Sitanshu Sekhar Kar

Concept of essential medicines and rational use in public health.

The Alma-Ata declaration during the International Conference on Primary Health Care in 1978 reaffirms that health is a fundamental human right and the attainment of the highest possible level of health is a most important worldwide social goal.(1) The Alma Ata declaration has outlined the eight essential components of primary health care and provision of essential medicines is one of them.(1) Medicines are integral parts of the health care and the modern health care is unthinkable without the availability of necessary medicines. They not only save lives and promote health, but prevent epidemics and diseases too. The medicines are undoubtedly one of the weapons of mankind to fight disease and illness. Accessibility to medicines is too the fundamental right of every person.

Clopidogrel resistance in North Indian patients of coronary artery disease and lack of its association with platelet ADP receptors P2Y1 and P2Y12 gene polymorphisms

Aspirin and Clopidogrel are used in prophylaxis of patients undergoing percutaneous coronary intervention and long-term prevention of cardiovascular and cerebrovascular events. Clopidogrel resistance has been attributed to P2Y1 and P2Y12 adenosine diphosphate (ADP) receptor polymorphisms. This study enrolled 100 patients of coronary artery disease (CAD) who were on the maintenance dose of clopidogrel (75 mg OD) with or without aspirin. In addition, 10 received loading dose (300 mg) prior to percutaneous coronary intervention. Relevant clinical and drug history were elicited. ADP-induced platelet aggregation study and PCR-RFLP for P2Y1 (1622A > G) and P2Y12 (i-T744C) polymorphisms were performed. Two groups of controls were used for defining cut-off for platelet aggregation response. Follow-up data, wherever available was recorded. The most common pattern of aggregation response was disaggregation, either complete (46.4%) or partial (53.6%). A frequency of 13% clopidogrel non-responders and 19% semi-responders was found. All the cases were H1/H1 haplotype for P2Y12 gene polymorphism and 28 (29.2%) patients carried P2Y1 1622A > G (21(21.9%) AG and 7(7.3%) GG) gene polymorphism, the frequency being greater in clopidogrel responders compared to semi/non-responders but difference was not statistically significant. There was no statistically significant difference between responders and semi/non-responders in terms of the history of risk factor for CAD, concurrent atorvastatin use or past history of an acute vascular event. On follow up, the two patients who developed myocardial infarction/acute coronary syndromes (MI/ACS) were clopidogrel semi- and non-responder, respectively. Variability in clopidogrel response with 13% non-responders and 19% semi-responders was seen in this study with adverse outcome (MI/ACS) on follow up seen in two patients. Hence, poor response to clopidogrel may be related to increased likelihood of adverse long-term coronary event that may benefit from additional or alternative anti-platelet therapy. Clopidogrel resistance was not associated with ADP receptor P2Y1 and P2Y12 gene polymorphisms. Hence, it is postulated that clopidogrel resistance in CAD patients is multifactorial and not caused by single-gene polymorphisms.

Health and environmental sanitation in India: Issues for prioritizing control strategies

Environmental sanitation is a major public health issue in India. Recent interventional studies on environmental sanitation in India highlighted the importance of prioritizing control strategies. Research related to the appropriate cost-effective intervention strategies and their implementation in Indian context is a big challenge. This paper discusses various intervention strategies related to environmental sanitation in India and emphasizes to prioritize it according to the need of country.

Childhood obesity-an insight into preventive strategies

Childhood obesity is now a global problem throughout the world. The major factors affecting weight regulation and the development of obesity in children are the result of a large number of biological, behavioral, social, environmental, and economic factors and the complex interactions between them that promote a positive energy balance. The changes in the dietary habits with the adoption of sedentary life style increases manifold obesity-related diseases and their complications. An obese child later on grows up to become an obese adult. Therefore, the role of primary prevention along with methodical diet control, behavioral changes, and physical activity are the important strategies against the battle of childhood obesity.

Integrated healthy workplace model: An experience from North Indian industry.

