A possible case of exfoliative dermatitis due to ibuprofen in an Eleven-month-old infant

Ibuprofen is a NSAID belonging to the class of propionic acid derivatives which is widely used for its analgesic, antipyretic and anti-inflammatory action. Well-known adverse effects of ibuprofen include gastric irritability leading to nausea and vomiting as well as allergic manifestations such as urticaria and skin rashes. Severe ADRs include renal papillary necrosis, SJS/TEN, and thrombotic events leading to myocardial infarction and stroke. Authors present a case of exfoliative dermatitis in an 11-month-old infant possibly due to ibuprofen. An 11-month-old infant was prescribed syrup ibuprofen by a local medical practitioner for unclear reasons. Three days after ibuprofen therapy, the infant developed erythematous, crusting exfoliative lesions predominantly over the face with a few lesions over the lower abdomen. Subsequently, the infant was admitted to Kempegowda Institute of Medical Sciences and Research Center Hospital, Bangalore. A diagnosis of drug-induced exfoliative dermatitis was made after ruling out other causes. Treatment was initiated with intravenous and topical dexamethasone along with saline compressions and amoxicillin + clavulanic acid for secondary bacterial infection as well as topical emollient cream applied over the affected areas. The lesions improved significantly with the above management and the infant recovered enough to be discharged from the hospital after 3 days. The reaction was assessed to be “possible” as per Naranjo and WHO-UMC causality assessment scales, “moderately severe” on modified Hartwig’s severity assessment scale and “not preventable” according to Schumock and Thornton criteria. Severe and serious reactions such as exfoliative dermatitis can be caused by commonly used drugs like ibuprofen

Assessment of knowledge, attitudes and practice among interns about over the counter drugs in a tertiary care hospital in India

Background: Drugs that are dispensed against a valid prescription issued to a patient by a registered medical practitioner are known as “prescription-only drugs”. In India, they have been regulated under schedule H, H1, G, and X of the Drugs and Rules (1945). The drugs which are not included in the list of “prescription-only drugs” are considered to be over-the-counter drugs (OTC). There is no provision for an OTC drug schedule in the Drugs and Cosmetics Rules 1945, and these drugs have higher chances of misuse or abuse. This study was undertaken to assess the knowledge, attitudes and practice among medical interns about OTC drugs in a tertiary care hospital in India.Methods: This was a cross-sectional study, which was conducted at Kempegowda Institute of Medical Sciences and Research Center, Bangalore, Karnataka, India, from March 2018 to September 2018. A pre-validated questionnaire consisting of 24 questions to assess the knowledge, attitude, and practice was administered to 80 medical interns chosen by simple randomization, out of which 14 questions were related to knowledge, 6 related to attitude and 4 related to the practice. The participants were provided 30 minutes to complete the questionnaire. The data recorded were analyzed using Microsoft Excel.Results: There were some gaps in the knowledge, attitude and practice among the medical interns about OTC medications.Conclusions: There is a need for special emphasis on the MBBS curriculum about the use of OTC drugs

Mental Health First Aid guidelines for helping a suicidal person: a Delphi consensus study in India

<p>Abstract</p> <p>Background</p> <p>This study aimed to develop guidelines for how a member of the Indian public should provide mental health first aid to a person who is suicidal.</p> <p>Methods</p> <p>The guidelines were produced by developing a questionnaire containing possible first aid actions and asking an expert panel of Indian mental health clinicians to rate whether each action should be included in the guidelines. The content of the questionnaire was based on a systematic search of the relevant evidence and claims made by authors of consumer and carer guides and websites. Experts were recruited by SC, EC and HM. The panel members were asked to complete the questionnaire by web survey. Three rounds of the rating were carried and, at the end of each round, items that reached the consensus criterion were selected for inclusion in the guidelines. During the first round, panel members were also asked to suggest any additional actions that were not covered in the original questionnaire (to include items that are relevant to local cultural circumstances, values, and social norms.). Responses to the open-ended questions were used to generate new items.</p> <p>Results</p> <p>The output from the Delphi process was a set of agreed upon action statements. The Delphi process started with 138 statements, 30 new items were written based on suggestions from panel members and, of these 168 items, 71 met the consensus criterion. These statements were used to develop the guidelines appended to this paper. Translated versions of the guidelines will be produced and used for training.</p> <p>Conclusions</p> <p>There are a number of actions that are considered to be useful for members of the public when they encounter someone who is experiencing suicidal thoughts or engaging in suicidal behaviour. Although the guidelines are designed for members of the public, they may also be helpful to non-mental health professionals working in health and welfare settings.</p

Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months.

BACKGROUND: Depressive and anxiety disorders (common mental disorders) are the most common psychiatric condition encountered in primary healthcare. AIMS: To test the effectiveness of an intervention led by lay health counsellors in primary care settings (the MANAS intervention) to improve the outcomes of people with common mental disorders. METHOD: Twenty-four primary care facilities (12 public, 12 private) in Goa (India) were randomised to provide either collaborative stepped care or enhanced usual care to adults who screened positive for common mental disorders. Participants were assessed at 2, 6 and 12 months for presence of ICD-10 common mental disorders, the severity of symptoms of depression and anxiety, suicidal behaviour and disability levels. All analyses were intention to treat and carried out separately for private and public facilities and adjusted for the design. The trial has been registered with clinical trials.gov (NCT00446407). RESULTS: A total of 2796 participants were recruited. In public facilities, the intervention was consistently associated with strong beneficial effects over the 12 months on all outcomes. There was a 30% decrease in the prevalence of common mental disorders among those with baseline ICD-10 diagnoses (risk ratio (RR) = 0.70, 95% CI 0.53-0.92); and a similar effect among the subgroup of participants with depression (RR = 0.76, 95% CI 0.59-0.98). Suicide attempts/plans showed a 36% reduction over 12 months (RR=0.64, 95% CI0.42–0.98) among baseline ICD-10 cases. Strong effects were observed on days out of work and psychological morbidity, and modest effects on overall disability [corrected]. In contrast, there was little evidence of impact of the intervention on any outcome among participants attending private facilities. CONCLUSIONS: Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders, suicidal behaviour, psychological morbidity and disability days among those attending public primary care facilities

Mapping the evidence on pharmacological interventions for non-affective psychosis in humanitarian non-specialised settings: a UNHCR clinical guidance.

BACKGROUND: Populations exposed to humanitarian emergencies are particularly vulnerable to mental health problems, including new onset, relapse and deterioration of psychotic disorders. Inadequate care for this group may lead to human rights abuses and even premature death. The WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG), and its adaptation for humanitarian settings (mhGAP-HIG), provides guidance for management of mental health conditions by non-specialised healthcare professionals. However, the pharmacological treatment of people with non-affective psychosis who do not improve with mhGAP first-line antipsychotic treatments is not addressed. In order to fill this gap, UNHCR has formulated specific guidance on the second-line pharmacological treatment of non-affective psychosis in humanitarian, non-specialised settings. METHODS: Following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, a group of international experts performed an extensive search and retrieval of evidence on the basis of four scoping questions. Available data were critically appraised and summarised. Clinical guidance was produced by integrating this evidence base with context-related feasibility issues, preferences, values and resource-use considerations. RESULTS: When first-line treatments recommended by mhGAP (namely haloperidol and chlorpromazine) are not effective, no other first-generation antipsychotics are likely to provide clinically meaningful improvements. Risperidone or olanzapine may represent beneficial second-line options. However, if these second-line medications do not produce clinically significant beneficial effects, there are two possibilities. First, to switch to the alternative (olanzapine to risperidone or vice versa) or, second, to consider clozapine, provided that specialist supervision and regular laboratory monitoring are available in the long term. If clinically relevant depressive, cognitive or negative symptoms occur, the use of a selective serotonin reuptake inhibitor may be considered in addition or as an alternative to standard psychological interventions. CONCLUSIONS: Adapting scientific evidence into practical guidance for non-specialised health workers in humanitarian settings was challenging due to the paucity of relevant evidence as well as the imprecision and inconsistency of results between studies. Pragmatic outcome evaluation studies from low-resource contexts are urgently needed. Nonetheless, the UNHCR clinical guidance is based on best available evidence and can help to address the compelling issue of undertreated, non-affective psychosis in humanitarian settings

