. Each discipline is a mix of simple and complex cases requiring specialized treatment. Alternate modified organization of surgical service is proposed. Activities of all disciplines are scrutinized according to the level of expected competence by the end of training. Categorization is shifted from the “discipline' to “activities.” Criteria applied for classification of activities are as follows: on completion, the trainee is capable to assume full responsibility-category 1; has gained sufficient experience-category 2; and is conversant with broad understanding of management-category 3. Activities of category 1 from all disciplines are assigned to general surgery and those of category 3 from all disciplines are assigned to respective super specialty. Those in the middle, comprising difficult cases but not requiring specialized training or heavy inputs in equipment, are in category 2. They are assigned to general surgery as additional/optional items, or super specialty, guided by local factors. The scope and practice of general surgery are broadened with a shift from “residual” to “comprehensive” discipline. Advantages, concerns, collateral issues of horizontal distribution of activities, its positive impact on research and education are discussed. It is concluded that the proposed organization of surgical services is a rational, logical, and practical strategy for good-quality surgical care in the society. The super specialists need to be convinced that “taking load off” is good for the specialty.

Cancer awareness & its association with demographic variables & mobile phone usage among the rural population of a district in north India

Background & objectives: Lack of awareness is one of the major reasons for the high morbidity and mortality associated with cancers. The present study was aimed to evaluate the awareness of prevalent cancers among the rural population in a district of north India and its association specifically with mobile phone usage. Methods: Using a stratified random sampling technique, households in three villages of Gautam Buddh Nagar district of India were selected. A house-to-house survey on cancer awareness was conducted among adults in selected households and data were analyzed to check for the association of such an awareness with sociodemographic factors and internet usage. Results: The study included 59 males and 145 females, with majority (115) being in the age group of 18-30 yr. Although most (96.5%) of the participants were aware of cancer, the common risk factors and warning signs of cancer were known to only a few. Specific risk factors for cervical and breast cancers were, however, not known to a majority (79.9% and 72.2%). A significant association between the awareness of general risk factors and warning signs as well as specific aspects including risk factors for breast, cervical and oral cancer, HPV vaccine and the education level of the participants (P<0.05 for all). Knowledge of risk factors, warning signs and cancer prevention modalities was higher among mobile phone users who accessed internet for health information. There was no significant association between age group and cancer risk factor awareness, though females were more aware of the risk factors for breast cancer (P=0.002). Interpretation & conclusions: The findings of this study highlight the existing low level of awareness of cervical and breast cancers among the rural population. The association of cancer awareness with education level and mobile phone-based internet usage suggests the potential utility of internet-based platforms such as m-health programmes for cancer prevention activities

Acute viral hepatitis in children: a prospective hospital based study

Background: Viral hepatitis is a major public health issue throughout the world affecting millions of children despite the availability of vaccines, prophylactic measures and improved sanitation. The objective of the study was to analyze the etiology, clinical features, laboratory parameters and sonological findings of Acute Viral Hepatitis in pediatric population.Methods: A total of 88 children admitted in paediatric department and gastroenterology unit of medicine department with confirmed acute viral hepatitis from June 2016 to July 2018 at tertiary health care teaching hospital of north India were included. The patients were divided in 3 age groups; 1-5, 6-10 and 11-18 years. Clinical features, laboratory parameters, ultrasound findings were compared in three age groups.Results: Out of 88 cases 48 were boys and 40 girls. In the present study hepatitis A was the most common (85.2%) etiology. Jaundice (90.9%) is the most common symptoms followed by dark colored urine (86.3%), loss of appetite (83.3%) and fever (68.2%) reported in this study. Icterus (90%) is the most common sign reported followed by hepatomegaly (86%). Out of 88 cases 4 cases died. Out of 4 deaths, 2 cases of hepatitis A and 2 cases positive for Hepatitis B. The cause of death was hepatic encephalopathy in both the cases.Conclusions: Majority of cases in children were hepatitis A cases. Most of the cases were aged above 5 years with slight male predominance. Those cases with elevated liver enzymes (SGOT >5000) and those with PT INR >3.5 at admission has higher mortality.

