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Background: The present study aims at comparing efficacy and safety of two different regimens of induction of labour (IOL) in pregnancies with fetal demise. Settings and Design: A randomised controlled trial was conducted on 100 eligible pregnant women diagnosed with intrauterine fetal demise who were admitted in the labour ward of a tertiary care hospital. Methods: All participants were randomly divided into two groups in group A and group B. In Group A, IOL was done with transcervical foley’s catheter and vaginal misoprostol while in group B, mifepristone with vaginal misoprostol were used for IOL. During intrapartum period the mode of delivery, induction-delivery interval, total dose of induction agent used and amount of total blood loss were noted. Any side effect if present was also noted. Results: Comparing both the groups, Induction delivery interval was less in group A as compared to group B. Conclusions: Use of mifepristone with misoprostol as well as Foley’s with misoprostol were found to be equally safe and effective methods.

Background: Adverse childhood experience (ACE) has cumulative consequences on physical, mental and social wellbeing. The impact of ACEs is amplified by stressors, such as academic, physical, social and emotional stressors, which medical students are constantly exposed to. Aim and Objective: This study is aimed at determining the association between adverse childhood experiences and adult psychosocial wellbeing and mediating role of selfesteem among preclinical medical students.Participants and setting:A total of 138 undergraduate medical students at C.U. Shah medical college and hospital, Surendranagar participated in the study. Methods: Participants completed online google forms having socio-demographic, an Adverse Childhood Experience, the World Health Organization's Quality of Life (WHOQOL-BREF) and the Rosenberg's self-esteem questionnaires. Data obtained were analysed using SPSS.Descriptive and inferential statistical analyses were performed. Results:At least one out of ten categories of ACEs were reported by 39.8% of respondents;physical abuse (19.1%),emotional abuse (18.2%),parental divorce (9.4%) and sexual abuse (9.0%). There was a significant association between adverse childhood experiences and adult psychosocial wellbeing (p

Both diabetes and obesity can affect the brain, yet their impact is not well characterized in children with type 2 (T2) diabetes and obesity. This pilot study aims to explore differences in brain function and cognition in adolescents with T2 diabetes and obesity and nondiabetic controls with obesity and lean controls.Participants were 12-17 years old (5 T2 diabetes with obesity [mean HgbA1C 10.9%], 6 nondiabetic controls with obesity and 10 lean controls). Functional MRI (FMRI) during hyperglycemic/euglycemic clamps was performed in the T2 diabetes group.When children with obesity, with and without diabetes, were grouped (mean BMI 98.8%), cognitive scores were lower than lean controls (BMI 58.4%) on verbal, full scale, and performance IQ, visual-spatial and executive function tests. Lower scores correlated with adiposity and insulin resistance but not HgbA1C. No significant brain activation differences during task based and resting state FMRI were noted between children with obesity (with or without diabetes) and lean controls, but a notable effect size for the visual-spatial working memory task and resting state was observed.In conclusion, our pilot study suggests that obesity, insulin resistance, and dysglycemia may contribute to relatively poorer cognitive function in adolescents with T2 diabetes and obesity. Further studies with larger sample size are needed to assess if cognitive decline in children with obesity, with and without T2 diabetes, can be prevented or reversed.

Objective:To analyze the opinion of Indian clinical experts on the current usage patterns of vildagliptin in the treatment of patients with type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). Methods:This report summarizes opinions and discussions that occurred during the 36 virtual round table meetings (May 2021 - March 2022) involving 540 healthcare practitioners (HCPs) across India. The collected data were analyzed and categorized into four grades: Level A, very strong (≥80% responses); Level B, strong (≥50-79% responses); Level C, moderate (25-49% responses); Level D, neutral/no consensus ( Results:Healthcare practitioners gave opinions for the following; Level A (90.9%): time-in-range (TIR) and glycemic variability are important clinical criteria for selecting antidiabetic therapy in patients with risks of macrovascular complications; Level B (70.8%): vildagliptin gives better TIR and less glycemic variability compared to other dipeptidyl peptidase-4 inhibitors; Level A (90.9%): addition of vildagliptin should be considered in patients with T2DM and established atherosclerotic CVD who have uncontrolled glycemia with metformin plus sodium-glucose cotransporter-2 inhibitors treatment; Level B (52.9%): Vildagliptin should be considered as a part of the treatment algorithm only when the patient population is elderly, with long-standing diabetes, newly diagnosed T2DM with prior CVD, patients with obesity, or renal impairment. The majority of HCPs reported clinical benefits including a reduction in the dose of insulin (52.4%) and the number of hypoglycemic incidences (33.3%) with vildagliptin plus insulin. Conclusion:Indian clinical experts recommended the safe and neutral use of vildagliptin in patients with T2DM and CV risk and/or CVD.

