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Aim Injudicious usage of antibiotics has led to the emergence of antibiotic resistance which is a major health-care problem in developing countries such as India. Our aim was to show how antibiotic therapy based on serial procalcitonin (PCT) assay can help in antibiotic de-escalation in septic patients. Materials and Methods A pre–post interventional study was conducted among 300 septic patients admitted to an intensive care unit (ICU). All septic patients admitted 2 months before and 2 months after the introduction of monitoring of PCT were included and they were divided into Group P (with PCT monitoring) and Group C (without PCT monitoring). The proportion of patients for whom antimicrobials were de-escalated, the average time taken to de-escalate antimicrobials, and the average duration of ICU stay were compared. Proportions and averages with standard deviations were calculated to describe the data. A test of proportions was done to compare the proportion de-escalated and a Student’s t-test was done to compare the average duration of antibiotic therapy. Results The proportion of patients in whom de-escalation of antimicrobials was done was 125 (83.33%) in Group P as compared to 92 (61.33%) in Group C. The time taken to de-escalate was 3.04 ± 0.83 days (95% confidence interval [CI] 2.89–3.18) in Group P compared to 4.7 ± 1.4 days (CI 4.41–4.98) in Group C. The duration of ICU stay was also less in Group P - 3.08 ± 0.91 days (CI 3.08–3.38) as compared to Group C - 5.16 ± 2.17 days (4.80–5.51). Conclusion Serial PCT assay-based antimicrobial therapy helped to wean patients with sepsis off antimicrobials earlier thus reducing the duration of ICU stay.

Background and Objectives: The capability to cause invasive infection, multi-drug resistance, and health care-associated outbreaks of Candida auris have made it a pathogen of great concern. Estimating how many patients in our intensive care unit had C. auris colonization and what characteristics put patients at risk for having Candida spp. colonization were the primary goals of the study. Materials and Methods: Swabs from axilla and groin were collected from 229 patients getting admitted to the ICU. Samples were inoculated into CHROMagarTM Candida Plus medium. Colonies presumptively identified as C. auris by the presence of light blue with blue halo and were confirmed by VITEK-2. Results: Our study showed that only one patient was colonized with C. auris. A total of 47 (20.5%) patients were colonized with Candida spp., of which Candida parapislosis was the predominant organism. History of antibiotic use and cerebrovascular accident were independent risk factors in Candida colonization. Conclusion: Active screening for Candida auris in all patients is not required in our hospital as the prevalence was very low and not cost-effective. Therefore we plan to modify our screening strategy and use risk factors based surveillance strategy as it may serve as an ideal strategy.

Background and Objectives: Early diagnosis of candidemia is of vital importance in reducing mortality and morbidity. The main objective of the study was to determine the TTP (Time to Positivity) of different species of Candida causing bloodstream infection and to see whether TTP can help differentiate Candida glabrata which is frequently fluconazole resistant from Fluconazole sensitive Candida. Materials and Methods: TTP (Time to positivity) and AAT (Appropriate Antifungal therapy) were noted for Blood cultures becoming positive for Candida. Presence of Risk factors for candidemia like prolonged ICU stay, neutropenia, Total Parenteral Nutrition (TPN), use of steroids , broad spectrum antibiotics, use of Central Venous Catheter, Foleys catheter were also analyzed. Results: The most frequent isolates were Candida parapsilosis, Candida tropicalis and Candida albicans. The median TTP for all Candida isolates in our study was 34 hours. The diagnostic sensitivity of TTP for detecting C. glabrata and C. tropicalis in patients with candidemia was 88% and 85% respectively. TTP showed that there was no difference in survival between TTP 24hrs. Initiation of antifungal therapy 24hrs after onset of candidemia had no association with survival. Conclusion: Longer TTP maybe predictive of C. glabrata while shorter TTP may be predictive of C. tropicalis. In our study we found that fluconazole resistant Candida causing blood stream infection is quite unlikely if the TTP of the isolate is