Significant perceived stressors in irritable bowel syndrome: a stress interventional module analysed

Background: Psychological stress is an important factor for the development of irritable bowel syndrome (IBS). More and more clinical and experimental evidences are showing that IBS is a combination of irritable bowel and irritable brain. As IBS is a stress sensitive disorder, its treatment should focus on managing stress and stress-induced responses.Methods: This is a hospital based longitudinal study. 72 patients fulfilling the Rome IV criteria for irritable bowel syndrome were enrolled into the study. Perceived stress was assessed using student stress dimension questionnaire (SSDQ) while IBS severity was assessed using IBS severity scoring system (IBS-SSS). The stress interventional module (SIM) consist of specific domain targeted psychological interventions given to the patients weekly based on the stress domain mapping. The effectiveness of these interventions on reducing stress as well as IBS severity was assessed at baseline, and weeks 2, 4 and 6 follow-ups.Results: Of the studied IBS patients, most had SPS in multiple life domains while familial and interpersonal domains were affected in 78%. Also, total stress load in form of mean cumulative stress load at baseline was 451.1 which decreased significantly to 274.4 over 6 weeks. This SIM brought about a reduction in mean irritable bowel syndrome severity score from 27.5 to 20.6 in 6 weeks. This reduction in IBS severity score overtime was significant (p=0.001).Conclusions: Patients of irritable bowel syndrome show significant stress in multiple domains of life, which require proper assessment and management. Authors propose that individual-specific interventions aimed at reducing stress in all psychosocial life domains are efficacious and should be an integral part of managing IBS.

A Study of Biochemical Changes of Rocuronium Bromide and other Muscle Relaxants in Cardiac Surgery

Introduction: CAPD is one of the renal replacement therapieswhich is gaining popularity in the developing world especiallyIndia. This study was aimed to study the clinical profile andcomplication of Complications of Continuous AmbulatoryPeritoneal Dialysis (CAPD).Material and Methods: Patients on CAPD at our center wereevaluated for their clinical profile, complication and outcomeon follow-up.Results: A total of 100 patients were included in the study.There were 66%males and 34% females. Mean age of thepatients was 47.95± 6 years. Hypertension was seen as etiologyin 36%, Diabetes in 27%, chronic glomerulonephritis in 22%,Analgesic nephropathy in 4%, Obstructive nephropathy in 3%and in 4% cases no obvious cause for CKD could be found.Among the complications pain was seen in 11%, pericatheterleak in 5%, bleeding 7%, intestinal perforation in 2%, herniain 5%, total obstruction in 4%, exit site infection in 7%,tunnel infection in 2% and total 111 episodes of peritonitis.Technique survival at 1 year and 2 years was 97%and 94%respectively. Patient survival at one and two years was 90%and 78% respectivelyConclusion: CAPD presents a viable form of renalreplacement therapy. There has been sustained decrease incomplication rates and improvement in technique and patientsurvival with advancement in catheter implantation andcomplication management

A Study of Hemodynamic Effects of Rocuronium Bromide and other Muscle Relaxants in Cardiac Surgery

Introduction: Use of muscle relaxants in cardiac surgeryposes a challenge to anaesthesia due to narrow margin of safetyand limited cardiovascular function. Therefore aim of presentstudy is to find out the hemodynamic effects of Rocuroniumbromide and other muscle relaxant in cardiac surgery.Material and Methods: Present study was carried out on sixty(60) patients of different age groups from both sexes scheduledfor various cardiac surgical procedures at L.P.S. Institute ofCardiology, GSVM medical college Kanpur during the periodof August 1998 to August 1999. Patients were classified in 3equal groups. Muscle relaxants were given according to thegroup and hemodynamic parameters were recorded carefullyat the interval of two, five and ten minutes.Results: No statistically significant changes were observed insystolic blood pressure, diastolic blood pressure and centralvenous pressure at 2 minutes, 5 minutes and 10 minutes afterthe administration of all three drugs (P >0.05) comparedwith control values. Significant increase in heart rate wasobserved at 2 minutes and 5 minutes after the administrationof Pancuronium (P <0.05).Conclusion: On basis of present study’s result, it can besaid that Rocuronium bromide is safer in cardiac surgery ascompared to Vecuronium & Pancuronium.