Background and purpose Gadolinium-based contrast agents (GBCAs) have been administered clinically since 1988. They are remarkably well tolerated by children and result in dose-dependent tissue deposition, even in patients with normal renal function. No adverse effects of gadolinium deposition in patients with normal renal function have been established. Given the uncertain effects of gadolinium deposition, we sought to analyze gadolinium use in the imaging follow-up of nonenhancing primary brain neoplasms in children. Materials and methods This retrospective, institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study evaluated pediatric patients who received GBCA in the routine evaluation of brain neoplasms. This special subset included 30 patients (18 years old) with initially nonenhancing primary intracranial neoplasms who received treatment and follow-up at our institution. Patient data included sex, age from diagnosis to most recent imaging follow-up, number of contrast-enhanced magnetic resonance imaging (MRI) follow-up exams, and histopathology from a biopsy or resection. Results The group had an expected variety of tumors, including low-grade astrocytomas, dysembryoplastic neuroepithelial tumors, oligodendrogliomas, and teratomas. Half of our patients had tumors of unknown histopathology that were not biopsied or resected. The median age at diagnosis was 8.9 years, the median of four follow-up MRIs per patient, and the median follow-up time of four years. Only one of the 30 patients developed an enhancing focus on follow-up MRI that remained stable and asymptomatic over two years and did not require surgical intervention. Conclusion Judicious use of GBCA in children, especially when numerous exams over many years are anticipated, is advised given the data regarding soft-tissue deposition. Preliminary results suggest that it may be feasible to omit GBCA from routine follow-ups of initially nonenhancing brain neoplasms.

Objective To evaluate an enhanced physical health clinic led by physician associates (PAs) for patients with severe mental illness. Methods A guidance and data collection tool was developed to support and document the outcomes of the PA-led enhanced physical health clinic. Results The clinic led to diagnoses of diabetes, hyperlipidemia, and hematologic abnormalities. One patient was started on metformin, two patients started a prediabetes program with their general practitioner, one patient started simvastatin, one patient switched from cigarettes to e-cigarettes, and one patient switched from olanzapine to aripiprazole because of metabolic adverse reactions. Three patients intended to contact the National Health Service for cancer screening for which they were eligible but they had not taken up. Conclusions PAs can be integrated into a community mental health multidisciplinary team and support the physical health of people with severe mental illness. Mental health trusts should consider roles for PAs in their workforce planning.

This research examines the impact of COVID-19 on Indian tourism and hospitality students’ perception of career opportunities and future prospects. Our findings indicate that perceived industry imag...

Agritourism has gained traction with a variety of stakeholders within the Pacific to supplement farm revenue, create linkages to tourism and ultimately contribute to sustainable economic development. This paper, with a focus on smallholders, examines the key constraints of agriculture, current agritourism products, policy development initiatives, and proposes an open framework for agritourism in Fiji. Among the key considerations are a careful examination of tourist preferences, the promotion of agritourism on working farms without displacing the key activity of food production, and redefining agritourism as a value for money experience rather than a niche market in the Pacific region.

PurposeThis study aims to analyse the factors that caused Indian tourists to avoid travelling abroad because of the recent outbreak of COVID-19 in 2020. It will also identify the relationship between the perceived risk of travelling and the probability of travel evading in India owing to COVID-19.Design/methodology/approachThis study used an online structured questionnaire to collect data from Indian tourists to study six independent variables linked with their behavioural intentions (travel evading). The health belief model was used to examine tourist behaviour.FindingsThe results revealed a positive correlation between the perceived risk associated with COVID-19 and travel avoidance. Familiarity with COVID-19 was positively correlated with travel evading behaviours.Practical implicationsThis study will assist stakeholders from around the world to adequately identify and thoroughly plan for logistical problems associated with travel such as travel insurance and pre-travel booking expenses to reduce travel evading behaviour and promote travel.Originality/valueWhile a few studies have been conducted related to pandemics (Ebola, MERS-CoV, SARS), there is a paucity of literature that examines the factors which influence tourists’ travel evading behaviour owing to COVID-19. Moreover, most of the previous literature on pandemics is concentrated on American and European countries, whereas studies on the Indian sub-continent are very scarce. This study will fill this gap and will identify the factors which influence tourists in India to evade travel in response to COVID-19.

This research analyses tourist’s characteristics and accommodation choice in Nainital, a renowned British-era hill station in India. Questionnaires were administered to a convenience sample of 200 ...

