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Important, trustworthy public health research evidence

April 28, 2011 Leave a comment

Prathap Tharyan

In February 2007, India created history by becoming the first, and only, low-income country to purchase a national provision for all its residents to access the online resources of The Cochrane Library (www.thecochranelibrary.com).

This initiative of the Indian Council of Medical Research (ICMR), is an example of responsible leadership in healthcare, as it enables all people in India with an internet connection to access without further payment, reliable, independent, and updated evidence for the safety and efficacy of the myriad treatments in use covering all branches and specialties of medicine, surgery, nursing, dentistry, rehabilitation, as well as other aspects of healthcare delivery.

The first step

The first step in effective healthcare is ready access to reliable evidence of whether treatments work, and if they do, how effective they are likely to be; and how safe.

The Cochrane Library provides a one-stop portal for the best evidence available on the efficacy and safety of interventions that healthcare professionals, health policy makers, and consumers of healthcare interventions need to make well-informed decisions that concern their health.

The Cochrane Library is a collection of six databases at the core of which is The Cochrane Database of Systematic Reviews (CDSR). The April 2011 release of this resource has over 6500 articles, making this the world’s largest collection of such reviews.

Well-conducted trials

These systematically assembled research articles summarize the results of well-conducted clinical trials from around the world that evaluate how effective and safe healthcare interventions are for a particular condition compared to other interventions in use for that condition, or to no interventions.

In addition to these reviews of interventions, the CDSR also contains systematic reviews of how accurate diagnostic tests are that are used to detect and diagnose particular diseases or healthcare conditions.

No biases

These reviews are prepared according to pre-determined methods that reduce the chances that biases and the effects of chance would influence the results. They are prepared by members of the Cochrane Collaboration (www.cochrane.org), an international organization of over 28,000 researchers, clinicians, and health professionals from over 100 countries, who are not funded by drug companies, and who use the best available methods to locate, select, evaluate, and summarize the effects of relevant research.

Standard methods

Cochrane Systematic Reviews are peer-reviewed and supported by strong editorial teams who use standard methods to ensure a high degree of accuracy and transparency, and scientific rigor.

They have been found to be more trustworthy than reviews from other sources, particularly those from the pharmaceutical industry.

These systematic reviews are used by many international and international organizations, such as the World Health Organization, to frame guidelines for the management of healthcare conditions such as tuberculosis, malaria, reproductive health, childbirth, cancer, anemia, nutritional disorders, etc.

For the lay person

All reviews have, in addition to the full article that can be downloaded, short abstracts, as well as plain language summaries meant for the lay person to understand.

The Cochrane Library also contains the Cochrane Central Register of Controlled Trials (CENTRAL), the world’s largest collection of bibliographic information, often with a summary, of clinical trials from published and unpublished sources, identified by groups within the Cochrane Collaboration.

There are currently over 6, 45,000 records of clinical trials in CENTRAL, far more than in PubMed or other commonly used databases. These records include over 2500 clinical trials of clinical trials conducted in India and other countries in South Asia that are not available in PubMed and similar databases.

South Asian database

These trials were identified by the South Asian Cochrane Centre in India and are also available in the South Asian Database of Controlled Clinical Trials (www.cochrane-sadcct.org). They are now available to be included in Cochrane Systematic Reviews, thereby increasing the relevance of these reviews to healthcare in India and the region.

The other databases in The Cochrane Library include the Database of Abstracts of Reviews of Effects (DARE) that contains quality-appraised summaries of systematic reviews published in other journals; The Cochrane Methodology Register(CMR) that provides bibliographic information about publications that report on the methods of conducting clinical trials; the Health Technology Assessment (HTA) Database that provides details of completed and ongoing assessments of the medical, social, ethical, and economic implications of healthcare interventions from around the world; and The NHS Economic Evaluation Database (EED) that provides details of quality-appraised economic evaluations of healthcare interventions from around the world.

A seventh database provides information about the 81 groups that contribute to the Cochrane Collaboration.

India, a user

India is now not only a user of health research generated by others but also a significant contributor to providing evidence of the effects of healthcare interventions.

Statistics provided by the Cochrane Collaboration on the top 50 reviews (http://www.cochrane.org/cochrane-reviews/top) accessed on April 26, 2011 places the review titled “Zinc for the common cold” as the Cochrane Review that was the most accessed review worldwide with 3363 hits in the last 30 days of the abstract from http://www.cochrane.org alone.