Non-valvular atrial fibrillation (NVAF) is a common form of cardiac arrhythmia that affects 1–1.5% of adults and roughly 10% of elderly adults with dysphagia. Apixaban is an anticoagulant referred to as a factor Xa inhibitor, which has been shown to reduce the risk of stroke and systemic embolism in cases of NVAF. Our objective in the current study was to formulate an orally disintegrating film to facilitate the administration of apixaban to elderly patients who have difficulty swallowing. Researchers have used a wide variety of cellulose-based or non-cellulose-based polymers in a variety of combinations to achieve specific characteristics related to film formation, disintegration performance, drug content, in vitro drug release, and stability. One of the two formulations in this study was specify that bioequivalence criteria met with respect to Cmax of the reference drug (ELIQUIS®) in terms of pharmacokinetic profile. Further research will be required to assess the applicability of orodispersible films created using colloidal polymers of high and low molecular weights to other drugs with poor solubility in water.

Abstract Background Undergraduate medical students in India participate in various research activities However, plagiarism is rampant, and we hypothesize that it is the lack of knowledge on how to avoid plagiarism. This study’s objective was to measure the extent of knowledge and attitudes towards plagiarism among undergraduate medical students in India. Methods It was a multicentre, cross-sectional study conducted over a two-year period (January 2018 – December 2019). Undergraduate medical students were given a pre-tested semi-structured questionnaire which contained: (a) Demographic details; (b) A quiz developed by Indiana University, USA to assess knowledge; and (c) Attitudes towards Plagiarism (ATP) questionnaire. Results Eleven medical colleges (n = 4 government medical colleges [GMCs] and n = 7 private medical colleges [PMCs]) participated. A total of N = 4183 students consented. The mean (SD) knowledge score was 4.54 (1.78) out of 10. The factors (adjusted odds ratio [aOR]; 95% Confidence interval [CI]; p value) that emerged as significant predictors of poor knowledge score were early years of medical education (0.110; 0.063, 0.156;

Antibiotic resistance (ABR) is increasing the mortality and morbidity associated with infectious diseases, besides increasing the cost of healthcare, saturating health system capacity, and adversely affecting food security. Framing an appropriate narrative and engaging local communities through the ‘One Health’ approach is essential to complement top-down measures. However, the absence of objective criteria to measure the performance of ABR interventions in community settings makes it difficult to mobilize interest and investment for such interventions. An exercise was therefore carried out to develop an indicator framework for this purpose. A comprehensive list of indicators was developed from experiences gathered through community engagement work in a local panchayat (small administrative area) in Kerala, India and a consultative process with health, veterinary, environment, and development experts. A prioritization exercise was carried out by global experts on ABR, looking at appropriateness, feasibility, and validity. A 15-point indicator framework was designed based on the prioritization process. The final set of indicators covers human health, animal health, environment management, and Water Sanitation and Hygiene (WASH) domains. The indicator framework was piloted in the panchayat (located in Kerala), which attained a score of 34 (maximum 45). The score increased when interventions were implemented to mitigate the ABR drives, indicating that the framework is sensitive to change. The indicator framework was tested in four sites from three other Indian states with different socioeconomic and health profiles, yielding different scores. Those collecting the field data were able to use the framework with minimal training. It is hoped that, this indicator framework can help policymakers broadly understand the factors contributing to ABR and measure the performance of interventions they choose to implement in the community as part of National Action Plan on AMR.

Purpose: Over-the-counter (OTC) sale of antibiotics have contributed to the growing threat of antibiotic resistance. The Government of India has instituted regulatory measures, such as Schedule H1 and public campaigns such as Red Line Campaign, to limit such sales. This study was conducted to assess the perceptions of stakeholders regarding their effectiveness. Methods: To assess Schedule H1, pharmacists who own retail pharmacies in the state of Kerala, India, were interviewed using a pre-prepared question guide. In the next phase, healthcare professionals and patients in a hospital were shown the Red Line on an antibiotic blister pack and asked about its significance. Finally, 100 patients were shown a blister pack of Amoxicillin, and asked to identify the medicine or its use. Results: It was observed that there is poor awareness about antibiotic regulations and a perception of laxity in enforcement. Regarding the Red Line, only 7% of healthcare professionals could describe its significance and none among patients. Among the 100 patients who were shown Amoxicillin, only 42 could identify it as an antibiotic or describe its use. Conclusions: There is a general perception that regulations are poorly enforced and all are not aware of the Red Line campaign including healthcare professionals. Greater awareness at all levels about appropriate antibiotic use through prescriptions followed by greater efforts towards regulatory implementation and compliance should form parts of a multi-modal strategy to contain OTC sales of antibiotics. This will greatly help to aid physicians in improving overall healthcare through safe and effective prescribing.

