Dr. Somervell Memorial CSI Medical College and Hospital

One of the characteristics that distinguish anticancer agents from other drugs is the frequency and severity of side effects at therapeutic doses. Most cytotoxic drugs target rapidly multiplying cells and the putative targets are the nucleic acids and their precursors, which are rapidly synthesised during cell division. Many solid tumours have a lower growth fraction than the normal bone marrow, gastro intestinal lining, reticuloendothelial system and gonads. Drugs affect these tissues in a dose dependant manner and there is individual susceptibility also. So toxicities are more frequently associated with these tissues. The side effects may be acute or chronic, self-limited, permanent, mild or potentially life threatening. Management of these side effects is of utmost importance because they affect the treatment, tolerability and overall quality of life. This paper gives an overview of different toxicities of anticancer drugs and its management.

OBJECTIVE: To evaluate the presentation, management, and outcomes of patients hospitalized for heart failure (HF) in Trivandrum, India. METHODS: The Trivandrum Heart Failure Registry (THFR) enrolled consecutive admissions from 13 urban and five rural hospitals in Trivandrum with a primary diagnosis of HF from January to December 2013. Clinical characteristics at presentation, treatment, in-hospital outcomes, and 90-day mortality data were collected. 'Guideline-based' medical treatment was defined as the combination of beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and aldosterone receptor blockers in patients with left ventricular systolic dysfunction (LVSD). RESULTS: We enrolled 1205 cases (834 men, 69%) into the registry. Mean (standard deviation) age was 61.2 (13.7) years. The most common HF aetiology was ischaemic heart disease (IHD) (72%). Heart failure with preserved ejection fraction (≥45%) constituted 26% of the population. The median hospital stay was 6 days (interquartile range = 4-9 days) with an in-hospital mortality rate of 8.5% (95% confidence interval 6.9-10.0). The 90-day all-cause mortality rate was 2.43 deaths per 1000 person-days (95% confidence interval 2.11-2.78). Guideline-based medical treatment was given to 19% and 25% of patients with LVSD during hospital admission and at discharge, respectively. Older age, lower education, poor ejection fraction, higher serum creatinine, New York Heart Association functional class IV, and suboptimal medical treatment were associated with higher risk of 90-day mortality. CONCLUSION: Patients hospitalized with HF in the THFR were younger, more likely to be men, had a higher prevalence of IHD, reported longer length of hospital stay, and higher mortality compared with published data from other registries. We also identified key areas for improving hospital-based HF medical care in Trivandrum.

Microteaching, a teacher training technique currently practiced worldwide, provides teachers an opportunity to perk up their teaching skills by improving the various simple tasks called teaching skills. With the proven success among the novice and seniors, microteaching helps to promote real-time teaching experiences. The core skills of microteaching such as presentation and reinforcement skills help the novice teachers to learn the art of teaching at ease and to the maximum extent. The impact of this technique has been widely seen in various forms of education such as health sciences, life sciences, and other areas. The emerging changes in medical curricula by the Medical Council of India and the role of medical teachers envisage the need of this special training of teachers and monitoring of their skills for their continued efficient performance at any age. The alleged limitations of microteaching can be minimized by implementing this at the departmental level in several sequences. The author made literature search of research and review articles in various educational databases, journals, and books. From the reference list of published articles, books were also reviewed. This paper presents an outline of the various phases of microteaching, core teaching skills, implementation aspects, and the impact of microteaching on medical education.

Al 6061 alloy is widely used for commercial applications in the transportation, construction and similar engineering industries. It possesses excellent mechanical properties in addition to good corrosion resistance due to which the alloy finds extensive application in naval vessels manufacturing. Al-TiB 2 composite is a metal matrix composite (MMC) that can be manufactured using the in-situ salt-metal reaction. With TiB 2 as the particulate addition the properties of Al 6061 alloy can be greatly improved. A comparison of the mechanical properties and the microstructure of Al 6061 alloy with Al-TiB 2 metal matrix composite containing 12% by weight TiB 2 p manufactured through the in-situ process was presented.