This review was conducted by a team from the Postgraduate Institute at Chandigarh, and the press release by the publishers of The Cochrane Library in February 2011 that accompanied its publication saw over 800 articles in various media around the world in the first two days after publication, and about 1000 references to it by day 10 — twice as many as any other Cochrane press release to date (http://www.cochrane.org/features/widespread-media-coverage-cochrane-review-zinc-common-cold).

Data provided by the publishers also indicates that in 2008, a full text article was downloaded from The Cochrane Library by users in India every 7 minutes and over 70,090 such downloads took place that year.

Still growing

The usage continues to grow every year and there are an ever increasing number of contributors, as authors and editors, and peer-reviewers to the Cochrane Collaboration from India.

However, if this investment by the Indian government to ensure that people in India have access to research evidence they can trust are to be fully realized, more people should use resources in The Cochrane Library as the first point of reference for evidence to inform health decisions.

(The author is Director of the South Asian Cochrane Network & Centre (www.cochrane-sacn.org) based at the Prof BV Moses and ICMR Centre for Advanced research In Evidence-Informed Healthcare at the Christian Medical College, Vellore )

Source:- The Hindu

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MCI proposes national eligibility test for PG courses

April 26, 2011 Leave a comment

In line with its decision to revamp medical education in the country, the Medical Council of India has proposed to hold National Eligibility cum Entrance tests for (NEET) Post Graduate and Super Speciality courses in a changed format from next year.

A total of 1,50,000 under graduate candidates, who have completed internship, or those expecting to complete by March 31, 2012 will be eligible to take the NEET for entrance to Post Graduate courses.

It will be notified in August 2011 with applications collected by September end, MCI sources said.

The admit cards will be dispatched by the middle of November, The examination will be online type conducted in the middle of January, 2012 and the number of sessions will be finalised after the feasibility is explored.

The MD/MS courses will commence from May 2, 2012. The candidates aspiring for direct five-year neurosurgery and neurology super-specialty or similar courses will have to take this NEET-PG examination for the courses commencing in August.

There will be a common paper with 180 questions at MBBS standard to be answered in three hours.

The National Eligibility-cum-Entrance Test for Super Specialities (NEET-SS) for 2012 would be held for candidates who have completed post-graduation (MD/MS) or those expecting to complete post-graduation by June 15, 2012.

About 6,000 to 7,000 candidates are expected to take the examination with courses commencing from August one, 2012. It will be notified in February 2012 in all online formats by April end. The admit cards will be dispatched by the middle of May and the exam will be conducted in the middle of June.

The paper will consist of about 150 to 180 questions of three-hours duration, the sources said, adding the examination will be online.

The changes in the examination patterns are yet to be cleared by the Union Health Ministry.

Another proposed examination, the Medical Council of India, Indian Medical Graduate (IMG) Licentiate Examination is also proposed to be held for the first time on 2013.

The examination will consist of questions to assess minimum defined standards for an Indian Medical Graduate(IMG).

Approximately 35,000 to 40,000 medical graduates will take the licentiate examination. Foreign graduates who intend to practice in India will have to qualify in the examination.

The examination will be on-line with most questions based on static images, audio and video clippings. The paper will have only questions of single response from four alternatives or just true/false.

There will be one or more papers of three-hour duration. Each correct question will carry one mark. There will be no negative marking for wrong answers. The examination will be for candidates who completed internship after March 2013. The examination will be conducted in four sessions commencing from April 2013.

The proposed examinations are part of the “Vision 2015” document by the Board of Governors which replaced the MCI last year.

The document is the outcome of a series of deliberations and extensive debates that were held under the aegis of various Working Groups and Committees which worked in the past 10 months.

Source :- The Hindu

Is your child at risk for autism?

April 26, 2011 Leave a comment

Kamlalakshmi Chongtham/TSE

Autism is a condition that effects a person’s communication and socialization skills including a behaviour of restrictive, stereotyped and repetitive patterns of behaviour. The onset of Autism generally starts before 3 years of age and impairments persist throughout the lifespan. In 1911, Eugen Bluer, a Swiss psychiatrist, coins the term-Autism from the Greekword, autos (self) and in 1943, Leo Kanner, a child psychiatrist, describe the characteristics of a childhood disorder he calls early infantile Autism.