Histone H2A isoforms: Potential implications in epigenome plasticity and diseases in eukaryotes

Epigenetic mechanisms including the post-translational modifications of histones, incorporation of histonevariants and DNA methylation have been suggested to play an important role in genome plasticity by allowingthe cellular environment to define gene expression and the phenotype of an organism. Studies over the pastdecade have elucidated how these epigenetic mechanisms are significant in orchestrating various biologicalprocesses and contribute to different pathophysiological states. However, the role of histone isoforms and theirimpact on different phenotypes and physiological processes associated with diseases are not fully clear. Thisreview is focussed on the recent advances in our understanding of the complexity of eukaryotic H2A isoformsand their roles in defining nucleosome organization. We elaborate on their potential roles in genomic complexity and regulation of gene expression, and thereby on their overall contribution towards cellular phenotypeand development of diseases

School related factors affecting non communicable diseases risk factors among 13-15 years old adolescents from two schools in Delhi

Background: Children and adolescents are more vulnerable to developing NCD (non communicable diseases) risk factors due to changing lifestyles. Hence it is essential to recognize NCD risk factors among adolescents. School plays an important role in imparting knowledge and shaping the behaviours and practices among children. This study focusses on the school related factors that may be influencing the NCD risk factors among adolescents.Methods: The study was conducted among 438 students, 13 to 15 years old of two central government schools in Delhi. A self-administered modified STEPS questionnaire, an observation checklist for assessing facilities at schools and an interview schedule for school staff were used to collect data.Results: The statistically significant determinants of inadequate fruits and vegetable intake and excess fast food intake were consumption of fast food from vendors selling food outside the school (OR=4.36), inadequate physical activity at school (OR=2.56) and feeling stressed at school (OR=2.93). Physical activity at school was an important determinant for overall physical activity of students (OR=2.38). Current tobacco use and current alcohol use was determined by feeling stressed at school (OR=3.12). Health education classes at school had a protective effect on the NCD risk factors.Conclusions: Many school related factors such as absence of playground at school, stressed life at school and vendors selling fast food outside school were seen to influence lifestyle risk factors amongst adolescents. Hence an active involvement of school by increasing health education classes and providing adequate facilities for physical activities may help in reducing the NCD risk factors among students.

Assessment of death registration coverage and its delays in district Faridkot: an urban rural comparison

Background: Death registration has been made compulsory under the RBD Act 1969 as it acts as a back bone for planning services and formulates policies. According to CRS 2013, at national level, 70.9% of deaths were registered which is far from magic figure of 100% despite of concerted efforts of government. So this study was conducted to assess the coverage of death registration and its delays. Methods: A cross sectional study was conducted over a period of one year where 332 households(166 each from urban and rural area reporting deaths in last two years were included in study after taking informed written consent. Relevant information was collected using a predesigned and pretested questionnaire by house to house survey. Coverage was calculated with possession of death certificate. Data was compiled and analyzed using EpiInfo07 (CDC, Atlanta, USA). Results: Out of 332 deaths, 245 (74%) out of which only140 (57%) possessed the death certificate. The main cause of death was cardiac diseases. Maximum coverage was seen in the age group 41-60 years. Delay in registration was seen in 48% with significantly higher proportion in rural area (59%) than in urban area (40%). Reasons for delay were time constraints, lack of knowledge and financial constraints. Socio demographic variables like religion, caste, type of family, family size and SES were not found to be associated with delay. Conclusions: The coverage of death registration was comparatively higher than national data and delay was observed in about half of the death registration coverage

Socio-demographic co-relates of depression among housewives in rural area of district Ludhiana

