Characteristics, therapeutic modalities and outcomes of COVID-19 ventilated patients in a tertiary care hospital in counter-insurgency zone: Our experience.

BACKGROUND: Coronavirus disease 2019 (COVID-19) can result in severe life-threatening course requiring ventilatory support. This study highlights data pertaining to ventilated patients to enhance our understanding of COVID-19 as it evolves. METHODS: A descriptive, retrospective analysis was carried out on 50 COVID-19 RT-PCR positive patients who received mechanical ventilation at a tertiary care hospital in counter-insurgency (CI) zone, from June to December 2020. Data pertaining to patient characteristics, treatment, ventilator support and outcomes was analysed. RESULTS: Out of 50 patients, 74% were aged 50 years and above with 60% patients having comorbidities. 39 patients received non-invasive ventilation (NIV) and 04 patients received invasive mechanical ventilation (IMV) while 07 patients were converted from NIV to IMV during the hospital stay. Out of the 50 patients who received ventilator support 25 (50%) survived to discharge. The overall survival was 47.3% amongst the males while it was 58.3% for the females. The majority of survivors were in the NIV category (61.5%) while only 9.0% survived amongst those who received IMV. Average length of stay on NIV for patients was 5.3 days and for IMV was 7.5 days. All 50 patients received therapy in the form of steroids, anticoagulants, broad spectrum antibiotics and antivirals. Remdesivir was given to 40 of these patients out of which 20 survived (50%). Interleukin-6 therapy (Tocilizumab) was given to five patients of which four survived (80%). CONCLUSION: This study helps us to gain insights into the outcomes of COVID-19 patients managed in a tertiary care hospital in CI zone.

Food safety and quality control: Best practices in the Indian Armed Forces.

The Army Marches on its Stomach". To provide nutritious, wholesome, safe and quality food to the large Indian Armed Forces, spread over various terrains, ranging from the icy Himalayas to the burning deserts of Rajasthan or the humid jungles of the North East and over various platforms like tanks, ships and aircraft is a challenge. The major issue in this is to procure and supply the food while ensuring that it is safe and retains its quality till it is cooked. This vital part of the supply chain viz from farm to the military cook house is the responsibility of the Army Service Corps (ASC) supported by the Army Medical Corps (AMC) and the Remount and Veterinary Corps (RVC). The Food Inspection Organization of the ASC lays down the best practices to be followed in terms of inspection, sampling, analysis, dispatch and issue of both fresh and processed edible foodstuff. The Armed Forces have their own network of Composite Food Laboratories for sampling and analysis of the food items. To ensure superior quality the Defence Food Specifications are much higher than legislated by the Food Standards and Safety Authority of India (FSSAI) for the general public. This paper highlights the best practices followed to ensure food safety and quality control in the Indian Armed Forces.

Chylous ascites and podocytopathy as the presentation of childhood lupus-an unusual occurrence.

Systemic lupus erythematosus (SLE) is an autoimmune disorder that can affect virtually any organ. Chylous ascites as a presenting manifestation of SLE has been described in a handful of cases in adults. However, to the best of our knowledge this presentation has never been reported in the pediatric age group. Podocytopathy in SLE was initially considered to be a chance association. However, more recently it has been suggested that minimal change disease is not only a chance association; it is part of the lupus nephritis spectrum.

Infant and young child feeding practices amongst children referred to the paediatric outpatient department.

BACKGROUND: Worldwide, sub-optimal breastfeeding still accounts for deaths of 1.4 million children aged less than five years. Optimal infant and young child feeding (IYCF) practices have been recognised as the most important intervention for improving child survival and development. Causal association has been found between exclusive breastfeeding with infection-specific infant morbidity and mortality. METHODS: A cross sectional study was undertaken to assess the IYCF practices among 100 caregivers of children aged less than five years, using a semi-structured questionnaire, attending the Paediatric OPD. RESULTS: Children from higher income groups were not given colostrum at birth. 57% mothers started breastfeeding within an hour and 88% of the mothers admitted to have given prelacteal feed. Healthy complementary food was found to be given by most of the mothers. Prevalence of infections was found to be higher (p < 0.05) in children whose birth weight < 2.5 kg and in bottle fed children. CONCLUSION: Traditional beliefs and practices, besides lack of knowledge regarding current feeding recommendations, were found to have played an important role in the feeding practices. Creating an enabling environment for comprehensive nutrition education of mothers by health care providers is required.

Qualitative research in medicine - An art to be nurtured.

To acquire complete knowledge on a subject both qualitative and quantitative research methods need to be perused by researchers. However, over the period of time qualitative research teaching among medical professionals has reduced. Wisdom amongst doctors seems getting muddled in 'data'. Operational research as well as health systems research have been the basis of 'key' policy changes in situations and programmes including polio immunization to achieve desired objectives. Both qualitative and quantitative methods complement each other and cannot replace one another. We need to protect the 'endangered art' of qualitative research before it becomes extinct from medical schools.

Antimicrobial resistance: A public health challenge.

Antimicrobial resistance has become a global concern. Though an evolutionary phenomenon, it is promulgated by faulty human behaviours. It is a growing concern ever since first reported in 1940s. Today, a plethora of newer generation antimicrobials have become ineffective against previously susceptible organisms. This is a huge challenge for health care managers all across the globe, compounded by the "discovery void" in the field of development of new antibiotics. If proper steps are not taken presently, the lurking fear of reaching a therapeutic dead end will become a reality. This paper aims at describing the pandemic of AMR from a public health perspective and suggesting strategies to deal with it in an effective and collaborative manner.

Statins: Can we advocate them for primary prevention of heart disease?

The discovery of cholesterol-lowering agents, namely HMG-CoA reductase inhibitors or statins, ushered in a series of large cholesterol reduction trials. The first of these studies was the Scandinavian Simvastatin Survival Study (4S) in which hypercholesterolemic men with CHD who were treated with simvastatin had a reduction in major coronary events of 44% and a reduction in total mortality of 30%. Many more secondary prevention trials followed to establish unequivocally the benefit of cholesterol reduction. Strategies that aim to improve primary prevention are important for managing the overall burden of disease. Recently therefore, the role of statin in primary prevention is being debated. The JUPITER trial and more recently the Cholesterol Treatment Trialists collaborators, proved that incidences of first major cardiovascular events in apparently healthy individuals were reduced by statins. Statins have also been discussed to be having certain pleiotropic effects on other diseases like diabetes, cancer and osteoporosis. However, issues of cost effectiveness and adverse effects like myositis, and transaminitis still loom large. The medical community needs to debate and evolve a possible consensus on the path breaking subject.

Emerging organisms in a tertiary healthcare set up.

BACKGROUND: One-tenth of all infectious diseases are attributable to emerging organisms. As emerging organisms sporadically affect a relatively small percentage of population they are not studied at large. This study was aimed at studying the characteristics of emerging organisms encountered from various clinical samples in an apex tertiary care multispeciality teaching and research hospital. METHODS: 16,918 positive isolates obtained from 66,323 culture samples processed in the clinical microbiology lab of an apex multispeciality hospital during 2011-2012 were included after a pilot study. Both manual and automated systems were used for identification and antimicrobial susceptibility. The frequency of isolation, sources, referring centers, resistance and susceptibility profiles, phenotypic characteristics and number of reports in PubMed were studied. RESULTS: Out of 16,918 isolates, 13,498 (79.78%) were Gram negative bacteria, 3254 (19.23%) were Gram positive bacteria and 166 (0.98%) were yeasts. A total of 483 (2.85%, 95% CI 2.6%-3.1%) emerging organisms including 116 (0.69%, 95% CI 0.57%-0.81%) emerging species were identified comprising 54 genera. CONCLUSION: Emerging organisms are likely to evade routine identification or be disregarded as non-contributory. Astute efforts directed at identification of emerging isolates, decisions by clinical microbiologists and treating physicians and containment of infection are required.

Bio-threat preparedness: Need for a paradigm shift.

India of late has been vulnerable to Chemical, Biological, Radiological and Nuclear (CBRN) threat, on account of its unique geographic position. Biological threat is an imminent threat in the hands of a terrorist. The public health system of our country is overburdened due to its present role and bio-attack response is not a priority area. This paper suggests that as the prime focus is on the CR and N threats in the integrated CBRN preparedness strategy and that specialized and technical forces are needed to deal with a bio-threat; hence there is a need for a paradigm shift in policy. The emerging field of bio-threat needs to be delinked from the joint family of 'CBRN', with consequent structural and functional changes. A separate specialized cadre needs to be formed for dealing with bio-threat, created from the pool of doctors and non-medical scientists from the AFMS and the DRDO. Structural changes are needed in the organization, to bring in the resources of NCDC, New Delhi for enhanced disease surveillance capacity and creation of a bio-threat mitigation node in the AFMC, Pune.