When the child does not orient to name when called, some parents take this for a sign of hearing loss and subsequently have hearing checked. It has been seen that some families even changed the name of their son/daughter thinking that the kid got confused of his/her name. Many alert parents do say that the child in fact posed superior hearing as s/he would be the first one to be alert to father’s car horn, or scooter sound and that response to music and television sound was very good.

Or when the child is unable to request desired item using index finger pointing and instead pull the hand or clothing of an adult there by leading towards the desired object. Index finger pointing is a gesture that serves three purposes; to label (what is it?) to request (I want that), to show a sight of interest (Did you see what I saw?). The third type of pointing gesture may not be mastered by many children with autism as they do not have an idea of joint attention and reference. Lack of joint attention like showing an object to the primary caregiver just to share the interest or pointing to a sight and making sure the caregiver has seen it. Triadic communication will not develop i.e., the ability to use eye gaze, gestures and vocalization effectively to communicate wants to the primary caregiver. This capability will be developed with children who are delayed in speech but do not have autism. This is one of the singular feature that can rule out autism among children with language delay. Usually it is very difficult to side track or divert attention like unusually long attention span while playing with a favourite ‘special interest’ toy. This by itself is not bad but the side effect is that the child does not get to interact with others. Major tantrums for minor problems, no sense of showing affection to younger babies or stuffed (cuddly) toys, inability to form and develop appropriate relationship with age peers and inability to play with age peers are some features of autism.

Some common queries from parents?

Is there any cure? Are there any medicines that can be tried?

Autism is not a disease, but it is a condition, therefore drug therapy has limited results. Autism does not show up in MRI scan, EEG’s or blood report. In this sense it will be appropriate to say autism cannot be treated. However some associated conditions like hyperactivity, seizures can be controlled by drugs.

Is my child retarded? Intelligence is a difficult concept to define, usually abilities of a person are measured by series of tests, the result is compared with that of the normal population.

Intelligence stays stable (give or take 15 points) over time. Children with autism are very difficult to test, however professionals having extensive experience in testing can and do assess Intelligence of children with autism. Unlike children with mental retardation, children with autism exhibits islets of abilities in some field ( drawing, math, music, computers, puzzles etc), which is difficult to explain whereas the child may be very poor in other areas. So they may get low scores on tests relying on verbal intelligence, and assessing social adaptive behavior.

Will my child speak? Early diagnosis and intervention will to a great extend determine whether a child with autism will learn to speak or not. It has been reported that 75% of recovery has been due to early intervention. The other most crucial factor is the involvement of parents and the third but not the least is timely remediation.

My child is not speaking, should I use sign language or other system of communication?

Definitely! It’s of the opinion not to exclude one system of communication to other. Use a mixture of sign, pictures and speech. The emphasis should be on communication and not on the mode of speech. The emphasis should be on communication and not on the mode of speech. A good communication system should have elements of all methods.

What are some of the therapies required by my child? Speech language therapy will ensure that the child gets one to one stimulation, however the skills learned have to be generalised. Even those children who are very fluent will benefit from training in pragmatics and learning conversational skills.

Children with autism experiences severe perceptual problems. Occupational therapy will help in coping with sensory dysfunction (extreme sensitivity in oral motor area, hearing, problems with balance and posture etc). Music is a strong area of interest for children with autism, so music therapy can be given. Also Yoga can be given.

When my child grows up will he/she outgrow autism? Not likely. It does not mean that progress will not be made. Even verbal children with autism need assistance to cope with the demands of life.

Should I try homoepathy? Alternative medicines are gaining ground as modes of treatment with autism. These treatments are symptomatic, that is they help in dealing with hyperactivity or any related problems. However the core deficits is that of aloofness and lack of social skills will not be alleviated by any medicine.

Is Autism contagious? Will my other child who does not have autism develop later? No. Autism is not contagious. Your other child or whosoever who interacts with the child wont develop autism.

Its never too late to start working on the child, though early intervention is the best prognosis. The good news is whatever stage of development you find your child now, s/he will improve and the skills learned will not be forgotten. Hence, the time to start is NOW. So dear parent, please don’t waste your precious time in self pitying and ruminating over “If Only”. This attitude is self-defeating, so I would like to request the parent to look forward and be more positive in their thinking.