Background: Keeping in view of rapid industrialization and growing Indian economy, there has been a substantial increase in the workforce in India. Currently there is no organized workplace model for promoting health of industrial workers in India. Objective: To develop and implement a healthy workplace model in three industrial settings of North India. Materials and Methods: An operations research was conducted for 12 months in purposively selected three industries of Chandigarh. In phase I, a multi-stakeholder workshop was conducted to finalize the components and tools for the healthy workplace model. NCD risk factors were assessed in 947 employees in these three industries. In phase II, the healthy workplace model was implemented on pilot basis for a period of 12 months in these three industries to finalize the model. Findings: Healthy workplace committee with involvement of representatives of management, labor union and research organization was formed in three industries. Various tools like comprehensive and rapid healthy workplace assessment forms, NCD work-lite format for risk factors surveillance and monitoring and evaluation format were developed. The prevalence of tobacco use, ever alcoholics was found to be 17.8% and 47%, respectively. Around one-third (28%) of employees complained of back pain in the past 12 months. Healthy workplace model with focus on three key components (physical environment, psychosocial work environment, and promoting healthy habits) was developed, implemented on pilot basis, and finalized based on experience in participating industries. A stepwise approach for model with a core, expanded, and optional components were also suggested. An accreditation system is also required for promoting healthy workplace program. Conclusion: Integrated healthy workplace model is feasible, could be implemented in industrial setting in northern India and needs to be pilot tested in other parts of the country.

Self-directed learning readiness among fifth semester MBBS students in a teaching institution of South India

Background: Lifelong learning is a skill that must be acquired by medical graduates and proposes that students take the responsibility for learning process. The present study was carried out to measure readiness for self-directed learning among fifth semester MBBS studentsin a tertiary care teaching hospital. Methods: Readiness assessment was carried out among 87 fifth semester MBBS students using Fishers′ 40-item self-directed learning readiness score (SDLRS) instrument after taking informed written consent. A total of 40 items were classified into three domains: Self-management (9 items), desire for learning (16 items) and self-control (15 items). Institute scientific society and ethical committee clearance was obtained. The data were entered and analyzed using IBM-SPSS version 21. Chi-square test was used to elicit relationship between readiness assessment and gender, presence of a physician in family and area of residence. Results: Out of 87 students, 64 (73.5%) students consented to be assessed for readiness toward self-directed learning. The mean SDLRS score was 140.4 ± 24.4, with 19 students (30%) scoring more than 150 indicating high readiness.The mean scores in the three domains of self-management, desire for learning and self-control were 38.8 ± 9.8, 47.3 ± 6.9 and 54.3 ± 10.4, respectively. Males had a higher readiness for self-directed learning than females (P = 0.045). Discussion: Self-directed learning scores were lower among our MBBS students than reported elsewhere in the literature.

Hepatic coagulopathy-intricacies and challenges; a cross-sectional descriptive study of 110 patients from a superspecialty institute in North India with review of literature.

Hemostatic defect in chronic liver disease (CLD) is complex involving opposing factors of primary hemostasis, coagulation, and fibrinolysis. The concept of causal relationship between abnormal tests and clinical bleeding is unclear. This study was undertaken to evaluate and correlate clinical bleeding and the commonly used laboratory tests for hemostasis in CLD patients including the subgroup of acute on chronic liver failure (ACLF) patients and test the reproducibility of international normalized ratio (INR) using different reagents. This was a cross-sectional descriptive study wherein clinical records and laboratory data from110 patients (95 CLD, 15 ACLF) over a 6-month period were analysed. Variceal bleeding (33.3%) was the commonest followed by mucosal/skin bleeds (5.4%). Thrombocytopenia seen in 70.9% patients was mostly mild (48.2%) to moderate (14.5%). Prothrombin time (PT) prolongation was seen in 81.8% with significant variation in PT/INR using different reagents. Adverse outcome in the form of disseminated intravascular coagulation, septic shock or death was seen in 13.6% patients (eight ACLF and seven CLD). There was no correlation of bleeding with prolonged PT/INR, decreased platelet count and adverse clinical outcome. However, individually, there was significant but weak correlation between variceal bleeding and lower platelet count and superficial bleeding and prolonged PT. Correction of PT/INR post-fresh frozen plasma was significant but platelet count postplatelet concentrate transfusion was not. ACLF patients compared with CLD patients had greater PT prolongation and adverse outcome but no increase in bleeding. Routine tests, although globally deranged inadequately reflect haemostatic imbalance in CLD and poorly predict bleeding risk.