This research aimed to interpret motivations of tourists for agritourism in Fiji. Data was collected through a paper-based face to face survey. Structured questionnaires were administered to a conv...

Hypospadias is a rare birth deformity characterised by shortening of urethra with dorsal ectopia of the urethral meatus. The occurrence of hypospadias in female patients is extremely rare. We present a young female complaining of recurrent urinary tract infection and voiding difficulty caused by hypospadias.

We present a case of a pediatric patient with congenital unfused anterior and posterior arches of the atlas (C1), also known as bipartite atlas, who sustained a traumatic injury during gymnastics. A computed tomography (CT) scan of the cervical spine raised concern for abnormal separation of the midline cleft of the anterior arch of C1. Subsequent magnetic resonance imaging (MRI) showed focal, edema-like signal in the midline cleft of C1. She was advised by neurosurgery to remain in a hard cervical collar for 6 weeks. She recovered after conservative treatment and returned to gymnastics. This case shows that a congenital unfused anterior arch of the atlas identified on CT after cervical trauma should not always be interpreted as an incidental finding. If a superimposed injury is suspected, MRI helps evaluate for traumatic injury, particularly if it is associated with upper cervical pain and tenderness or pain with neck movements. An additional case reiterates our findings.

Objectives Medicines reconciliation is an effective way of reducing errors at transitions of care. Much of the focus has been on medicines reconciliation at point of admission to hospital. Our objective was to evaluate medicines reconciliation after discharge from hospital by assessing the quality of information regarding medicines within discharge summaries and determining whether the information provided regarding medicines changes were acted on within 7 days of receiving the discharge information. Methods A retrospective collaborative evaluation of medicines-related discharge information by Clinical Commissioning Group (CCG) pharmacists using standardised data collection tools. Outcomes of interest included compliance with national minimum standards for medication-related information on discharge summaries, such as allergies, changes to medication regimen, minimum prescription standards, for example, dose, route, formulation and duration, and medicines reconciliation by the primary care team. Data were analysed centrally. Results 43 CCGs covering each of the four National Health Service regions in England participated in the study and submitted data for 1454 patients and 10 038 prescribed medicines. The majority of medication details were stated in accordance with standards with the exception of indication (11.7% compliance), formulation (60.3% compliance) and instructions of ongoing use (72.5% compliance). Documentation about changes was poor: 1550/3164 (49%) newly started medicines, 186/477 (39%) dose changes and 420/738 (57%) stopped medicines had a reason documented. Changes were not acted on within 7 days of receiving the discharge information for 12.5% of patients. Conclusions Our evaluation revealed overall good compliance with discharge medication documentation standards, but a number of changes to medicines during hospitalisation were not fully communicated or documented on the discharge summary or actioned in the general practice after discharge.

OBJECTIVE: Various surgical techniques to release temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this paper is to report our Institution’s experience regarding the post-surgical outcome of different surgical techniques for the release of ankylosis of the TMJ. MATERIALS AND METHODS: The records from our hospital of 386 patients (521 joints) treated for TMJ ankylosis were reviewed. Data analysis included the etiology of TMJ ankylosis, gender distribution, age group, distribution of ankylosis based on location, type, interincisal opening and complications in the perioperative period. RESULTS: Out of 521 joints, 65.02% were unilateral and 73.89% had bony ankylosis. The mean maximal incisal opening preoperative was 5.4 mm (SD 3.63 mm) and at 1-year follow-up was 36.9 mm (SD 3.3 mm). There was no permanent facial nerve paralysis. However, transient facial nerve paresis was 14.78%. There was an overall recurrence rate of 8.82%. CONCLUSION: We conclude that after TMJ ankylosis release with interpositional arthroplasty, reconstruction of the RCU with L ramus osteotomy is the most favorable. This procedure not only causes least complications, but also maintains height of ramus, facilitating surgeries for secondary asymmetry correction.