Background: Endotracheal intubation is considered to be the benchmark for controlled ventilation during general anaesthesia. But supraglottic airway devices are taking the place of endotracheal tubes in many scenarios and i-gel is one such airway device. Aim and Objectives: To assess whether i-gel is comparable to endotracheal tube for pressure controlled ventilation at different inspiratory pressures. Material and Methods: Forty American Society of Anaesthesiologists (ASA) III patients undergoing elective surgery were selected. Following induction, airway was secured with i-gel. Pressure controlled ventilation was initiated at four different pressures (10, 15, 20, 25 cm of H2O). Inspiratory and expiratory tidal volumes were measured and leak volume was calculated as thedifference of the two. Leak fraction was calculated by dividing leak volume by inspiratory tidal volume. Then i-gel was withdrawn, patient was intubated and the measurements repeated. Statistical analysis was done using two-tailed student's t test. Results: There was no significant difference on comparing the leak volume and leak fraction in the two groups at 10, 15 and 20 cm of H2O. However, at 25 cm of H2O, there was statistically significant difference in leak volume and leak fraction between the two groups. Conclusion: Igel can be considered as a safe alternative to endotracheal tube for pressure controlled ventilation at moderate pressures during anaesthesia.

Abstract Background Focal lesions of the kidney comprise a spectrum of entities that can be broadly classified as malignant tumors, benign tumors, and non-neoplastic lesions. Malignant tumors include renal cell carcinoma subtypes, urothelial carcinoma, lymphoma, post-transplant lymphoproliferative disease, metastases to the kidney, and rare malignant lesions. Benign tumors include angiomyolipoma (fat-rich and fat-poor) and oncocytoma. Non-neoplastic lesions include infective, inflammatory, and vascular entities. Anatomical variants can also mimic focal masses. Main body of the abstract A range of imaging modalities are available to facilitate characterization; ultrasound (US), contrast-enhanced ultrasound (CEUS), computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET), each with their own strengths and limitations. Renal lesions are being detected with increasing frequency due to escalating imaging volumes. Accurate diagnosis is central to guiding clinical management and determining prognosis. Certain lesions require intervention, whereas others may be managed conservatively or deemed clinically insignificant. Challenging cases often benefit from a multimodality imaging approach combining the morphology, enhancement and metabolic features. Short conclusion Knowledge of the relevant clinical details and key imaging features is crucial for accurate characterization and differentiation of renal lesions.

Abstract Background Fish bones are the most common cause of accidental foreign body ingestion, especially in Asian and Mediterranean nations. In most cases, the fish bones pass through the alimentary tract without any complications and rarely require any intervention. Less than 5% of the patients with accidentally ingested fish bones develop complications. In this report, we present the first documented case of a fish bone induced bronchial artery pseudoaneurysm in an elderly male with underlying bronchiectasis; the latter recognized as a risk factor for developing bronchial artery hypertrophy. Case presentation We report a case of a fish bone induced bronchial artery pseudoaneurysm in a patient with underlying bronchiectasis. The vascular complication induced by the fish bone was identified only on intravenous contrast CT and would not have been identified on plain CT alone. The patient underwent bronchial artery embolization, following which the fish bone was dis-impacted endoscopically. Conclusions Intravenous post contrast chest CT may have an important role in the evaluation of accidental fish bone ingestion, especially in patients with underlying lung diseases, as vascular complications are most often overt on a non-contrast CT study.

Radiographs of the abdomen and pelvis are routinely obtained as a standard part of clinical care for the abdomen and pelvis. Brisk advances in technology over the last few decades have resulted in a multitude of medical devices and materials. Recognizing and evaluating these devices on abdominal and pelvic radiographs are critical, yet increasingly a difficult endeavor. In addition, multiple devices serving different purposes may have a similar radiographic appearance and position causing confusion for the interpreting radiologist. The role of the radiologist is to not only identify accurately these medical objects, but also to confirm for their accurate placement and to recognize any complications that could affect patient care, management or even be potentially life threatening. An extensive online search of literature showed our review article to be the most comprehensive work on medical devices and materials of the abdomen and pelvis, and in this second part of our two-part series, we discuss in depth about the neurologic and genitourinary devices seen on abdominal and pelvic radiographs.

