A comparative study to assess prescription pattern, cost, and appropriateness of antimicrobial usage in a rural government tertiary care hospital and rural private practitioners

Background: Antimicrobial resistance is defined as the ability of microorganism (bacteria, fungus, virus, or parasite) to resist the effects of a drug to inhibit microorganism growth, which is becoming a major concern worldwide particularly in developing country like India. Aim and Objectives: The aim of this study was to identify, compare, and assess the appropriateness of antimicrobials prescribed in a rural tertiary care hospital and those prescribed by rural private practitioners and to assess the average cost of antimicrobials per prescription. Materials and Methods: A cross-sectional study was conducted, in which a total of 2003 prescriptions were analyzed from outpatient department (OPD) of rural tertiary and prescriptions from nearby chemist shops for prescription pattern, cost, and appropriateness. Results: It was identified that most of the antimicrobial containing prescriptions in both private and public health sector were prescribed by MBBS doctors (56.33%). In Government Medical College (GMC) OPDs, antimicrobials were prescribed mostly for gastrointestinal infection (25.75%) and beta lactams (45.23%) followed by fluoroquinolones (27.10%) were the most commonly prescribed. While among rural private practitioners, gastrointestinal infections (33.50%) followed by fever (27.70%) were the most common clinical conditions, for which antimicrobials were prescribed and 13.40% prescriptions contained more than one antimicrobial. About 43.37% of antimicrobials prescribed in OPDs of GMC and 56.20% antimicrobials prescribed by private practitioners were found to be inappropriate which was statistically significant. Conclusion: The study concluded that around half of the prescriptions analyzed were inappropriate and so there is a strict need of supervising the antimicrobials prescribing patterns, consumption, and it’s dispensing from the pharmacy shops.

Prevalence of depression and health related quality of life among patients with diabetes mellitus and hypertension attending a secondary care hospital in district Faridabad, Haryana

Background: Diabetes mellitus (DM) and hypertension (HT) have significant effect on the mental health of the patient. and. Objective: To estimate the prevalence of depression, and the quality of life among patients with diabetes mellitus and hypertension who attended a secondary care hospital. Methods: A cross-sectional study was carried out among 618 patients who had DM and/or HT. PHQ-9 and WHO-BREF QOL questionnaire were administered to assess depression and health related quality of life respectively. Results: More than 2/3rd of patients had depression. Among those who had depression, nearly half (46%) had moderate depression and 2.1% had severe depression. The proportion of severely depressed patients was higher in diabetes mellitus group compared to the hypertension group. Patients that were depressed had poorer quality of life compared to non-depressed, and the difference was statistically significant. Conclusion: Patients with diabetes mellitus and hypertension may be screened for depression and managed accordingly

A 54-year-old male with diabetic nephropathy and suspected disseminated tuberculosis: Clinicopathologic correlation in a rare diagnosis

Tuberculosis (TB) and Non-Hodgkins lymphoma (NHL) share similar clinical and radiological features, which make diagnosis a challenge. It is often difficult to rule out a diagnosis of extrapulmonary and/or disseminated TB because of its paucibacillary nature and difficulty in accessing the involved organs. In countries with high prevalence of TB like ours, empirical antitubercular treatment (ATT) is started, and the patient is followed up closely for response. We present a rare case of a 54-year old diabetic male who was suspected to be a case of disseminated TB but had a rapid downhill course despite ATT. A postmortem revealed features of a rare, aggressive T-cell NHL masquerading as disseminated TB.

Assessment of implementation status of Cigarettes and Other Tobacco Products Act (COTPA) and its awareness among residents in a block of Haryana

Background: Legislative route is one of the known method to control behaviour of population. Cigarette and Other Tobacco Products Act is one of the laws enacted to control the use of tobacco in India lunched in the year 2003. Objective: The objective of this study was to find compliance of COTPA among tobacco stores and to find the knowledge of people regarding COTPA. Methods: All selected communities were studied by community audit. All stores selling tobacco products were assessed for its compliance to COTPA. Thirty participants from selected communities with in the age range of 18- 65 years were selected and interviewed for knowledge regarding COTPA. Results: A total of 218 stores were found to be selling tobacco. None of the stores were fully compliant to all COTPA clauses. Stores in rural areas were found to be more non-complaint than urban areas. 41% of stores were selling tobacco to minors, 10% were within 100 yards of schools.8% of schools have tobacco advertisement on fa鏰de and 24% displayed tobacco products openly. Around half of the participants (n-552) had heard about COTPA whereas only 4% were aware of all 4 provisions of COTPA. Conclusion: Although more than a decade passed since the law was enacted poor compliance and knowledge was found among participants.