Source:- TSE

Five-in-one vaccine to be introduced soon

April 26, 2011 Leave a comment

NEW DELHI: After years of discussion and a recent promise to Bill Gates, India is now rolling out the country’s first pentavalent vaccine.

The Union health ministry has written to the governments of Tamil Nadu and Kerala — the two states where the five-in-one vaccine will be first introduced, because of their high routine immunization coverage rate, to put in place manpower, train them and also finalise the implementation plan.

The ministry has also sent a letter to the Global Alliance for Vaccines and Immunisation (GAVI) asking them to dispatch the vaccine doses at the earliest.

GAVI, which is providing the vaccines free of cost to the ministry for the time being, has asked UNICEF to procure the vaccines and send them to India.

India plans to vaccinate 16 lakh children in these two states in the first year. The five-in-one vaccine will have diphtheria, pertussis, tetanus (DPT), Hepatitis B and HIB (Haemophilus influenzae type B — the bacterial microorganism that causes several serious childhood illnesses like meningitis and pneumonia).

Besides this shot, children will also get their oral polio doses as part of the routine immunization rounds.

“We are bringing to India the liquid pentavalent vaccine which are readymade. It will be a 10-dose package which will prove cheaper since it will require less storage space, lesser volume of cold chain and reduced transportation cost. All children attending the routine immunisation rounds will get the pentavalent shot at 6, 10 and 14 weeks. For the first year, we will require over 50 lakh doses. The vaccine vials will reach us by the end of June and the vaccine use will be rolled out immediately after that,” a ministry official said.

“HIB will prevent pneumonia in children. In the under five mortality, 20% are caused by pneumonia. And one-third of the pneumonia mortality is caused by HIB,” the official added.

The health ministry had initially thought of introducing pentavalent in 10 states, including Himachal Pradesh, Jammu and Kashmir and Karnataka. However, the vaccine’s cost made the ministry start with just two states.

A ministry official told TOI, “The pentavalent vaccine will greatly reduce chances of drop-out, will need no additional cold chain space as vaccine vials will reduce and the number of syringes used will also fall.”

The introduction of a pentavalent vaccine was recommended by the National Technical Advisory Group on Immunisation (NTAGI) on June 16, 2008.

Source:- TNN

World Malaria day — A Day to Act

April 25, 2011 Leave a comment

25 April is a day to commemorate global efforts to control malaria. The theme of the fourth World Malaria Day – Achieving Progress and Impact – heralds the international community’s renewed efforts make progress towards zero malaria deaths by 2015.

Malaria stakeholders will continue to report on the remaining challenges to reach the 2010 target of universal coverage of malaria treatment and prevention, as called for by the UN Secretary-General, Ban Ki-moon.

World Malaria Day represents a chance for all of us to make a difference. Whether you are a government, a company, a charity or an individual, you can roll back malaria and help generate broad gains in health and human development.

Reducing the impact of malaria is key to the achievement of the Millennium Development Goals, agreed by every United Nations Member State. These include not only combating the disease itself, but also goals related to women’s and children’s rights and health, access to education and the reduction of extreme poverty.

Hundreds of RBM partners – governments, international organizations, companies, academic and research institutions, foundations, NGOs and individuals – are already gaining ground against malaria. Diverse partner initiatives are guided by a single strategy, outlined in the Global Malaria Action Plan.

Learn how you can support RBM

The 2011 Achieving Progress and Impact theme invites the malaria community to share progress and impact made to date in order to encourage further action and investment against this disease.

We must identify the barriers that impede the implementation of the Global Malaria Action Plan. These include resource gaps to scale up interventions; produce and deliver nets and treatments; and develop endemic countries’ capacity to control malaria. We must also promote new initiatives and solutions and assess their impact by monitoring malaria cases.

Help mark this year by highlighting your progress and count the strides we collectively make towards eventually eliminating malaria. Make the lives of every man, woman and child count.

Med Mercenaries

April 25, 2011 Leave a comment

Bobby Irengbam in association with Haobam Nanao

It was a harrowing experience to say the least. It was the fourth day of the Yaoshang festival, that is, 22nd March, 2011. There was a “Sumang Leela” event in the evening. I had just reached my work place at about 3:30 pm as I wanted to catch up with some pending work. I was just beginning to make some headway on a particular drafting when I received a call from my wife. It was about 4:00 pm. She told me that Ibungo just had a heroin OD (“Overdose” to the lesser informed) and was evacuated to JN Hospital, Porompat.

For a moment, I thought that he would be all right after some first-aid measures like he always used to do in such situations before. He always used to somehow recover from his comatose state at the hospital and be the one to pester us to go back home. However the persistent thought that the situation might be different this time raked my mind and I could not continue working any longer.

It was about 4:45 pm that I reached home to pick up my wife. She was already prepared to go and we reached the Casualty Ward of JN Hospital at about 5:00 pm.

A few doctors were on duty at the Casualty Ward and I found Ibungo struggling for his life with the aid of oxygen cylinders and God-knows-what-else. Upon making inquiries, I learnt that not only one but two Naloxone injections (a life saving drug for reviving such OD cases) had already been administered but he failed to respond positively. He lay on one of those makeshift type beds of the casualty. Instead of breathing, he gave out deep gasps after short intervals and his skin was a sickly pallor. We were waiting for the Naloxone to take effect.

I was getting pretty desperate as the situation was rapidly slipping out of control. I called a few of my friends who came to mind and managed to contact one who works in a drug sector NGO. He was in Guwahati at that time but he somehow coordinated a few people for assistance. In the meantime, the condition of Ibungo had gone from bad to worse and I panicked. My friend in Guwahati told me to get another Naloxone fast from the DIC (Drop in Centre) run by an NGO at North AOC where the said drug is dispensed free of cost to those in need.

I sped towards North AOC and upon reaching there, I made hurried inquiries only to find out that the DIC had closed for the day. Somebody asked what the problem was and I explained the situation as best as I could. He immediately offered to help and hurriedly ran into one of the lanes where I found a stall giving Naloxone to those in need. After getting the injection, the two of us rushed back to the hospital but we found that another injection had already been administered. The third dose was given by the same pharmacy where the previous two doses were taken from.

After the third dose, Ibungo showed some signs of regaining his senses as he started to respond to our instructions to open his eyes and to extend his tongue. But our sighs of relief were soon snuffed out when the pharmacy people, which we later came to know were runners of Ema Medical Store, JN Hospital, Porompat, made their move at the first signs of life.

They were asking for an exorbitant amount of Rs. 5,000/- per vial (the retail price of which is about Rs. 70/- at the prevailing market rate) for the three doses which comes to a total of Rs. 15,000/-. We tried to reason with them that we are extremely grateful to them for saving the life of Ibungo and we are willing to pay but fervently requested for showing a little leniency in the price. They flatly rejected our request and argued that we should not bargain over the amount after the life saving drug has saved the life of the patient. We were in an extremely vulnerable state and at that point of time the NGO people who had come down to assist us intervened by telling them that they are ready to replace the three doses of Naloxone if they would agree to reduce their price.

However, the pharmacy people adamantly stuck to their stand as a result of which a few hot words were exchanged between them and the NGO people and they almost came to fisticuffs. As it was hardly the time or place for any scuffle, we tried to pacify them and the haggling over the price continued. We were in a dilemma as to whether to attend to the patient or to take part in the whole bargaining process or to pacify the potential scuffle which may break out at any time.

At around 7:30 p.m. when Ibungo was shifted to the Male Ward, one savvy guy in a loud shirt and white shoes came to the ward and informed us that he was the proprietor of Ema Medical Store. We started negotiating with him and as if doing us a grand favour, he agreed to waive the price of one dose and told us that he was willing to accept just Rs. 10,000 only. We had to literally empty all our pockets to put together a sum of Rs. 8,000 and after paying him the same, we bargained with him for that to be the final offer as we still had to pay for the other medicines like DNS, 10% Dextrose, vitamins, anti-bacterials and what-nots which were supplied by their pharmacy. But the guy in the loud shirt stubbornly stuck to his stand and told us to cough up another Rs. 1,000 to make the final deal Rs. 9,000. We were still reeling under the pressure of the concerned doctor telling us to admit Ibungo in the ICU Ward as there was a possibility of cardiac arrest and he had to be shifted in that very night into ICU.

We had an eventful two days as the health and general condition of Ibungo was closely monitored and we were told that he was still not fit to be discharged. Probably seeing the seriousness of the situation, the pharmacy people laid low during the said two days. However, sometime in the evening of the third day, one runner of the pharmacy came again apparently upon sensing that the patient was going to be discharged and asked for the balance amount of Rs. 1,000 over and above the cost of other medicines which we had taken on credit. We again requested him to waive the balance amount telling him that our extended stay at the hospital has caused unprecedented extra expenses. He did not relent in any way and upon our persistent requests, he became incensed and told us whether we thought the whole thing as a joke.

We finally came to the conclusion that these people are purse-milking and heartless vultures who prey upon the misery of other people and ended up paying the balance amount.

After the incident, the excessively obtuse acts of the pharmacy people continued to persist in my mind and feel that something should be done to prevent such occurrences in future. I also feel the urgent need for setting up more D.I.C.s dispensing such life saving drugs within the reachable proximities of each and every hospital, clinic and wherever possible.

Moreover, it is a dire necessity for such medicine to be made available round the clock for an event of O.D. can happen irrespective of time and places. It is a very happening thing for a place like Manipur and there is no point denying it. Literally, I should say that it is worth naming a daily event.  In conclusion, I would like to earnestly appeal to all the Health Authorities of the state, NGOs and people working in the drug sector for making this wish a reality.

Source:- TSE

Doctors in developing nations spend less than 60 sec to prescribe medicine: WHO

April 23, 2011 Leave a comment

NEW DELHI: On an average, doctors in developing countries spend less than 60 seconds in prescribing medicines and explaining the regimen to their patients, according to World Health Organization’s (WHO) World Medicines Situation 2011 that was released on Friday.

As a result, only half of patients receive any advice on how to take their medicines and about one third of them don’t know how to take their medicines immediately on leaving the facility.

Though around 80% of all prescribed medicines are dispensed — usually, they are done by untrained personnel — and as many as 20%–50% of medicines dispensed are not labelled.

According to the report, “the dispensing process greatly influences how medicines are used. The WHO database shows that, on average, dispensing time is one minute. In such circumstances it is not surprising that patient adherence to medicines is poor.”

Dr Ranjit Roychoudhury, eminent clinical pharmacologist, told TOI that “the issue of doctors taking no time to explain the drugs they give to their patients is an acute problem, especially in overcrowded hospitals in India. Adherence also improves if doctor and patient have a rapport among them which develops by giving each other time.”

As per the report, only about 60% countries train their medical students on various aspects of prescribing medicines, and only about 50% require any form of continuing medical education.

The basic training for nurses and paramedical staff, who often do a bulk of prescribing, was even less — only about 40% of countries give them any basic training on how to prescribe.

The problem of non-adherence, according to the WHO, is not only relevant for acute complaints, but even more so for chronic diseases.

Due to the increasing number of patients suffering from diabetes, cardiovascular disease, mental health problems, epilepsy and chronic obstructive pulmonary disease (COPD), adherence to medication is becoming increasingly important, the report added.

WHO feels many countries are making relatively little investment in promoting rational use of medicines.

“It could be argued that such investment would be paid back many times over by the savings from better use of medicines, particularly reduced misuse. However, these savings would take some time to achieve and thus might not be felt by the investing government, particularly in health systems where there is a very large private sector and most medicines are paid for out-of-pocket by patients and not by government,” the report said.

In India, over 80% of health expenditure is out of pocket — majority of which is spent in purchasing drugs.

Globally — and mainly in developing countries — doctors prescribe antibiotics to patients who do not need them, while patients do not adhere to their treatment causing the risk of antibiotic resistance. The report says two thirds of all antibiotics are sold without prescription through unregulated private sectors. Low adherence levels by patients are common, many patients taking antibiotics in under-dose or for shortened duration — like three instead of five days.

“Irrational use of medicines is a serious global problem that is wasteful and harmful. In developing countries, in primary care, less than 40% of patients in public sector and 30% of patients in private sector are treated in accordance with standard treatment guidelines,” said Kathleen Holloway from WHO’s Department of Essential Medicines and Pharmaceutical Policies.

Source:- TNN