Background: Depression is the most common psychiatric disorder in general practice. It is much more common among women than men, with female/male ratio roughly 2:1. In today’s hectic life, stress is increasing in housewives. Very few data is available on depression among housewives in India. So the present study is aimed to assess the prevalence of depression and study its epidemiological co-relates among housewives aged 18-59 years in rural area of district Ludhiana. Objectives were to assess depression among housewives aged 18-59 years in a rural area and determine the association of depression with socio-demographic co-relates. Methods: This study is a community based cross-sectional study carried out in the field practice area of Department of Community Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab. 300 subjects were selected by systematic random sampling. Assessment of depression among the housewives was done by using Patient Health Questionnare-9 (PHQ-9). Results: In the present study, 43% of the subjects were found to have depression. Mean age of subjects with depression was found to be 42.4 (±10.3) years. There was an increasing trend of depression among housewives with increasing age (p=0.000). Inverse relationship was found between level of education and depression (p=0.000). Lower socio-economic status was found to be associated with higher rates of depression (p=0.039). Conclusions: Depression was seen to be on higher side among housewives in rural area of Ludhiana. Housewives should be educated about warning signs and symptoms of depression and motivated to avail the primary health care services.

A study on safe injection practices among healthcare professionals in a tertiary care hospital in Delhi

Background: As per available estimates, around three billion injections are administered annually in India and out of these, 1.89 billion are being unsafe. The present study was undertaken to observe and assess injection practices among Healthcare Professionals (HCP) in a tertiary care hospital.Methods: This was a cross-sectional, descriptive study conducted among doctors and nurses of purposively selected five departments in a government tertiary care hospital in Delhi. Primary data was collected using Self-administered questionnaire (SAQ) technique for which WHO Tool C Questionnaire was suitably modified, pre-tested and administered to HCP. Number of participants were 250 (131 doctors and 119 nurses). Injection practices were also observed in HCP and a total of 126 observations (60 in doctors & 66 in nurses) were made. Collected data was analyzed using Microsoft Excel & SPSS.Results: Though overall injection practices of the HCP were satisfactory but unsafe practices with respect to use of unclean surface for injection preparation (35%), not maintaining proper hand hygiene (33%) and not segregating bio medical waste at source by (22.3%) HCP were observed.Conclusions: Though compliance to best international injection practices in many areas were observed still unsafe practices were observed. Guidelines on Injection safety, Post Exposure Prophylaxis (PEP), judicious use of injections and reporting of adverse events/ sentinel events/near miss events to be prepared by the hospital at the earliest. It must be ensured that these guidelines are complied with by the HCP.

Effectiveness of medicine Malaria Off 200 as mass prophylaxis against Malaria in the high-risk villages of Shahdol, Madhya Pradesh

Background: Learning from the past experiences, the district health authority Shahdol has planned a mass-prophylactic activity with the Homeopathy Medicine (Malaria Off 200) in the selected high-risk villages (above 5 API) in the year 2016 Objective: The present paper reports the effectiveness of Malaria off 200 as mass-prophylactic drug in addition to routine antimalarial activities under NVBDCP in district Shahdol, Madhya pradesh in year 2016. Methodology: A Homeopathic drug Malaria Off 200 was used for the mass-prophylaxis of  Malaria in high malaria transmission season in selected 28 villages of district Shahdol. The effectiveness of the drug was ascertained as “Reduction of ≥20% villages, having more than 2 malaria case in six-month period (July-December 2016)in comparison to the previous year”. Result: Of the 28 villages, seven (25%) reported Malaria case  incidence equal to or less than two in six-month period (July-December 2016). In the same time period in previous year 23 (82%) villages reported Malaria case  incidence more than two. So, reduction of number of villages with 'biannual Malaria case  incidence’ rate was 57%. Conclusion: The short term finding validate the campaign as effective, as per the operational definition of effectiveness coined for the campaign. However, further time series studies with Autoregressive Integrated Moving Average (ARIMA) is recommended for future.

The Effect Of Upanaha Sweda And Vatari Guggulu In The Management Of Janusandhigata Vata (knee Osteoarthritis): A Comparative Study

Every man derives the happiness and benefit of his life through locomotion i.e., using his joints. For the minute if he loses this power of locomotion he not only feels himself a miserable creature but also becomes a burden both of his family and society. The loss or reduction in his locomotive power is due to dysfunction of the joints causing an impediment to his movements. If not treated in time, the disease makes man disable. Sandhigata Vata is most common articular disorder. It is a type of Vata Vyadhi which mainly occurs in Vriddhavastha, due to Dhatukshaya. Sandhigata Vata can be correlated with osteoarthritis (OA) which is one such chronic, degenerative, inflammatory disease and has a great impact on the quality of the life of an individual. Different modalities of treatment have been explained in the classics to tackle the condition effectively. The present study was aimed to assess clinically the effect of Upanaha Sweda and Vatari Guggulu in the management of Janusandhigata Vata. In this study total 42 patients were divided in 2 groups. In Group A, patients were treated with only Upanaha Sweda and other group patients were treated with Upanaha Sweda and Vatari Guggulu. Results obtained were analyzed for statistical significance which shows group B in which Vatari Guggulu and Upanaha Sweda were given, was more effective in bringing relief in signs and symptoms of Janusandhigata Vata.

