Study of clinical and epidemiological profile of poisonous snake bite in a tertiary centre in North Kerala

Background: Snakebites are well-known medical emergencies in many parts of the world, especially in rural areas.The incidence of snakebite mortality is particularly high in South-East Asia. Rational use of snake anti-venom can substantially reduce mortality and morbidity due to snakebites. Snake bite is an important health problem in India also especially in North Kerala which has an agricultural background. There is a lack of study regarding this topic in this area. North Kerala differs from other areas in the country as hump nosed pit viper bites are more common here due to its proximity to western Ghats where it .Anti snake venom is ineffective to bites by hump nosed pit viper. Authors objectives  was to assess the clinical and epidemiological profile and outcome of poisonous snake bites.Methods: Retrospective observational study done among patients with snake bite with envenomation admitted in Academy of Medical education, Pariyaram, Kannur, Kerala from January 2018 to September 2018.Results: There were 90 cases of venomous snake bite during the study period. Of these males were predominant (70%). Majority were in the age group between 20 and 40. Majority of bites occurred in the months of June and July. Bite in the extremities were more common. Nine patients were brought 1 day after the bite. Snake identified most common was Russell’s viper followed by pit viper. Majority of the systemic envenomation was hemotoxic 80 patients (85%).Conclusions: The study stress the fact that snake bite is an important problem in North Kerala. The study also shows that delay in treatment is a major risk factor for morbidity. Hump nosed pit viper bites are more common in this area

Study of acute febrile illness with thrombocytopenia in a tertiary care centre

Background: In the recent period there is an upsurge in the incidence of fever with thrombocytopenia in the Northern Kerala. This may be due to the several emerging and re emerging infections which causes frequent epidemics in the region. Early diagnosis and meticulous management will prevent fatal out come. Studies on fever with thrombocytopenia are very few in the Northern part of Kerala.Methods: This was a descriptive study conducted at Academy of Medical Sciences Pariyaram over a period of one year from November 2015 to October 2016. The study includes 251 cases attending outpatient and inpatients units in the department of medicine. All patients with a platelet count less than 150000 was included in this study and detailed clinical and laboratory evaluation was done and assessed for the etiology and outcome.Results: Among the 251 cases, Dengue fever accounts 54.5 % of cases and 26.2% are other viral fever where the exact causative organism was not detected. Leptospirosis, malaria were also important causes of fever with thrombocytopenia. Major incidence of hemorrhagic manifestation occurred in the age group of 20 to 30 years whose platelet count was in the range of 10000 to 40000/mm3.Conclusions: In this study more than 50 % had dengue fever and in 26.2% cases an exact etiology cannot be determined. This finding highlights the fact that there may be many unidentified infection which cause fulminant thrombocytopenia and there is a need for wider screening of infection.

Clinical profile of dengue fever in a tertiary care centre in North Kerala

Background: Dengue fever is the most common arboviral disease and fifty percent of world population is at risk. Frequent outbreaks are reported from all states of our country and incidence increases every year. This case study is of 305 patients from Academy of Medical Sciences, which is a tertiary care centre and research Institute in North Kerala. The objective of this study was to study the clinical profile of dengue fever.Methods: Study was prospective observational study conducted during the epidemic for a period of one year. All the cases which fulfilled WHO criteria for diagnosis of dengue fever and those who are positive for IGM antibody detected by enzymelinked immunosorbent assay (IgM ELISA) were only included in this study.Results: There is male preponderance, and those above the age of 30 years affected more. All patients had fever. Gastrointestinal manifestation like nausea and vomiting were commonly observed symptoms. Hepatomegaly, rash and conjuctival suffusion were important physical findings, whereas splenomegaly noted only in 8.2% cases. Thrombocytopenia is noticed in 73.96%.Conclusions: The mortality is 2.6%. Hypotension and thrombocytopenia are the two important determinants of mortality. Dengue Shock syndrome and Dengue Hemorrhagic Fever were relatively less when compared to other epidemics from different regions

Study to assess the changing pattern of clinical profile and determine the prognosis in hepatic encephalopathy