An epidemiological study of road traffic accident cases admitted in a tertiary care hospital.

BACKGROUND: Road traffic accidents are a leading cause of mortality and morbidity globally. In India, more than a million are injured annually and about a lakh are killed in road traffic accidents.(1) It causes the country to lose around 55,000 crores annually which is 2-3% of Gross Domestic Production (GDP).(2) This cross sectional study was conducted to elucidate the role of various factors involved in road traffic accidents. METHODS: Road traffic accident cases admitted to a tertiary care hospital between 01 Oct 2009 and 28 Feb 2011 were included in the study. A total of 182 patients were studied. Information was collected through questionnaire, hospital records and on-site visit. OPD cases, comatose patients and deaths were excluded. RESULTS: Two-wheelers were the commonest vehicle involved in vehicular accidents. Most accidents happened at a speed of 40-60 km/h (37.9%). Most of the patients were aged between 20 and 30 years. Majority had a driving experience of less than 5 years. Monsoons witnessed 46.7% cases. Most cases occurred between 6 and 10 pm. Among severe injuries, the commonest was lower limb fractures (19.8%). CONCLUSION: There are multiple factors associated with road traffic accidents which due to the lack of road safety measures in the country are playing their role. It is the need of the hour to address this issue and formulate comprehensive, scientific and practical rules and regulations as well as evaluate its enforcement.

Health promotion initiatives: An experience of a Well Women's Clinic.

BACKGROUND: Army Medical Corps provides comprehensive health care services to troops and their dependents. This approach is in consonance with the concept of Health Promoting Hospitals (HPH) initiative introduced by WHO in 1986. However, the concept is still at an infancy stage in civil health care system in India. This article describes the experiences and advantages of establishing a Well Women's Clinic (WWC) in a station of North India. METHODS: A system analysis approach was followed for analyzing input, process and output of the WWC during 2007-2009. Inputs included manpower and material i.e public health expert, non medical attendant and a nursing officer charts, poster, models, Television with Compact Disc (CD) player and CDs etc. Health promotion activities were conducted in the form of lectures, demonstrations, workshops, training, screening of movies, quiz, essay writing and declamation contests etc. RESULTS: Overall 385 lectures, 12 competitions, 07 training capsules were conducted. Coverage of target population was 92%. First aid training workshop trained 300 women. Six percent of the counseled women opted for tubectomy. Twelve new cases of diabetes and four new cases of hypertension were detected through screening. Seventy-two women were referred for dental treatment after a dental screening camp. CONCLUSION: Establishment of WWC using HPH approach was quite cost effective.

Biomedical waste disposal: A systems analysis.

BACKGROUND: In view of the contemporary relevance of BMW Management, a system analysis of BMW management was conducted to ascertain the views of Service hospitals/HCE's on the current system in BMW management in-vogue; to know the composition and quantity of waste generated; to get information on equipment held & equipment required and to explore the possibility of outsourcing, its relevance and feasibility. METHODS: A qualitative study in which various stake holders in BMW management were studied using both primary (Observation, In-depth Interview of Key Personnel, Group Discussions: and user perspective survey) and secondary data. RESULTS: All the stake holders were of the opinion that where ever possible outsourcing should be explored as a viable method of BMW disposal. Waste generated in Colour code Yellow (Cat 1,2,3,5,6) ranged from 64.25 to 27.345 g/day/bed; in Colour code Red (Cat 7) from 19.37 to 10.97 g/day/bed and in Colour code Blue (Cat 4) from 3.295 to 3.82 g/day/bed in type 1 hospitals to type 5 hospitals respectively. CONCLUSION: Outsourcing should be explored as a viable method of BMW disposal, were there are government approved local agencies. Facilities authorized by the Prescribed Authority should be continued and maintained where outsourcing is not feasible.

Understanding the synthesis of DEGVE pulsed plasmas for application to ultra thin biocompatible interfaces.