Isolated giant ileal neurofibroma sans neurofibromatosis

Neurofibromas are benign neoplasms that are usually seen in hereditary disorders such as von Recklinghausen's disease [neurofibromatosis type 1 (NF1)]. The occurrence of isolated ileal neurofibroma in patients without the classic manifestations of NF1 or multiple endocrine neoplasia (MEN) syndromes is an extremely rare entity . We report one such case of isolated ileal neurofibroma in a 60 year old woman without any other stigmata of NF. It may be the initial manifestation of NF1 or MEN 2b or malignant transformation, all of which necessitate further follow-up of these patients.

Variations In Splenic Notches And Fissures: Study With Clinical Importance

The objective of the study had been to note the presence of notches and fissures in 60 spleens. The study wasdone on 60 spleens of both sexes obtained from autopsy of dead bodies in the Department of Forensic Medicineand variations noted in the Department of Anatomy. The notches were observed on the upper border in 51samples (85%) and on the lower border in 5 samples (8.33%). 6.67% of the spleen samples presented withfissures on the upper border and lower border each. Notches and fissures are quite a common occurrence inspleen. Notches on superior border are clinically significant as they assist in palpation of spleen duringsplenomegaly. Information of notches and fissures on the lower border of spleen are important during splenicsurgeries and radiological investigations. In the present study; the notches and fissures have been noted on the60 spleen samples.

Preliminary evaluation of indigenous 90Y-labelled microspheres for therapy of hepatocellular carcinoma.

Background & objectives: Yttrium-90 (90Y)-based radioembolization has been employed to treat hepatocellular carcinoma (HCC) as commercial radioactive glass and polymeric resin microspheres. However, in India and other Asian countries, these preparations must be imported and are expensive, validating the need for development of indigenous alternatives. This work was aimed to develop an economically and logistically favourable indigenous alternative to imported radioembolizing agents for HCC therapy. Methods: The preparation of 90Y-labelled Biorex 70 microspheres was optimized and in vitro stability was assessed. Hepatic tumour model was generated in Sprague-Dawley rats by orthotopic implantation of N1S1 rat HCC cell line. In vivo localization and retention of the 90Y-labelled Biorex 70 microspheres was assessed for seven days, and impact on N1S1 tumour growth was studied by histological examination and biochemical assays. Results: Under optimal conditions, >95% 90Y-labelling yield of Biorex70 resin microspheres was obtained, and these showed excellent in vitro stability of labelling (>95%) at seven days. In animal studies, 90Y-labelled Biorex 70 microspheres were retained (87.72±1.56% retained in liver at 7 days). Rats administered with 90Y-labelled Biorex 70 microspheres exhibited lower tumour to liver weight ratio, reduced serum alpha-foetoprotein level and greater damage to tumour tissue as compared to controls. Interpretation & conclusions: 90Y-labelled Biorex 70 microspheres showed stable retention in the liver and therapeutic effect on tumour tissue, indicating the potential for further study towards clinical use.

Comparison of interferon gamma release assay & tuberculin skin tests for diagnosis of latent tuberculosis in patients on maintenance haemodialysis.