When compared with chest radiographs, medical devices of the abdomen and pelvis are less frequently seen. However, with recent advances in technology the interpreting radiologists are seeing more medical objects on these radiographs. The identification of these devices and materials are crucial for not only enabling the radiologist to understand the underlying background pathology but also for evaluating any related complications. An online survey of literature showed our review article to be the most detailed. In this first part of our two-part series, we discuss about the various gastrointestinal and vascular devices and materials seen on abdominal and pelvic radiographs.

Objectives Though dissertation is mandatory for postgraduates (PG), it is unknown if adequate knowledge on plagiarism exists at that level. Thus, we intended to study the knowledge and attitude towards plagiarism among junior doctors in India.Design Cross-sectional studySetting PG medical residents and Junior faculty from various teaching institutions across south India.Participants A total of N=786 doctors filled the questionnaires of which approximately 42.7% were from government medical colleges (GMCs) and the rest from private institutions.Methods Participants were given a pretested semistructured questionnaire which contained: (1) demographic details; (2) a quiz developed by Indiana University, USA to assess knowledge and (3) Attitudes towards Plagiarism Questionnaire (ATPQ).Outcome measures The Primary outcome measure was knowledge about plagiarism. The secondary outcome measure was ATPQ scores.Results A total of N=786 resident doctors and junior faculty from across 11 institutions participated in this study. Of this, 42.7% were from GMCs and 60.6% were women. The mean (SD) knowledge score was 4.43 (1.99) out of 10. The factors (adjusted OR; 95% CI; p value) that emerged as significant predictors of knowledge were number of years in profession (−0.181; −0.299 to –0.062; 0.003), no previous publication (0.298; 0.099 to 0.498; 0.003) and working in a GMC (0.400; 0.106 to 0.694; 0.008). The overall mean (SD) scores of the three attitude components were: Permissive attitudes—37.33 (5.33), critical attitudes —20.32 (4.82) and subjective norms—31.05 (4.58), all of which corresponded to the moderate category.Conclusion Participants lacked adequate knowledge on how to avoid plagiarism suggesting a need for a revamp in medical education curriculum in India by incorporating research and publication ethics.

Introduction: Implementing a sustainable and effective Antimicrobial Stewardship (AMS) programme in secondary level hospitals, in Low-Middle Income Country (LMIC) contexts, has numerous challenges. It is important to understand these challenges so that the stewardship initiatives can be tailored according to the unique requirements thrown up by these healthcare facilities. This study explores the experiences of implementing AMS in secondary level hospitals in the state of Kerala, India.Methods: A qualitative study was planned to map the challenges in implementing AMS in the secondary level hospitals. Toward the end of the 1 year followup period, the nodal officers at each hospital were interviewed using a semi-structured interview guide. The in-depth interviews were transcribed and later subjected to content analysis using N-Vivo 11.0, a popular software tool used for qualitative analysis.Results: Many physicians cite perceived patient satisfaction as one of the reasons for increased antibiotic use, as many patients consider antibiotics as standard of care. Also, the distance traveled by the patient and advancing age are factors which increase antibiotic use. The physician factors which determine use include empiric treatment needs, outbreak of diseases, absence of education programmes in antibiotic usage to fill in the knowledge gap and fear of litigation. The promotional activities by companies and antibiotics being a major source of income for small hospitals, affects use patterns. The factors which determine antibiotic selection includes conformism, experience of the physician, perceived resistance to certain antibiotics, emergence of specific diseases, and promotional activities related to antimicrobial agents. The challenges in implementing a sustainable stewardship programme is multifactorial. It includes competition between doctors, time constraints faced by physicians, absence of a champion, sub-optimal interdepartmental cooperation, absence of supporting facilities, dysfunctional regulatory systems, and unreliability of antibiograms.Discussion: AMS in resource-limited setting is going to be a challenge, especially in terms of financing, access to technologies and capacity building. Political and regulatory willpower of international partnerships should be effectively harnessed for designing solutions for LMIC contexts. Also, models for stewardship from elsewhere should undergo an adaptation process before implementation in low resource settings.