Autopsy findings in an atypical case of occult massive fatal pulmonary embolism in a backdrop of hyperhomocysteinemia

A 43-year-old apparently healthy male presented with fever and presyncope. He was suspected to have massive pulmonary thromboembolism based on the clinico-biochemical profile. Despite aggressive thrombolytic therapy, he succumbed to his illness within 12 h of admission. Postmortem examination showed massive pulmonary thromboembolism and hyperhomocysteinemia with low high-density lipoproteins (HDL) cholesterol with antemortem blood sample. Herein, we report autopsy findings in a rare case of a young male with occult massive pulmonary thromboembolism without deep vein thrombosis, who had an atypical clinical presentation and was found to have underlying hyperhomocysteinemia and decreased HDLc. An acute, massive PE can present a diagnostic challenge due to the rate and severity of decompensation seen in afflicted patients. A high index of suspicion is required for early detection of pulmonary embolism in a young patient with atypical presentation and without obvious risk factors.

Teaching community medicine to medical undergraduates—learning by doing: Our experience of rural posting at All India Institute of Medical Sciences, New Delhi, India.

Background. The goal of medical education is to ensure that the medical graduate has acquired broad public health competencies needed to solve the health problems of the community. We present the current teaching of community medicine to medical students of the All India Institute of Medical Sciences (AIIMS), New Delhi during their 5-week posting at the rural centre at Ballabgarh, Haryana. Methods. The teaching activities consist of field visits to different levels of health facilities and meeting with health workers, epidemiological exercises, a community-based exercise, posting in inpatient and outpatient departments of a secondary hospital, and domiciliary visits to families of patients. These are spread over 80 sessions of about 200 hours. There is very little didactic teaching and the assessment is broad-based. The evaluation of the posting was based on comparison of blinded pre- and post-posting assessments as well as anonymous feedback of the posting by the students. Results. There was a significant increase in the mean scores of all components of the posting—epidemiology (5.1 to 8.4), health systems (6.8 to 9.3) and clinical (8.0 to 10.8). The posting did not result in a better understanding of a public health approach as compared to a clinical approach. The feedback provided by students was generally positive for all activities with 94% of them rating it as good or very good. Conclusion. The teaching of community medicine can be made more practical and interesting without compromising on learning. However, despite such a programme, getting medical students to develop a public health approach is a daunting task.

Utilization of the prevention of parent-to-child transmission of HIV (PPTCT) services in a tertiary care hospital, Odisha, India.

Aims: To assess seroprevalence of HIV among antenatal women and the extent of utilization of interventions to minimize the risk of mother-to-child transmission. Study Design: Descriptive cross-sectional study was carried out among antenatal women who attended integrated counseling and testing center (ICTC) of HIV. Sample sizes were determined from the number of pregnant women that attended ICTC. Place and Duration of Study: Data and samples were collected from a tertiary care hospital, Odisha, India during January 2009 to December 2012. Methodology: All pregnant women were counseled and tested for HIV by rapid test. All HIV-seropositive antenatal women (ANW) were linked to services and followedup for institutional delivery, single-dose nevirapine (sdNVP) prophylaxis, infant feeding options and testing of children at 18 months. Results: Out of 11,508 ANW registered and pretest counseled, 11,390 (98.97%) accepted HIV testing. Sixty women were found to be seropositive, thus showed seroprevalence rate of 0.53% (60/11,390). CD4 testing was carried out in all ANW and five (8.33%) were eligible for antiretroviral therapy (ART). Seven (11.67%) had opted for medical termination of pregnancy (MTP). All 48 ANW delivered institutionally, only 7 (14.58%) received cesarean delivery. Out of 46 live births, 5 (10.87%) ANW were on ART, 35/41 (85.37%) received sdNVP mother baby-pair prophylaxis and only 8/46 (17.39%) mother opted for replacement feeding. Twenty one children have reached 18 months till date and among them three (14.29%) were HIV-seropositive. All three were delivered vaginally, received sdNVP prophylaxis and were exclusively breast fed for 6 months. Conclusion: The HIV-seroprevalence rate among antenatal women was 0.53% and mother-to-child transmission (MTCT) rate was 14.29%. Reduction in MTCT rate needs pre or early antenatal HIV testing, prenatal antiretroviral medication, preference for cesarean delivery, 100% antiretroviral prophylaxis coverage and education on avoidance of breast feeding.

Determinants of Neonatal Mortality in Rural Haryana: A Retrospective Population Based Study.