There is interest in the development of novel surface treatments for biocompatibility and non-fouling behaviors on various surfaces of in vivo devices. Polyethylene glycol thin films have shown promise as non-fouling passivation layers for such devices. Studies of the surface chemistry and non-fouling effectiveness of plasma deposited di(ethylene glycol) vinyl ether (DEGVE) films have observed that non-fouling performance is maximized when plasma deposition occurs at low values of average power, (<5W). [Y.J. Wu, R.B. Timmons, J.S. Jen, Frank E. Molock, Non-fouling surfaces produced by gas phase pulsed plasma polymerization of an ultra low molecular weight ethylene oxide containing monomer, Colloids and Surfaces B: Biointerfaces 18 (2000) 235-248.] Chemical properties of plasma deposited films were directly attributed to the complex interactions occurring within the gas phase. In order to better understand the deposition process, as well as the significance of the conclusions drawn by Wu et al. [Y.J. Wu, R.B. Timmons, J.S. Jen, Frank E. Molock, Non-fouling surfaces produced by gas phase pulsed plasma polymerization of an ultra low molecular weight ethylene oxide containing monomer, Colloids and Surfaces B: Biointerfaces 18 (2000) 235-248.] an investigation of the gas phase behavior in DEGVE pulsed plasma discharges was performed. Infrared spectra were used to characterize the chemical composition and dissociative behavior of DEGVE plasmas across a range of average powers. This allowed for the construction of a dissociative model of the DEGVE monomer in the plasma discharge. Analysis of the observed dissociative pattern demonstrates the presence of key daughter species which would account for the observations made on deposited DEGVE films by Wu et al. [Y.J. Wu, R.B. Timmons, J.S. Jen, Frank E. Molock, Non-fouling surfaces produced by gas phase pulsed plasma polymerization of an ultra low molecular weight ethylene oxide containing monomer, Colloids and Surfaces B: Biointerfaces 18 (2000) 235-248.].

The Highest Battlefield of the World : Medical Problems and Solutions.

The Indian Armed Forces Medical Services has been engaged in providing medical to the soldiers serving on Siachen Glacier for the last 25 years. This paper attempts to highlight the medical problems faced by troops on the world's highest battlefield as perceived by a medical officer located on the forward most medical echelon on Siachen Glacier. The medical problems on the glacier include high altitude pulmonary oedema, acute mountain sickness, frost bite chilblains, hypothermia, snow blindness, injury non enemy action due to avalanches, crevasses and fires, carbon monoxide poisoning and problems in disposal of nightsoil. A large number of problems are taken care of by following a well documented acclimatisation drill. However under such conditions providing medical support is a difficult task and requires innovations and improvisations entailing a high degree of mental mobility on the part of medical commanders and the Regimental Medical Officers located on the forward posts.

Polio Eradication in India: Myth or Reality.

BACKGROUND: Poliomyelitis has been eradicated from large parts of the world. In South East Asian Region, India and Pakistan remain the only countries where active transmission of the disease persists. A decade-long initiative to eradicate the disease is in progress in India. Initial results were encouraging, with the number of fresh polio decreasing till 2001. The year 2002, however, witnessed a setback, with significant rise in cases of poliomyelitis. METHODS AND RESULTS: The eradication measures have been reviewed. The corrective measures appear to be succeeding. Various facets of eradication and their impact are evaluated. CONCLUSION: Poliomyelitis is controlled but the ultimate target of eradication may still be elusive, keeping in mind operational lacunae and vaccine virus characteristics.

Injection induced nerve injury : an iatrogenic tragedy.

11 patients with injection induced nerve injury were evaluated. There were 9 adults and 2 children, 8 had radial nerve injury and 3 sciatic nerve injury. 6 had evidence of severe involvement with active denervation. Nature of the drug was not known in 81%, thus faulty site of injection was the most important factor responsible. The need to discourage indiscriminate use of intramuscular injections and choice of a proper site of selection is stressed.

Herpes Gestationis (pemphigoid Gestationis).

Three patients of herpes gestationis, a rare dermatosis of pregnancy, are being described along with a short review of literaure on the recent immunological backdrop. The characteristic periumbilical cutaneous lesions with classical buflae en cocade appeared during the third trimester of pregnancy and were controlled with corticosteroids. Classical histopathological basal cell necrosis in all the three patients and C3 deposition on dermo-epidermal interface in two patients were demonstrated. Post partum exacerbation was noted in all the three patients. Re occurred after 13 weeks in one patient, the rest did not report for follow up.