AimsAnalyse the pattern of psychotropic drug use and deprescribing (in the context of STOMP) in people with Intellectual disability and Challenging behaviour in Hertfordshire community team(s) during 2016-17. STOMP stands for Stopping Over Medication in People with Learning Disability, Autism or both.BackgroundPublic Health England in 2015 estimated that on an average day in England, between 30,000 and 35,000 adults with a learning disability, autism or both were taking prescribed psychotropics without appropriate clinical indications . HPFT signed up to the STOMP pledge in 2017 to actively review psychotropic prescribing in line with NICE guidance alongside patients, carers and professional partnerships. This audit provides the outcomes of applying the STOMP Pledge to clinical practice.MethodData collection for the current audit occurred over Q1-5 in 2016–2017. All patients with Intellectual Disabilities on psychotropic medication were reviewed in psychiatric clinics. Awareness was raised about STOMP in teams. A semi-structured tool was developed based on the Self assessment framework published by the ID faculty RCPsych and prospective data were collected after each outpatient visit.Result347 patients were prescribed psychotropic medication and reviewed quarterly between 2016-2017. 96 patients were prescribed antipsychotics for challenging behaviour. Other prescribed medications included mood stabilisers, anticonvulsants, anti-depressants and benzodiazepines. Common antipsychotics used: Risperidone (63), Aripiprazole (14), Quetiapine (9), Olanzapine (4); Chlorpromazine (2). Four patients were maintained on two antipsychotics in varying combinations. The data collection tool noted that alternatives to medication were tried in 32 cases. Deprescribing occurred in 41 casesConclusionThis study represents an attempt to capture the impact of the STOMP principles in a clinical sample. Various alternatives to medications were pursued in the sample such as positive behaviour support, sensory integration, psychological therapies, social support. Younger adults (under 30 years) represented the largest proportion of cases where medication was increased. Adults over 30 years represented the largest proportion of cases where a STOMP reduction occurred. This may reflect the individual factors at play. Younger people with ID and /or Autism are more likely to experience changes in support and structure at transition, whilst older adults may have more physical comorbidities that may influence this decision.zcvv

Health visitors have a pivotal role in promoting, supporting and monitoring breastfeeding, and should be aware of the benefits and risks associated with prescribed medication during breastfeeding. Taking medication does not usually mean that a mother has to stop breastfeeding and the list of drugs that are unsafe for breastfeeding mothers is small. This article discusses the use of common medications while breastfeeding, including their drug safety profile, the effect of the drug on the infant and whether there is any monitoring that the health visitor could undertake. Health visitors should encourage mothers to continue breastfeeding if it is safe to do so and can seek expert advice from their local medicines information pharmacist around the use of medication in lactation.

BACKGROUND AND PURPOSE: The American College of Radiology–American Society of Neuroradiology–Society for Pediatric Radiology Practice Parameter for a neck CT suggests that coverage should be from the sella to the aortic arch. It also recommends using CT scans judiciously to achieve the clinical objective. Our purpose was to analyze the potential dose reduction by decreasing the scan length of a neck CT and to assess for any clinically relevant information that might be missed from this modified approach. MATERIALS AND METHODS: This retrospective study included 126 children who underwent a neck CT between August 1, 2013, and September 30, 2014. Alteration of the scan length for the modified CT was suggested on the topographic image on the basis of the indication of the study, with the reader blinded to the images and the report. The CT dose index volume of the original scan was multiplied by the new scan length to calculate the dose-length product of the modified study. The effective dose was calculated for the original and modified studies by using age-based conversion factors from the American Association of Physicists in Medicine Report No. 96. RESULTS: Decreasing the scan length resulted in an average estimated dose reduction of 47%. The average reduction in scan length was 10.4 cm, decreasing the overall coverage by 48%. The change in scan length did not result in any missed findings that altered management. Of the 27 abscesses in this study, none extended to the mediastinum. All of the lesions in question were completely covered. CONCLUSIONS: Decreasing the scan length of a neck CT according to the indication provides a significant savings in radiation dose, while not altering diagnostic ability or management.

The process of obtaining an up-to-date and accurate patient medication list, medicines reconciliation (MedRec), is vital to ensuring patient safety. Despite its high status as a patient safety issue, and the efforts made to drive and implement robust MedRec processes, further efforts are required to identify and disseminate best practice (Greenwald et al 2010). This article outlines some of the principles involved in conducting effective MedRec and invites interested nurses to join a working group that aims to develop a best-practice toolkit.

Granulomatous lung disease is a rare and perplexing differential in pediatrics. Pulmonary Cryptococcus falls into the differential but is not high on the list, particularly in a non-AIDS patient. Methotrexate (MTX) is a commonly used agent for chemotherapy in oncology and has been documented to cause lung injury in both patients with rheumatologic and oncologic diseases. Our patient had chronic cough and then developed an opportunistic infection resulting in respiratory failure. Lung biopsy showed two underlying unusual diagnoses: MTX lung injury and cryptococcal pneumonia. His case is presented with particular attention to his prolonged road to diagnosis.

The process of obtaining an up-to-date and accurate patient medication list, medicines reconciliation (MedRec), is vital to ensuring patient safety. Despite its high status as a patient safety issue, and the efforts made to drive and implement robust MedRec processes, further efforts are required to identify and disseminate best practice (Greenwald et al 2010). This article outlines some of the principles involved in conducting effective MedRec and invites interested nurses to join a working group that aims to develop a best-practice toolkit.