Estimation of the Cardiovascular Risk Using World Health Organization/International Society of Hypertension (WHO/ISH) Risk Prediction Charts in a Rural Population of South India

BACKGROUND World Health Organization/International Society of Hypertension (WHO/ISH) charts have been employed to predict the risk of cardiovascular outcome in heterogeneous settings. The aim of this research is to assess the prevalence of Cardiovascular Disease (CVD) risk factors and to estimate the cardiovascular risk among adults aged >40 years, utilizing the risk charts alone, and by the addition of other parameters. METHODS A cross-sectional study was performed in two of the villages availing health services of a medical college. Overall 570 subjects completed the assessment. The desired information was obtained using a pre-tested questionnaire and participants were also subjected to anthropometric measurements and laboratory investigations. The WHO/ISH risk prediction charts for the South-East Asian region was used to assess the cardiovascular risk among the study participants. RESULTS The study covered 570 adults aged above 40 years. The mean age of the subjects was 54.2 (±11.1) years and 53.3% subjects were women. Seventeen percent of the participants had moderate to high risk for the occurrence of cardiovascular events by using WHO/ISH risk prediction charts. In addition, CVD risk factors like smoking, alcohol, low High-Density Lipoprotein (HDL) cholesterol were found in 32%, 53%, 56.3%, and 61.5% study participants, respectively. CONCLUSION Categorizing people as low (<10%)/moderate (10%-20%)/high (>20%) risk is one of the crucial steps to mitigate the magnitude of cardiovascular fatal/non-fatal outcome. This cross-sectional study indicates that there is a high burden of CVD risk in the rural Pondicherry as assessed by WHO/ISH risk prediction charts. Use of WHO/ISH charts is easy and inexpensive screening tool in predicting the cardiovascular event.

Prevention of childhood obesity in India: Way forward

Childhood obesity is a burden in developed and developing countries. Overweight and obesity are caused by numerous social and environmental factors that influence peoples food habit and physical activity. Role of primary or secondary prevention is the mainstay plan for controlling this epidemic. Various adaptable best practice models are available in the developed nations. However, further research needs to be done to examine the most effective strategies of intervention, prevention, and treatment of obesity in our setting. Through this paper, we would like to highlight best practices and potential interventions to reduce the burden of obesity in India.

Utilization of maternal health-care services by tribal women in Kerala

Background: The coverage of maternal care services among the tribal women in Kerala is better as compared to other states in India. Aim: This study was done to identify the factors contributing to better coverage of maternal care services among the tribal women in Kerala and to study the reasons for remaining differences that exists in utilization of services between tribal and non-tribal pregnant women. Settings and Design: This was a descriptive cum qualitative study conducted in Thariode Gramapanchayat in the Wayanad district of Kerala. Materials and Methods: Among all women who had registered their pregnancies in the 5 sub-centres under CHC Thariode and had delivered between September 2009 and October 2010, equal numbers of tribal and non-tribal ante-natal women, 35 each were interviewed in-depth using a semi-structured questionnaire. Statistical Analysis Used: Quantitative data was analysed using SPSS Version 16.0. Content analysis was done for qualitative data. Results: The determinants of utilization in tribal women were general awareness, affordability, accessibility and quality of services along with motivation by health workers. Among tribal antenatal women, 85% utilized maternal health care facilities fully compared to 100% among non-tribal women. Lower levels of education and lack of transport facilities were prime factors contributing to under utilization by tribal women. Conclusions: Affordable, accessible and good quality of services in the public health system in Kerala and motivation by health workers were important contributing factors for better utilization of maternal care services.