Objective: To identify the determinants of neonatal mortality. Study design: Nested case-control study. Study setting: 28 villages under the intensive field practice area of Comprehensive Rural Health Services Project, Ballabgarh, Haryana serving a population of 87,016, as on 31st December 2009. The study period was from 2005 to 2009. Methods: The data were obtained from Health Management Information System and analyzed using multivariate logistic regression analysis. A hierarchical approach was used to analyze the factors associated with neonatal deaths, using community level factors, socio-economic status and biological determinants. The population attributable fractions were estimated for significant variables. Results: The total live births during the study period were 10392 and neonatal deaths were 248. The infant and neonatal mortality rates during the study period were 45.6 and 23.8 per 1000 live births, respectively. Socio-economic determinants (Low educational status of parents [OR 2.1, 95% CI; 1.4, 3.3]; father’s occupation [OR 1.8, 95% CI; 1.0, 3.0]; Rajput caste [OR 2.0, 95% CI; 1.2, 3.4] appeared to explain a major fraction (45.7%) of neonatal deaths. Community level factors (villages with no health facility [OR 1.5, 95% CI; 1.0, 2.1]; villages with population >6000 [OR 1.7, 95% CI; 1.2, 2.5]) were associated with 27.3% of all neonatal deaths. Proximate determinants (early childbearing age of mother (<20 years) [OR 2.0, 95% CI; 1.2, 3.2]) were least important. All the three level of variables seemed to act independently with little mediation among them. Conclusion: Neonatal mortality is affected by socioeconomic, community level and proximate biological determinants.

Linking undergraduate medical education to primary health care.

Under graduate medical education aims at producing doctors who are competent in preventive, promotive and curative knowledge and skills. The community medicine curriculum in All India Institute of Medical Sciences, New Delhi has been designed with this objective in view. Students are given community oriented training in urban and rural settings whereby students are taught to carry out various activities under the guidance of faculty members. This curriculum has evolved over many years and provides ample exposure to the students to understand the health problems, and health system of the country especially at the primary and secondary level. There is a sequential teaching of community medicine, which starts from fourth semester through internship. Successful training in community medicine lies outside the walls of the department and the involvement of other partners like the community, health systems etc contribute largely.

Quality assurance of annual HIV sentinel surveillance 2006: experience of regional institute, central zone.

National AIDS Control Organisation (NACO) identified five regional institutes (RIs) to monitor and supervise the 2006 round of annual HIV sentinel surveillance. The task mandated was quality control of both epidemiological data collection and HIV testing. The team at RI consisted of epidemiologist and microbiologist. We describe here the process of quality control and the quality of surveillance in the states of Uttar Pradesh, Uttarakhand, Bihar, Jharkand, and Delhi. The supervisors visited almost 90% of the sentinel sites. Performance of vast majority of the sentinel sites (92%) was satisfactory. The testing laboratories were found to be adhering to standard operating procedures. Concordance rate of test results between testing laboratory and the designated reference laboratory was high. Overall, the quality of sentinel surveillance was good. The lacunae found during the visit have been enumerated along with the recommendations for future surveillance round.

Interaction between warfarin and tamoxifen: a case report.

Warfarin is a commonly used anticoagulant with documented reports of drug interactions. Tamoxifen is used in the adjuvant hormonal treatment of women with oestrogen-receptor- positive breast cancer. Warfarin and tamoxifen are known to interact with each other with a resultant increase in the bleeding tendency. These reports are mainly from the white population. We report a case of drug interaction between warfarin and tamoxifen with an acute onset. This report suggests that when these drugs are co administered, careful monitoring of the coagulation profile is needed.

Systematic and ecological studies on Chlorophyceae of North India and their relationship with water quality.

In the course of systematic and ecological studies on algal flora of fresh water environment of three different agroclimatic zone of Uttar Pradesh revealed one hundred eighty two species represented by fifty-two genera inhabiting fresh water bodies having different physico-chemical properties. In both the regions members of order Conjugales were dominant and represented by ninety nine species belonging to fourteen genera. This is followed by Chlorococcales having fifty two species represented by nineteen genera and Chaetophorales with nine species of four genera only. In the central Uttar Pradesh a positive correlation was found between hydrogen ions concentration with temperature and species diversity, while in western Uttar Pradesh a highly positive correlation was found in electrical conductivity and total dissolved solids.

Fresh water blue green algae from three agro-climatic zones of Uttar Pradesh, India: distribution pattern with seasonal variation.

The paper deals with 45 species of 21 genera of fresh water blue green algae (BGA) from three different agro-climatic zones of Uttar Pradesh. Samples were collected from different habitats varying in physico-chemical properties. Out of 45 species, 13 species belonged to order Chroococcales, 31 to order Nostocales, while only 1 species belonged to order Stigonimatales i.e. Fischerella mucicola. The physico-chemical parameters like pH, temperature, dissolved oxygen, electrical conductivity, nitrate, nitrite and rainfall play an important role in the periodicity of BGA. A positive correlation was found between dissolved oxygen (DO) of different ponds and species diversity, except in the case of western region of Uttar Pradesh (Farukhabad and Mahoba districts) where a positive correlation was found in electrical conductivity and total dissolved solids.