Background: Hepatic encephalopathy (HE) is a common complication of liver disease that requires intensive care management. The prevalence of HE is increasing during recent period. The most important factors of HE are alcohol consumption, chronic hepatitis, hepatotoxic drugs and unhealthy changes in life style. There were only relatively few studies from our region on the changing profile of hepatic encephalopathy under the background of life style changes. This study was conducted with the aim to detect the changing pattern of clinical profile, precipitants and to assess the prognosis of patients with hepatic encephalopathy.Methods: This was a prospective study for a period of 18 months since January 2012 at Academy of Medical Sciences, Pariyaram, Kannur, a tertiary care centre situated in the northern part of Kerala. Patients admitted in the medical and gastroenterology wards and intensive care units that fulfilled the inclusion criteria were enrolled in this study.Results: Among the 76 patients with HE, 60 were suffering from CLD and 16 due to acute liver failure. The common etiologies for HE in CLD patients were Alcoholic cirrhosis (63%), Cryptogenic cirrhosis (17%) and cirrhosis due to chronic HBV (10%) and HCV hepatitis (7%) respectively. Among the CLD patients at the start of observation majority were in Child Pugh class B and C. Based on West Haven grading most of them had Grade 2 and 3 HE. Majority with Grade 1, 2 and 3 improved where as those with Grade 4 and Grade 3 in Child Pugh class C worsened. The common precipitants of HE were GI bleed, dyselectrolemia, constipation and infections. Among these precipitants a statistically significant association for a worse outcome was present only with infection. Leptospirosis and deliberate self-harm due to ingestion of hepatotoxic rodenticide and paracetamol were the leading cause of hepatic encephalopathy in acute liver failureConclusions: In present study HE was most commonly seen in patients with alcoholic liver disease. Cryptogenic cirrhosis associated with other life style diseases was the second common condition. Among all precipitating factors infection appeared as a statistically significant factor predicting a worse outcome. Health education among alcoholic patients and life style modifications to prevent cryptogenic cirrhosis are of paramount importance in curtailing the increase in incidence of HE in this region

A proposal for expansion of the medical specialty of rehabilitation medicine

The workforce of the medical specialty of Rehabilitation Medicine (RM) in the UK is 10 times less than the European average for the specialty of Physical and Rehabilitation Medicine (PRM). This can be explained partly by the difference in the scope of practice within the specialty between the UK and other European countries and USA. This opinion paper aims to compare the rehabilitation needs in chronic medical conditions and compare the scope of practice between countries within Europe and other regions of the world. The potential advantages of a broader remit specialty to improve rehabilitation care for patients by involving rehabilitation physicians in various medical conditions is explored. Recommendations have been put forward in the Rehabilitation Medicine Expansion Proposal (RMEP), which is likely to make the medical specialty of RM/ PRM more satisfying for the doctors working in the specialty and a more attractive career choice for those entering training in the specialty. There is a need for an international universal framework for the scope of the specialty to have a greater impact on improving the lives of those with chronic medical conditions

Maternal death inquiry and response in India - the impact of contextual factors on defining an optimal model to help meet critical maternal health policy objectives

<p>Abstract</p> <p>Background</p> <p>Maternal death reviews have been utilized in several countries as a means of identifying social and health care quality issues affecting maternal survival. From 2005 to 2009, a standardized community-based maternal death inquiry and response initiative was implemented in eight Indian states with the aim of addressing critical maternal health policy objectives. However, state-specific contextual factors strongly influenced the effort's success. This paper examines the impact and implications of the contextual factors.</p> <p>Methods</p> <p>We identified community, public health systems and governance related contextual factors thought to affect the implementation, utilization and up-scaling of the death inquiry process. Then, according to selected indicators, we documented the contextual factors' presence and their impact on the process' success in helping meet critical maternal health policy objectives in four districts of Rajasthan, Madhya Pradesh and West Bengal. Based on this assessment, we propose an optimal model for conducting community-based maternal death inquiries in India and similar settings.</p> <p>Results</p> <p>The death inquiry process led to increases in maternal death notification and investigation whether civil society or government took charge of these tasks, stimulated sharing of the findings in multiple settings and contributed to the development of numerous evidence-based local, district and statewide maternal health interventions. NGO inputs were essential where communities, public health systems and governance were weak and boosted effectiveness in stronger settings. Public health systems participation was enabled by responsive and accountable governance. Communities participated most successfully through India's established local governance Panchayat Raj Institutions. In one instance this led to the development of a multi-faceted intervention well-integrated at multiple levels.</p> <p>Conclusions</p> <p>The impact of several contextual factors on the death inquiry process could be discerned, and suggested an optimal implementation model. District and state government must mandate and support the process, while the district health office should provide overall coordination, manage the death inquiry data as part of its routine surveillance programme, and organize a highly participatory means, preferably within an existing structure, of sharing the findings with the community and developing evidence-based maternal health interventions. NGO assistance and the support of a development partner may be needed, particularly in locales with weaker communities, public health systems or governance.</p

Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-Adjusted life-years for 29 cancer groups, 1990 to 2017 : A systematic analysis for the global burden of disease study

Importance: Cancer and other noncommunicable diseases (NCDs) are now widely recognized as a threat to global development. The latest United Nations high-level meeting on NCDs reaffirmed this observation and also highlighted the slow progress in meeting the 2011 Political Declaration on the Prevention and Control of Noncommunicable Diseases and the third Sustainable Development Goal. Lack of situational analyses, priority setting, and budgeting have been identified as major obstacles in achieving these goals. All of these have in common that they require information on the local cancer epidemiology. The Global Burden of Disease (GBD) study is uniquely poised to provide these crucial data. Objective: To describe cancer burden for 29 cancer groups in 195 countries from 1990 through 2017 to provide data needed for cancer control planning. Evidence Review: We used the GBD study estimation methods to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-Adjusted life-years (DALYs). Results are presented at the national level as well as by Socio-demographic Index (SDI), a composite indicator of income, educational attainment, and total fertility rate. We also analyzed the influence of the epidemiological vs the demographic transition on cancer incidence. Findings: In 2017, there were 24.5 million incident cancer cases worldwide (16.8 million without nonmelanoma skin cancer [NMSC]) and 9.6 million cancer deaths. The majority of cancer DALYs came from years of life lost (97%), and only 3% came from years lived with disability. The odds of developing cancer were the lowest in the low SDI quintile (1 in 7) and the highest in the high SDI quintile (1 in 2) for both sexes. In 2017, the most common incident cancers in men were NMSC (4.3 million incident cases); tracheal, bronchus, and lung (TBL) cancer (1.5 million incident cases); and prostate cancer (1.3 million incident cases). The most common causes of cancer deaths and DALYs for men were TBL cancer (1.3 million deaths and 28.4 million DALYs), liver cancer (572000 deaths and 15.2 million DALYs), and stomach cancer (542000 deaths and 12.2 million DALYs). For women in 2017, the most common incident cancers were NMSC (3.3 million incident cases), breast cancer (1.9 million incident cases), and colorectal cancer (819000 incident cases). The leading causes of cancer deaths and DALYs for women were breast cancer (601000 deaths and 17.4 million DALYs), TBL cancer (596000 deaths and 12.6 million DALYs), and colorectal cancer (414000 deaths and 8.3 million DALYs). Conclusions and Relevance: The national epidemiological profiles of cancer burden in the GBD study show large heterogeneities, which are a reflection of different exposures to risk factors, economic settings, lifestyles, and access to care and screening. The GBD study can be used by policy makers and other stakeholders to develop and improve national and local cancer control in order to achieve the global targets and improve equity in cancer care. © 2019 American Medical Association. All rights reserved.Peer reviewe

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016

Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND: Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). METHODS: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. FINDINGS: The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9-78·6) for females and 72·0 years (68·8-75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0-49·5]) and for males was in Lesotho (41·5 years [39·0-44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97-6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74-6·27) for males and 6·49 years (6·08-6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61-1·93) for males and 1·96 years (1·69-2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (-2·3% [-5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. INTERPRETATION: At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support. FUNDING: Bill & Melinda Gates Foundation

Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. Methods: We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting. Findings: Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs 1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]). Interpretation: Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury