Improving trauma care in India: a recommendation for the implementation of ATLS training for emergency department medical officers.

BACKGROUND: Trauma is major cause of morbidity and mortality in India. The Advanced Trauma Life Support (ATLS) programme teaches a standardised method for the initial assessment and management of trauma patients, and has been adopted by more than 50 countries worldwide. AIM: We sought to assess the theoretical knowledge of ATLS principles among emergency department (ED) medical officers (MOs) in Salem, Tamil Nadu, India, and from the Royal Adelaide Hospital, Adelaide, South Australia. METHODS: All MOs answered a trauma management quiz based on ATLS-type questions. Quiz scores were compared between senior and junior MO groups for each country, and within each professional group between countries. Categorical data were analysed using chi(2). An alpha value less than 0.05 was deemed to be statistically significant. RESULTS: We discovered significant differences in the theoretical knowledge of ED MOs from Salem compared with colleagues in Adelaide. Our results demonstrated the positive influence of completion of an ATLS programme upon obtaining a passing grade on the trauma quiz. We failed to determine a link between self-rated experience in trauma management and the ability to pass the quiz. CONCLUSIONS: Our study demonstrated the positive influence of completion of an ATLS-type programme on the score obtained on the trauma management quiz. Although previous work has demonstrated mixed results concerning improvement in the care of trauma patients following completion of an ATLS programme, we recommend that such programmes be integrated into the training of Indian ED MOs and suggest that ATLS should be viewed as an integral part of medical training.

Prevalence of HIV infection and high-risk characteristics among leprosy patients of south India; a case-control study.

With the observation of the occurrence of the human immunodeficiency virus (HIV) infection among leprosy patients in our pilot study carried out in Tamil Nadu, South India, a case-control study was planned to explore whether HIV infection is a risk factor for leprosy and to understand the characteristics of HIV infection and high-risk behaviors among leprosy patients. We screened 556 patients and 1004 nonleprosy controls (matching 502 cases for age, sex and area of residence) for HIV-1 and HIV-2 antibodies. They also were interviewed for personal information on history of blood transfusion, intravenous drug abuse, high-risk sexual behavior, and sexually transmitted diseases. Of the 1019 total cases screened (of both pilot and extended studies), 5 were found to be position for HIV antibodies (HIV-1 = 4, HIV-2 = 1); of the 1019 nonleprosy controls, 6 were positive for HIV-1 antibodies. An analysis by odds ratio revealed no association between leprosy and HIV infection (OR = 0.824, 95% CI = 0.201-3.593). A strong association was found only between high-risk behavior and HIV infection (OR = 5.186, 95% CI = 1.717-15.667). However, unmarried, unmarried after 30 years of age, exposure to spouses of the leprosy patients, and a history of surgery were all observed to be significantly more common among leprosy patients than the controls.

Simple predictors to differentiate acute asthma from ARI in children: implications for refining case management in the ARI Control Programme.

There is a considerable overlap in the clinical presentation of acute asthma and ARI. According to the current ARI Control Programme recommendations, a child with cough and rapid breathing is overtreated for ARI (pneumonia) with antibiotics and undertreated for asthma with bronchodilators. The present study, therefore, evaluated simple predictors to differentiate these two conditions to refine the recommended case management. In a case control comparison, children between 6 to 60 months age who presented with cough and rapid breathing due to acute asthma (n = 100) and ARI (n = 100) were evaluated. Only 34% of asthmatics had an audible wheeze. Significant independent predictors on multiple logistic regression analysis were number of earlier similar attacks and fever (or temperature). The best predictor for asthma was two or more earlier similar episodes (sensitivity 84%, specificity 84%) followed by temperature < 37.6 degrees C (sensitivity 73% and specificity 84%). Absence of fever, audible wheeze and a family history of asthma had excellent specificities (98-100%) but low sensitivities (20-34%). It is concluded that simple clinical predictors can differentiate acute asthma and ARI. The recommended case management can, therefore, be refined by either: (i) Prescribing bronchodilators and no antibiotics with two or more earlier similar episodes of cough and rapid breathing; or (ii) To further minimize undertreatment for pneumonia, prescribing bronchodilators as above, but denying antibiotics in such cases only if there is audible wheeze or family history of asthma or no fever.