OBJECTIVE: To evaluate the performance of the non-laboratory INTERHEART risk score (NL-IHRS) to predict incident cardiovascular disease (CVD) across seven major geographic regions of the world. The secondary objective was to evaluate the performance of the fasting cholesterol-based IHRS (FC-IHRS). METHODS: Using measures of discrimination and calibration, we tested the performance of the NL-IHRS (n=100 475) and FC-IHRS (n=107 863) for predicting incident CVD in a community-based, prospective study across seven geographic regions: South Asia, China, Southeast Asia, Middle East, Europe/North America, South America and Africa. CVD was defined as the composite of cardiovascular death, myocardial infarction, stroke, heart failure or coronary revascularisation. RESULTS: Mean age of the study population was 50.53 (SD 9.79) years and mean follow-up was 4.89 (SD 2.24) years. The NL-IHRS had moderate to good discrimination for incident CVD across geographic regions (concordance statistic (C-statistic) ranging from 0.64 to 0.74), although recalibration was necessary in all regions, which improved its performance in the overall cohort (increase in C-statistic from 0.69 to 0.72, p<0.001). Regional recalibration was also necessary for the FC-IHRS, which also improved its overall discrimination (increase in C-statistic from 0.71 to 0.74, p<0.001). In 85 078 participants with complete data for both scores, discrimination was only modestly better with the FC-IHRS compared with the NL-IHRS (0.74 vs 0.73, p<0.001). CONCLUSIONS: External validations of the NL-IHRS and FC-IHRS suggest that regionally recalibrated versions of both can be useful for estimating CVD risk across a diverse range of community-based populations. CVD prediction using a non-laboratory score can provide similar accuracy to laboratory-based methods.

OBJECTIVES: This study examines in a cross-sectional study 'the tobacco control environment' including tobacco policy implementation and its association with quit ratio. SETTING: 545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014. PARTICIPANTS: Community audits and surveys of adults (35-70 years, n=12 953). PRIMARY AND SECONDARY OUTCOME MEASURES: Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models. RESULTS: Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1). CONCLUSIONS: This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.

OBJECTIVE: To compare and contrast three models of community mental health services in low-income settings. DATA SOURCES/STUDY SETTING: Primary and secondary data collected before, during, and after site visits to mental health programs in Nigeria, the Philippines, and India. STUDY DESIGN: Qualitative case study methodology. DATA COLLECTION: Data were collected through interviews and observations during site visits to the programs, as well as from reviews of documentary evidence. PRINCIPAL FINDINGS: A set of narrative topics and program indicators were used to compare and contrast three community mental health programs in low-income countries. This allowed us to identify a diversity of service delivery models, common challenges, and the strengths and weaknesses of each program. More definitive evaluations will require the establishment of data collection methods and information systems that provide data about the clinical and social outcomes of clients, as well as their use of services. CONCLUSIONS: Community mental health programs in low-income countries face a number of challenges. Using a case study methodology developed for this purpose, it is possible to compare programs and begin to assess the effectiveness of diverse service delivery models.

BACKGROUND: The Indian Scale for Assessment of Autism (ISAA) was developed to assess the severity of autism among Indian cases. AIMS: The present study evaluated the ISAA in relation to the Childhood Autism Rating Scale (CARS) and the Developmental Disability- Children Global Assessment Scale (DD-CGAS). MATERIALS AND METHODS: Indian children with ICD 10 diagnoses of Autistic disorder (AD, n = 50), Intellectual Disability (ID, n = 50), Attention Deficit Hyperactivity Disorder (ADHD, n = 26), other psychiatric disorders (PD-N=25) and control children without psychiatric disorders (n = 65) were evaluated using the ISAA, DD-CGAS and the CARS (total n = 216). STATISTICAL ANALYSES: In addition to descriptive statistics and correlation, analysis of variance (ANOVA) was used to assess whether the ISAA scores were significantly different across diagnostic groups. RESULTS: Total ISAA scores were significantly higher among children diagnosed with autistic disorder compared to four other diagnostic groups. Total ISAA scores were significantly correlated with CARS scores and DD-CGAS scores. Groups sub-divided on the basis of recommended ISAA cutoff points of severity showed significant differences in CARS scores. CONCLUSION: The ISAA can thus be used to assess severity of AD among Indian children.