Background & objectives: Tuberculosis (TB) is a common infection in patients on haemodialysis. There is a definite role of treatment of latent TB (LTB) in these patients. However, diagnosis of LTB in these patients by tuberculin skin test (TST) is unreliable. There is suggestion that interferon gamma release assay (IGRA) will be more reliable test for diagnosis of LTB in this setting. Thus, we evaluated value of IGRA and TST for the diagnosis of LTB in patients on dialysis in an Indian setting. Methods: Patients with end stage kidney disease on dialysis were included. Patients with active TB were excluded. Each patient was subjected to TST (induration of ≥10 mm was taken as positive) and QuantiFERON TB Gold In-Tube test (QFT-GIT) for diagnosis of LTB. Results: A total of 185 patients were included; 129 (69.7%) were males and mean age was 36.7 ± 12.3 yr. Past history of TB was present in 18 (9.7%) patients. One hundred and thirty four (72.4%) patients had scar of BCG vaccination. QFT-GIT test was positive in 66 (36%), TST in 32 (17%) and both in 13 (7%) patients. Of the 66 patients positive with QFT-GIT, only 13 (19.6%) were positive for TST. Of the 32 patients positive with TST, only 13 (40.6%) were positive with QFT-GIT; 100 (54%) patients were negative for both the tests. Overall, 85 (45.9%) patients were positive for either of the two tests. Poor agreement was shown between the two methods. On logistic regression analysis, odds of QFT-GIT to be positive in patients with BCG vaccination was 1.23 and with history of TB 0.99, both being insignificant. odds of tuberculin skin test to be positive in patients with BCG vaccination was 1.04 and with history of TB 0.99, both again being insignificant. Interpretation & conclusions: Our findings showed that more number of patients (36%) on haemodialysis were positive for QuantiFERON Gold In-Tube test as compared to TST (17%). There was poor agreement between the two tests. no significant effect of BCG vaccination and history of TB in past was observed on both tests.

A comparative study of fascial sheath interposition versus no fascial sheath interposition in No Scalpel Vasectomy.

Background: Since the introduction of male sterilization by surgery on deferens, several techniques have emerged to improve the results in terms of time, invasiveness, post operative infection, complications and success rate. Introduction: Vasectomy was introduced by Sharp in 1897. No scalpel vasectomy was introduced in China by Dr. Li Shun-Qiang in 1974. Intact fascial sheath helps in restoration of vas lumen and fascial sheath interposition prevents recanalization of vas by prevention of meeting of epithelialization from cut end of vas. Material and methods: The study was performed at PGIMS, Rohtak by performing surgery and follow-up up to one year of 326 subjects of no scalpel vasectomy. Clients were allocated in two groups. Group - A (155) with fascial sheath interposition and Group - B (171) without fascial sheath interposition. Surgeries were performed as a routine surgical procedure after full preparation of client including consent. Results: Majority of clients (56.1%) in Group - A were in age group 31-40 years followed by 22-30. years (28.4%), 41-50 years (14.8%) and 0.7% in age group more than 50 years. in Group - B, majority were also in age group 21-30 years (63.7%), followed by 31-40 years (29.8%), 41-50 years(5.9%) and 0.6% were of above 50 years. In Group - A, fascial sheath interposition was not possible in 17.2% clients due to non separation of sheath from vas. Sperm granuloma formation was observed in 8.6% in Group - A and 5.6% in Group-B. In comparison of 100% success rate in Group - A failure rate of 1.8% was observed in Group - B. Conclusion: The present study supports the existing literature that fascial sheath interposition adds a little more to the operating time of vasectomy, increases chances of wound infection and granuloma but has a less failure rate of vasectomy.

A study of morbidity and mortality profile of 500 road traffic accident cases in Malwa region of Punjab.

Background: Road Traffic Accidents (RTA) are increasing in an alarming ways. Globally, nearly 1.2 million people killed in RTA during the year 2002. Developing and underdeveloped countries accounted for 80% of these deaths. Aim: The aim of the study was to know the morbidity and mortality profile of 500 road trafic accident cases in malwa region of punjab. Material and methods: Total 500 road traffic accident cases admitted at Guru Gobind Singh Hospital, Faridkot, Punjab from May 2013 to December 2013 were selected for the study. Results: The age wise distribution of victims showed that 157 (31.4%) occurred in 21-30 years age group, 215 (43%) victims reached the health facility within one hour and the 242 (48.4%) victims stayed in the hospital for the duration of 1-7 days. Conclusion: When enquired about the probable cause of accident most of the victims complained about the poor lighting condition on the roads at night time. The other major cause was alcohol or influence of others intoxication on the victim or the driver of the hitting vehicle.