Indeterminate leprosy: a seroimmunological and histochemical evaluation.

An effort was made to differentiate indeterminate (IND) leprosy from other types of the paucibacillary (PB) group of leprosy and to identify among indeterminate leprosy cases those which may evolve to multibacillary (MB) leprosy, using serological, immunological and histochemical parameters. A total of 92 untreated, histologically classified (TT-19, BT-30, IND-32) patients, including 11 cases diagnosed as nonspecific dermatitis (NSD), which were clinically strongly suspected to be leprotic, were screened for antibodies against PGL-I, 35-kDa and LAM antigens. Lepromin tests and antigen demonstration in tissue by indirect immunoperoxidase staining were also carried out. Though a qualitative analysis did not differentiate, a quantitative analysis in terms of a cumulative index (CI) showed a higher antibody level amongst the indeterminate group of patients than the other groups included in PB leprosy. Also, the lepromin negative indeterminate group patients showed a higher CI than the lepromin positive cases, indicating that perhaps these may be the cases which may develop into MB leprosy. Thus, the semiquantification of antibody levels in the form of a CI may be a useful parameter to predict the possible evolution of a given case of indeterminate leprosy. Interestingly 64% of NSD cases had either antigen or antibody which indicated that they were probably cases of leprosy.

Serological response of leprosy patients to Mycobacterium leprae specific and mycobacteria specific antigens: possibility of using these assays in combinations.

The serological response of 147 leprosy patients to 3 mycobacterial antigens, PGL-I, 35 kDa (Mycobacterium leprae-specific) and LAM (which is a common mycobacterial antigen) were analysed. A stronger serological response was seen amongst the MB patients than the PB patients in all the assays. The 3 antibody levels correlated positively with each other in both MB and PB cases. An overlap of seropositivity was seen between anti-PGL-I and anti-LAM (p > 0.05). A progressive increase in seropositivity and a significant difference of absorbance or titre in antibody levels in all 3 assays over increasing grades of BI were seen in the MB patients (p < 0.05). A significant difference in seropositivity between untreated and treated groups of patients was observed for anti PGL-I (p < 0.05) and antiLAM (p < 0.01) antibodies. The sensitivity, specificity and efficiency of antiPGL-I (50%; 99%; 70%), antiLAM (43%; 95%; 64%) and anti35 kDa (66%; 100%; 80%) assays taken individually were less than that of combinations of antiPGL-I/anti-35 kDa (74%; 99%; 84%) or antiPGL-I/anti-35 kDa/antiLAM (80%; 94%; 86%). The difference in the efficiency of both sets of combination of assays were not statistically significant (p > 0.05).

Use of eluates of filter paper blood spots in ELISA for the serodiagnosis of leprosy.

Blood samples were collected from 59 leprosy patients and 35 normal healthy subjects by veni-puncture and finger prick methods to obtain serum samples and blood spots on filter paper respectively. The serum samples at 1:300 dilutions and the eluates of dried blood spots at 1:40, 1:80, 1:160 and 1:320 dilutions were applied in ELISA to measure the antibody levels (IgM) against synthetic ND-O-BSA antigen. The antibody levels were found to be high in the multibacillary leprosy patients than the pauci-bacillary patients irrespective of whether serum samples or eluates were used. The OD values obtained at 1:160 dilution of the eluates were equivalent to that of values obtained at 1:300 dilution of the serum samples. The positivities differ in different dilution of the eluates, showing the highest in the 1:40 dilution and the lowest in the 1:320 dilution.