Infections caused by Chromobacterium violaceum are extremely rare but can be relatively fatal in septicemia. We report a case of a 76 year old female who presented with pustules in the skin and later developed into septicemia. She succumbed to the illness despite escalating the antibiotic therapy to meropenem. To the best of our knowledge this is the 16th case report from India.

Background: Quality of Life (QoL) reflects the quality and outcome of healthcare along with key indicators of performance such as mortality and morbidity. Objective: The aim of the study was to measure the QoL among patients with End Stage Renal Disease (ESRD) on maintenance hemodialysis and to understand various correlates of QoL. Methods: A total of 95 ESRD patients from three dialysis centres in Southern districts of Kerala were interviewed. QoL was measured using vernacular version of World Health Organization Quality Of Life – Brief Version (WHOQOL-BREF) questionnaire. Results: The mean age of the patients was 56.2 ± 13 years and 73.7% were males. Mean converted scores for overall QoL was 42.37 ± 21.3 and Health-related QoL (HRQoL) was 43.3 ± 18.3, indicating poor QoL. Males had significantly higher physical domain scores (p < 0.03). Occupation, income and Socio-economic Status (SES) influenced overall HRQoL while better income and higher SES predicted better scores in psychological and environmental domains. Conclusion: Patients with better control over inter-dialysis weight gain (≤1600 g) had significantly higher scores. This study highlights the importance of using QoL tools in assessing the QoL of patients and the factors contributing to it.

Antimicrobial resistance (AMR) is now a global public health issue and is projected to affect the longevity of people and increase health expenditure of countries. Its impact is going to be higher in low-middle income countries as the healthcare systems are suboptimal and ill-equipped to deal with the issue. As antibiotic misuse is the primary driver for AMR, there is an acute need to create awareness among general public regarding antibiotic misuse. This calls for a comprehensive communication strategy, which takes into account the various drivers of AMR and the solutions associated with it. In the short term, the focus of communication strategies can be on raising awareness in specific interest groups. It can help in channeling limited resources to achieve specific objectives for raising awareness among these groups, thereby improving the chances of behavior change. The general public can be targeted at a later stage or as a second phase with definite strategies and messages. But, it is erroneous to assume that a higher level of awareness will translate into a positive change in behavior. We propose that behavior change is the final fruit of a long and dynamic process. This process should rest on four pillars: adequate awareness, robust regulatory environment, emotional or material incentives, and an enabling social structure. Unless all these domains are satisfactorily addressed, the communication strategy will not be able to bring about a discernible change in behavior in terms of antibiotic use.

Treating cases of facial asymmetry is always a challenge for oral and maxillofacial surgeons especially when the face has minor deformities and patients expectations are very high. Various non surgical and surgical techniques including orthognathic and orthomorphic surgeries with graftings have kept their milestones for treating such cases. This report presents a similar case of achieving fullness on unilateral side of face to accomplish symmetry which was treated using an interpoistional iliac graft in unilateral saggital split osteotomy to correct the disharmony of face.

Background and Aims: Transversus abdominis plane (TAP) block is a technique proposed to minimise pain after anterior iliac crest bone harvesting. This study aims to evaluate the postoperative pain in patients who receive ultrasound-guided TAP block to supplement routine wound infiltration. Material and Methods: A total of 143 patients aged between 6 and 22 years were randomised into two groups. Patients in group A received supplemental TAP block on the same side. Patients in group B received local anesthetic wound infiltration alone. Pain scores were compared at the first and 24th postoperative hours. Results: TAP block significantly reduced pain and delirium in the immediate postoperative period. The mean FLACC (Face, Legs, Activity, Cry, Consolability) score after 10 min was 0.8 in group A versus 1.8 in group B (P = 0.001). The mean Watcha scale at 10 min was 1.0 in group A versus 1.2 in group B (P = 0.001). After 24 h, 81.7% of patients in group A had no pain versus 59.7% in group B (P = 0.004). The incidence of intolerable pain at 24 h was 5.6% in group B versus 0% in group A (P = 0.04). Cumulative ambulation scores were significantly better in group A (P < 0.05). There was a strong and positive correlation between the analgesia and ability to ambulate comfortably at 24 h postop (Pearson's coefficient 0.95). Conclusion: Supplemental ultrasound-guided TAP block given intraoperatively reduces the postoperative pain. The incidence of emergence delirium was low. These patients were also able to ambulate earlier.