Blue light-sensitive plasma membrane bound exogenous NADH oxidase in Cuscuta reflexa.

Protoplasts isolated from Cuscuta reflexa exhibited a higher rate of exogenous NADH oxidation as compared to NADPH in the dark. NAD(P)H oxidation was monitored by measuring the rate of oxygen consumption and this oxidase system was sensitive to blue light. Both NADH oxidase and its blue light sensitivity were inhibited by -SH group reacting agents. The corresponding changes occurring in H+-extrusion activity and intracellular ATP levels were also monitored. Stimulation of NADH oxidation under blue light corresponded to increased rate of H+-extrusion and intracellular ATP level, the converse was also true under NADH oxidase inhibitory conditions. These observations suggested a close functional association between blue light-sensitive plasma membrane bound redox activity and H+-ATPase in this tissue. Further, concanavalin A binding of protoplasts resulted in a loss in NADH oxidase activity and its blue light sensitivity suggesting apoplastic location and glycoprotein nature of the blue light sensitive NADH oxidase system in Cuscuta.

Trends in poisoning in children: experience at a large referral teaching hospital.

BACKGROUND: Poisoning is a major problem in the paediatric population. The offending substances used vary from place to place. Information on poisoning trends in India is meagre and there is an impression among clinicians that there has been a change in the commonly used poisons over the years. This retrospective study aimed to determine the pattern of poisoning in children and to study the nationwide trend over the past five decades. METHODS: Case records of children (age group: 1 month and above) admitted to the Department of Paediatrics, King George's Medical College, Lucknow, Uttar Pradesh in three alternate calendar years, i.e. 1989, 1991 and 1993 were screened. All children were grouped into three categories based on the poison: (i) bites and stings, (ii) medicinal compounds, and (iii) non-medicinal compounds. The Indian literature on poisoning in children was reviewed and decade-wise data from a total of 22 studies (including the present study) were used to determine the changing trend. RESULTS: Childhood poisoning constituted 2.1% of the total paediatric admissions and 1.2% of total deaths. Non-medicinal compounds were the largest contributors (69.2%), of which kerosene alone was responsible for 47% of cases. Medicinal compounds, and bites and stings accounted for 21.6% and 9.2% of these cases, respectively. The case-fatality rate was 9.2%. Comparison of our data, after excluding bites and stings, with a previous study (1977-79) from our institution showed that kerosene poisoning continues to be responsible for a substantial part of the morbidity (51.8% v. 31.5%). Also, poisoning due to insecticides and pesticides has increased (13.7% v. 2.1%) while that due to plant poisons (primarily dhatura) has reduced markedly (4.8% v. 19.2%). CONCLUSION: Mortality due to poisoning in children has remained high over the last five decades (2.9%-4.7%). Kerosene has remained the single largest contributor to childhood poisoning (51.5% in the 1960s v. 52.8% in the 1990s).

Brainstem auditory evoked response in newborns with hyperbilirubinemia.

OBJECTIVE: To determine the initial Brainstem Auditory Evoked Response (BAER) abnormalities in neonates with hyperbilirubinemia and the possible reversibility of abnormal BAER after therapy. DESIGN: Prospective cohort study. SETTING: Tertiary care hospital. SUBJECTS: 30 term neonates with hyperbilirubinemia (S. bilirubin < 15 mg/dl) as cases and 25 normal term neonates as controls. METHODS: Duration of study was from August 1995 to August 1996. BAER were recorded before therapy at peak hyperbilirubinemia, after therapy, and the age of 2-4 months using electric response audiometer (Nihon Neuropack Four Machine). Denver Development Screening Test (Denver II) was performed at 1 year of age. RESULTS: Seventeen out of thirty (56.7%) neonates with hyperbilirubinemia showed abnormalities on initial BAER. Commonest abnormality seen was raised threshold of wave V in 12 neonates (40%). Other abnormalities observed were absence of all waves at 90 dB (23.3%), prolongation of latencies of various waves (26.7%) and prolongation of various intervals (26.7%). Abnormalities in BAER correlated significantly with bilirubin level. After therapy abnormalities reverted back to normal in 10 cases but persisted in 7 out of 17 (41.17%) cases with initial abnormal BAER. Development screening at 1 yr was abnormal in 3 infants all of whom had persistent abnormalities in BAER. CONCLUSION: Serial BAER is a useful, non invasive tool to detect neurodevelopment delay secondary to neonatal hyperbilirubinemia.

Pseudohypoparathyroidism-Albright hereditary osteodystrophy.

A 13 year old girl with short stature, and retarded mental growth with coarse facies and deranged thyroid function test was initially suspected as a case of hypothyroidism and was started on thyroxine. Lack of response to treatment and on further investigations it was diagnosed as a case of pseudohypoparathyroidism. High index of suspicion and careful evaluation is important to diagnose such an entity.