BACKGROUND: Motorcycles account for a large proportion of road traffic accidents in India and the riders of these vehicles run a high risk of injuries or death. This study aims to explore the determinants of helmet use among motorcyclists in Kerala, India. METHODS: A cross-sectional study conducted in Kerala, India, over a period of six months. 309 motorcyclists in Kerala were interviewed for this study using a pretested structured questionnaire. RESULTS: Among 309 motorcyclists, 80% were less than 40 years of age, and only 24% were females. Among the total, only 31.4% used a helmet. There was a statistically significant association between the use of helmet and gender, marital status, drunken driving, use of alcohol and attitude towards implementing legislative measures. Odds Ratios observed were 5.3 for female gender compared to male, 4.5 for those with a positive attitude towards the implementation of legislative measures on helmet use, 3.7 for those who were not drunk while driving and 2.3 for unmarried compared to married persons. CONCLUSIONS: The study concludes that the determinants associated with the practice of helmet use were gender, drunken driving, marital status and positive attitude towards legal measures. ‎

BACKGROUND: Antenatal depression is a highly prevalent disorder with serious implications on maternal and child outcomes. There are few studies examining this in low-middle-income community settings. AIMS: To determine the prevalence of antenatal depression in women from a coastal rural background in Kerala and Tamil Nadu and to determine its associated factors. MATERIALS AND METHODS: In this cross-sectional community-based study, in 202 antenatal women, standard interview and diagnostic criteria (Clinical Interview Schedule-Revised (CIS-R)) were employed for identifying depression and examining a wide range of putative clinical and sociocultural risk factors including domestic violence. RESULTS: There was a 16.3% prevalence of depression among the 202 women sampled. The possible risk factors after stepwise backward regression were pressure to have a male child, 11.48 (2.36-55.78); financial difficulties, 8.23 (2.49-27.22); non-arranged marriage, 6.05 (1.72-21.23); history of miscarriage-still birth, 5.77 (1.55-21.43) and marital conflict, 9.55 (2.34-38.98). CONCLUSION: There is a need to develop strategies for recognition and appropriate intervention for antenatal depression, in the context of locally relevant risk factors, so as to improve both maternal and child outcomes.

After only Alzheimer's disease (AD), Parkinson's disease (PD) is the second most prevalent neurodegenerative disease. The incidence of this disease increases with age, especially for those above 70 years old. There are many risk factors that are well-established in the contribution to the development of PD, such as age, gender, ethnicity, rapid eye movement sleep disorder, high consumption of dairy products, traumatic brain injury, genetics, and pesticides/herbicides. Interestingly, smoking, consumption of caffeine, and physical activities are the protective factors of PD. A deficiency of dopamine in the substantia nigra of the brainstem is the main pathology. This, subsequently, alters the neurotransmitter, causing an imbalance between excitatory and inhibitory signals. In addition, genetics is also involved in the pathogenesis of the disease. As a result, patients exhibit characteristic motor symptoms such as tremors, stiffness, bradykinesia, and postural instability, along with non-motor symptoms, including dementia, urinary incontinence, sleeping disturbances, and orthostatic hypotension. PD may resemble other diseases; therefore, it is important to pay attention to the diagnosis criteria. Parkinson's disease dementia can share common features with AD; this can include behavioral as well as psychiatric symptoms, in addition to the pathology being protein aggregate accumulation in the brain. For PD management, the administration of pharmacological treatment depends on the motor symptoms experienced by the patients. Non-pharmacological treatment plays a role as adjuvant therapy, while surgical management is indicated in chronic cases. This paper aims to review the etiology, risk factors, protective factors, pathophysiology, signs and symptoms, associated conditions, and management of PD.