Introduction: Conjoined twins are identical twins with fused bodies, joined in utero. They are rare complications of monochorionic twinning. The purpose of this study is to describe the various types of conjoined twins, the role of imaging and recent advances aiding in their management. Material and methods: This was a twin institutional study involving 3 cases of conjoined twins diagnosed over a period of 6 years from 2010 to 2015. All the 3 cases were identified antenatally by ultrasound. Only one case was further evaluated by MRI. Results: Three cases of conjoined twins (cephalopagus, thoracopagus and omphalopagus) were accurately diagnosed on antenatal ultrasound. After detailed counseling of the parents and obtaining written consent, all the three cases of pregnancy were terminated. Delivery of the viable conjoined twins was achieved without any complications to the mothers, and all the three conjoined twins died after a few minutes. Conclusion: Ultrasound enables an early and accurate diagnosis of conjoined twins, which is vital for obstetric management. MRI is reserved for better tissue characterization. Termination of pregnancy when opted, should be done at an early stage as later stages are fraught with problems. Recent advances, such as 3D printing, may aid in surgical pre-planning, thereby enabling successful surgical separation of conjoined twins.

Introduction: The educational environment affects the academic performance of students. One of the most widely utilized tools for measuring the educational environment is Dundee Ready Education Environment Measure (DREEM). The objective of the study was to assess the attitude toward study environment, as measured using DREEM questionnaire, and to find out the differences in perception of various batches of dental students. Materials and Methods: All Bachelor of Dental Surgery students from Government Dental College, Kottayam, Kerala, India, were included in the study. They were given the well-established DREEM questionnaire. A total of 234 students took part in the study, belonging to 2009, 2010, 2011, 2012, 2013, and 2014 batches. DREEM subcategories were analyzed for significance using analysis of variance. The significance of DREEM score across the different batches was further analyzed using post hoc test. Results: Overall, DREEM score was positive (111.14), but there is need for improvement. Individual questions also were given positive score for most questions. The maximum score was obtained for 3rd year students. Similar results are obtained for three of the five subcategories of DREEM. Conclusion: The total DREEM score was positive (111.14). The total score as well as the scores for the subcategories was highest in 3rd year dental students. The increase might be due to the excitement of clinical exposure for the first time in 3rd year students.

Introduction: Cancer of the ovaries is the 2nd most common gynaecological malignancy and has the highest mortality rate among all gynaecological malignancies with an overall 5 year survival rate of 46%. A large number of the lesions are incidentally detected, for which imaging plays a vital role in treatment planning by characterizing these masses. Identifying benign lesions accurately may obviate unnecessary surgery, where as indeterminate or malignant lesions will require surgery with or without radio/chemotherapy. Aim: To inform the readers the imaging patterns of common and rarely encountered ovarian neoplasms and to provide an algorithm based approach to these ovarian lesions, which will not only aid in the management of these conditions but also obviate unnecessary investigations and surgeries. Materials and Methods: This was a prospective study conducted over a period of one year from January 2014 to January 2015 at the Department of Radiology, Father Muller Medical College, Mangalore, India. Data were collected from 82 patients who presented with ovarian cystic lesions on ultrasound and were either followed up by USG or underwent further evaluation by CT. Diagnosis was confirmed by histopathology. Statistical analysis involved percentage frequency. Results: Of the 82 patients included in the study, the largest age group belonged to the 3rd decade (41%). Patients belonging to the 6th decade and above presented with the largest cases of ovarian cystic malignancies (61%). On imaging, papillary projections, vascular solid components and thick septations (>3mm) favoured malignancy. All cases of teratoma were accurately diagnosed (100% accuracy) due to the presence of fat and calcifications. Conclusion: Both Ultrasound and CT are excellent tools in the diagnosis of ovarian cystic masses. An algorithm based approach to ovarian masses allows early detection, saves time and unnecessary burden to the patients and their families. In addition imaging is also useful to identify the extent of the disease and pre-treatment planning.