Abstract Using dimethyl peroxide as a thermal source of methoxy radicals overthe temperature range of 110–160°C, and the combination of methoxy radicals and nitrogen dioxide as a reference reaction: equation image a value was determined of the rate constant for the reaction of methoxy radicals with oxygen: equation image is independent of nitrogen dioxide or oxygen concentration and added inert gas (carbon tetrafluoride). No heterogeneous effects were detected. The value of k 4 is given by the expression In terms of atmospheric chemistry, this corresponds to a value of 10 5.6 M −1 ·sec −1 at 298 K. Extrapolation to temperatures where the combustion of organic compounds has been studied (813 K) produces a value of 10 7.7 M −1 ·sec −1 for k 4 . Under these conditions, reaction (4) competes with hydrogen abstraction or disproportionation reactions of the methoxy radical and its decomposition (3): equation image In particular k 3 is in the falloff region under these conditions. It is concluded that reaction (4) takes place as the result of a bimolecular collision process rather than via the formation of a cyclic complex.

Context: Antibiotic prescribing by physicians has gained due importance across the globe, mainly because of an increase in antibiotic usage, prevalence of infections, and drug resistances. Aims: The present study aimed to evaluate the prescribing pattern of antibiotics, their adherence to essential medicines list, disease conditions for which they were prescribed, and their adverse effects. Settings and Design: A cross-sectional prospective study was carried out in six inpatients departments (Surgery, Orthopedics, ENT, Ophthalmology, Medicine, and Pediatrics) of a 550-bed tertiary care hospital in Trivandrum, India for two months (July-August 2012). Institutional Research and Ethics Committee clearance were obtained prior to the study. Materials and Methods: The data were collected in a predesigned performa from the medical case sheets, drug charts, and laboratory investigations of 100 in-patients. The enrolled patients were observed from admission till discharge. Descriptive statistics were applied to the collected data and analyzed using Microsoft Excel software. Results: The mean duration of hospitalization among the study population was 5.48 (±4.28) days. Of the 410 medicines prescribed, antibiotics contributed 151 (36.8%). They were mostly indicated for respiratory infections, and the most common antibiotic was Beta-lactams (91 (60.2%). Interestingly, 89 antibiotics (60%) were administered as injections. About 70 (46%) of the antibiotics were prescribed without any combinations. The adherences to World Health Organization′s essential medicines list were 122 (81%). A total of seven adverse drug reactions were reported in the current study. Of which, none were serious, and five (70%) were cutaneous reactions. Conclusions: Of the 100 patients analyzed from six in-patient departments, it was observed that the hospital physicians prescribed antibiotics more rationally with no banned drugs and less newer drugs. Rational prescribing of antibiotics would help avoid polypharmacy and prevent drug resistances.

OBJECTIVE: To examine and compare tobacco marketing in 16 countries while the Framework Convention on Tobacco Control requires parties to implement a comprehensive ban on such marketing. METHODS: Between 2009 and 2012, a kilometre-long walk was completed by trained investigators in 462 communities across 16 countries to collect data on tobacco marketing. We interviewed community members about their exposure to traditional and non-traditional marketing in the previous six months. To examine differences in marketing between urban and rural communities and between high-, middle- and low-income countries, we used multilevel regression models controlling for potential confounders. FINDINGS: Compared with high-income countries, the number of tobacco advertisements observed was 81 times higher in low-income countries (incidence rate ratio, IRR: 80.98; 95% confidence interval, CI: 4.15-1578.42) and the number of tobacco outlets was 2.5 times higher in both low- and lower-middle-income countries (IRR: 2.58; 95% CI: 1.17-5.67 and IRR: 2.52; CI: 1.23-5.17, respectively). Of the 11,842 interviewees, 1184 (10%) reported seeing at least five types of tobacco marketing. Self-reported exposure to at least one type of traditional marketing was 10 times higher in low-income countries than in high-income countries (odds ratio, OR: 9.77; 95% CI: 1.24-76.77). For almost all measures, marketing exposure was significantly lower in the rural communities than in the urban communities. CONCLUSION: Despite global legislation to limit tobacco marketing, it appears ubiquitous. The frequency and type of tobacco marketing varies on the national level by income group and by community type, appearing to be greatest in low-income countries and urban communities.

Magnesium phosphate (MgP) is a family of newly developed resorbable bioceramics for bone tissue engineering. Although calcium phosphates (CaP) are the most commonly used bioceramics, low solubility, and slow degradation, when implanted in vivo, are their main drawbacks. Magnesium (Mg) is an essential element in the human body as it plays important role in bone metabolism, DNA stabilization, and skeletal development. Recent research on magnesium phosphates has established their higher degradability, in vitro, and in vivo biocompatibility. Compared to CaP, very limited research work has been found in the area of MgP. The prime goal of this review is to bring out the importance of magnesium phosphate ceramics for biomedical applications. In this review, we have discussed the synthesis methods, mechanical properties, in vitro and in vivo biocompatibility of MgP bioceramics. Moreover, we have highlighted the recent developments in metal ion-doped MgPs and MgP scaffolds for bone tissue engineering.

A sixty year old patient presented with a slowly progressive swelling of the nose, of one year duration, suggesting a clinical diagnosis of subcutaneous zygomycosis. On investigation, the tissue fungal culture grew Conidiobolus coronatus, confirming the diagnosis as rhinoentomophthoromycosis. He was treated with a combination of oral fluconazole and oral potassium iodide for a total period of 5 months. His symptoms subsided completely. Serial CT scanning of paranasal sinuses showed the gradual resolution of the swelling, in response to the treatment. Early detection of the disease and combination therapy gave rapid and good results. This is the first case of its kind to be reported from Kerala, the southern state of India.

Treatment of melasma is known to be less satisfactory, often incomplete, and relapse is frequent. Although many treatment options are available, they are either known to be unsafe on long-term use or their long-term safety profile is unknown. Patients often use various drugs, even topical steroid-based preparation without any medical supervision for long period of time, making the skin unsuitable for many of the drugs available. Thus, there has been gross disparity among the treating physician about what drugs and what regimen are best suitable for various categories of melasma patients and in different situations. With this background, numerous newer drugs, mostly combinations of some proprietary molecules or even unknown plant extracts, have flooded the market for the management of melasma. Information on efficacy or safety of these products are almost unknown. Studies on Asian people, especially Indian population, are far less commonly available. Therapeutic guideline for use on Indian patients with melasma is almost missing. Extrapolation of data from Caucasian people for use on Asian people may not be scientifically justifiable because Caucasian and Asian people are known to have inherent difference in their response as well as tolerance to the drugs used for melasma. With this background, we have extensively evaluated, following a strict, scientifically designed protocol, all the available studies on melasma management till May 2016 and prepared this document on level of evidence, grade of recommendation and suggested therapeutic guideline for melasma as per the method proposed by Oxford Centre of Evidence-Based Medicine. Various ethical, social, logical, regional, and economic issues in the context of Indian and similar populations were given due importance while preparing the suggested therapeutic recommendation.

BACKGROUND: Bidis are minimally regulated, inexpensive, hand-rolled tobacco products smoked in south Asia. We examined the effects of bidi smoking on baseline respiratory impairment, and prospectively collected data for all-cause mortality and cardiorespiratory events in men from this region. METHODS: This substudy of the international, community-based Prospective Urban Rural Epidemiology (PURE) study was done in seven centres in India, Pakistan, and Bangladesh. Men aged 35-70 years completed spirometry testing and standardised questionnaires at baseline and were followed up yearly. We used multilevel regression to compare cross-sectional baseline cardiorespiratory symptoms, spirometry measurements, and follow-up events (all-cause mortality, cardiovascular events, respiratory events) adjusted for socioeconomic status and baseline risk factors between non-smokers, light smokers of bidis or cigarettes (≤10 pack-years), heavy smokers of cigarettes only (>10 pack-years), and heavy smokers of bidis (>10 pack-years). FINDINGS: /forced vital capacity (FVC) ratio were larger for heavy bidi smokers than for the other smoking categories. Hazard ratios (relative to non-smokers) showed increasing hazards for all-cause mortality (light smokers 1·28 [95% CI 1·02-1·62], heavy cigarette smokers 1·59 [1·13-2·24], heavy bidi smokers 1·56 [1·22-1·98]), cardiovascular events (1·45 [1·13-1·84], 1·47 [1·05-2·06], 1·55 [1·17-2·06], respectively) and respiratory events (1·30 [0·91-1·85], 1·21 [0·70-2·07], 1·73 [1·23-2·45], respectively) across the smoking categories. INTERPRETATION: Bidi smoking is associated with severe baseline respiratory impairment, all-cause mortality, and cardiorespiratory outcomes. Stricter controls and regulation of bidis are needed to reduce the tobacco-related disease burden in south Asia. FUNDING: Population Health Research Institute, Canadian Institutes of Health Research, and Heart and Stroke Foundation of Ontario.

BACKGROUND: The prevalence of gestational diabetes is on the rise. Understanding the various outcomes of it is necessary to face this challenge. OBJECTIVES: To study the frequency of occurrence of various maternal and fetal outcomes among gestational diabetes patients. METHODS: This is a retrospective cohort study conducted in rural Kerala, a southern state of India. The study participants were followed up for a period of 4 years, from 2007 to 2011. The participants included 60 women with gestational diabetes and 120 women without gestational diabetes. Gestational diabetes was the major exposure variable. The frequencies of various outcomes were computed. Multivariable logistic regression was done to compute the risk for various outcomes in gestational diabetes. RESULTS: The major outcomes included termination of pregnancy by caesarean section, long-term progression to type 2 diabetes, in-born nursery (IBN) admissions and increased neonatal birth weight. The maximum adjusted RR [13.2 (1.5-116.03)] was for the development of type 2 DM later. CONCLUSION: Gestational diabetes can result in significant feto-maternal outcomes; so better facilities are needed to manage gestational diabetes.

Obesity in recent years has become an epidemic. A high body mass index (BMI) is one of today's most crucial population health indicators. BMI does not directly quantify body fat but correlates well with easier body fat measurements. Like smoking, obesity impacts multiple organ systems and is a major modifiable risk factor for countless diseases. Despite this, reports have emerged that obesity positively impacts the prognosis of patients with chronic illnesses such as chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD), a phenomenon known as the Obesity Paradox. This article attempts to explain and summarize this phenomenon. As it stands, two theories explain this paradox. The muscle mass hypothesis states that obese patients are better adapted to tide through acute exacerbations due to increased reserve because of greater muscle mass. The other theory focuses on brown adipose tissue and its anti-inflammatory effects on the body. We performed a literature review on research articles published in English from 1983 to the present in the following databases - PubMed, Elsevier, and Google Scholar. The following search strings and Medical Subject Headings (MeSH) terms were used: "Obesity," "Heart Failure," "COPD," and "Cardio-Respiratory Fitness." In this review, we looked at the obesity paradox in Heart Failure and COPD. We summarized the current literature on the Obesity Paradox and reviewed its relationship with Cardio-Respiratory Fitness.