The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India

BACKGROUND: Care for schizophrenia in low and middle income countries is predominantly facility based and led by specialists, with limited use of non-pharmacological treatments. Although community based psychosocial interventions are emphasised, there is little evidence about their acceptability and feasibility. Furthermore, the shortage of skilled manpower is a major barrier to improving access to these interventions. Our study aimed to develop a lay health worker delivered community based intervention in three sites in India. This paper describes how the intervention was developed systematically, following the MRC framework for the development of complex interventions. METHODS: We reviewed the lierature on the burden of schizophrenia and the treatment gap in low and middle income countries and the evidence for community based treatments, and identified intervention components. We then evaluated the acceptability and feasibility of this package of care through formative case studies with individuals with schizophrenia and their primary caregivers and piloted its delivery with 30 families. RESULTS: Based on the reviews, our intervention comprised five components (psycho-education; adherence management; rehabilitation; referral to community agencies; and health promotion) to be delivered by trained lay health workers supervised by specialists. The intervention underwent a number of changes as a result of formative and pilot work. While all the components were acceptable and most were feasible, experiences of stigma and discrimination were inadequately addressed; some participants feared that delivery of care at home would lead to illness disclosure; some participants and providers did not understand how the intervention related to usual care; some families were unwilling to participate; and there were delivery problems, for example, in meeting the targeted number of sessions. Participants found delivery by health workers acceptable, and expected them to have knowledge about the subject matter. Some had expectations regarding their demographic and personal characteristics, for example, preferring only females or those who are understanding/friendly. New components to address stigma were then added to the intervention, the collaborative nature of service provision was strengthened, a multi-level supervision system was developed, and delivery of components was made more flexible. Criteria were evolved for the selection and training of the health workers based on participants' expectations. CONCLUSIONS: A multi-component community based intervention, targeting multiple outcomes, and delivered by trained lay health workers, supervised by mental health specialists, is an acceptable and feasible intervention for treating schizophrenia in India

Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial

Background: Observational evidence suggests that community-based services for people with schizophrenia can be successfully provided by community health workers, when supervised by specialists, in low-income and middleincome countries. We did the COmmunity care for People with Schizophrenia in India (COPSI) trial to compare the eff ectiveness of a collaborative community-based care intervention with standard facility-based care. Methods: We did a multicentre, parallel-group, randomised controlled trial at three sites in India between Jan 1, 2009 and Dec 31, 2010. Patients aged 16–60 years with a primary diagnosis of schizophrenia according to the tenth edition of the International Classifi cation of Diseases, Diagnostic Criteria for Research (ICD-10-DCR) were randomly assigned (2:1), via a computer-generated randomisation list with block sizes of three, six, or nine, to receive either collaborative community-based care plus facility-based care or facility-based care alone. Randomisation was stratifi ed by study site. Outcome assessors were masked to group allocation. The primary outcome was a change in symptoms and disabilities over 12 months, as measured by the positive and negative syndrome scale (PANSS) and the Indian disability evaluation and assessment scale (IDEAS). Analysis was by modifi ed intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 56877013. Findings: 187 participants were randomised to the collaborative community-based care plus facility-based care group and 95 were randomised to the facility-based care alone group; 253 (90%) participants completed follow-up to month 12. At 12 months, total PANSS and IDEAS scores were lower in patients in the intervention group than in those in the control group (PANSS adjusted mean diff erence –3·75, 95% CI −7·92 to 0·42; p=0·08; IDEAS –0·95, −1·68 to −0·23; p=0·01). However, no diff erence was shown in the proportion of participants who had a reduction of more than 20% in overall symptoms (PANSS 85 [51%] in the intervention group vs 44 [51%] in the control group; p=0·89; IDEAS 75 [48%] vs 28 [35%]). We noted a signifi cant reduction in symptom and disability outcomes at the rural Tamil Nadu site (−9·29, −15·41 to −3·17; p=0·003). Two patients (one in each group) died by suicide during the study, and two patients died because of complications of a road traffi c accident and pre-existing cardiac disease. 18 (73%) patients (17 in the intervention group) were admitted to hospital during the course of the trial, of whom seven were admitted because of physical health problems, such as acute gastritis and vomiting, road accident, high fever, or cardiovascular disease. Interpretation: The collaborative community-based care plus facility-based care intervention is modestly more eff ective than facility-based care, especially for reducing disability and symptoms of psychosis. Our results show that the study intervention is best implemented as an initial service in settings where services are scarce, for example in rural areas

Experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in India.

Stigma associated with schizophrenia significantly affects family caregivers, yet few studies have examined the nature and determinants of family stigma and its relationship to their knowledge about the condition. This paper describes the experiences and determinants of stigma reported by the primary caregivers of people living with schizophrenia (PLS) in India. The study used mixed methods and was nested in a randomised controlled trial of community care for people with schizophrenia. Between November 2009 and October 2010, data on caregiver stigma and functional outcomes were collected from a sample of 282 PLS-caregiver dyads. In addition, 36 in-depth-interviews were conducted with caregivers. Quantitative findings indicate that 'high caregiver stigma' was reported by a significant minority of caregivers (21%) and that many felt uncomfortable to disclose their family member's condition (45%). Caregiver stigma was independently associated with higher levels of positive symptoms of schizophrenia, higher levels of disability, younger PLS age, household education at secondary school level and research site. Knowledge about schizophrenia was not associated with caregiver stigma. Qualitative data illustrate the various ways in which stigma affected the lives of family caregivers and reveal relevant links between caregiver-stigma related themes ('others finding out', 'negative reactions' and 'negative feelings and views about the self') and other themes in the data. Findings highlight the need for interventions that address both the needs of PLS and their family caregivers. Qualitative data also illustrate the complexities surrounding the relationship between knowledge and stigma and suggest that providing 'knowledge about schizophrenia' may influence the process of stigmatisation in both positive and negative ways. We posit that educational interventions need to consider context-specific factors when choosing anti-stigma-messages to be conveyed. Our findings suggest that messages such as 'recovery is possible' and 'no-one is to blame' may be more helpful than focusing on bio-medical knowledge alone

Estimating nitrogen risk to Himalayan forests using thresholds for lichen bioindicators

Himalayan forests are biodiverse and support the cultural and economic livelihoods of their human communities. They are bounded to the south by the Indo-Gangetic Plain, which has among the highest concentrations of atmospheric ammonia globally. This source of excess nitrogen pushes northwards into the Himalaya, generating concern that Himalayan forests will be impacted. To estimate the extent to which atmospheric nitrogen is impacting Himalayan forests we focussed on lichen epiphytes, which are a well-established bioindicator for atmospheric nitrogen pollution. First, we reviewed published literature describing nitrogen thresholds (critical levels and loads) at which lichen epiphytes are affected, identifying a mean and confidence intervals based on previous research conducted across a diverse set of biogeographic and ecological settings. Second, we used estimates from previously published atmospheric chemistry models (EMEP-WRF and UKCA-CLASSIC) projected to the Himalaya with contrasting spatial resolution and timescales to characterise model variability. Comparing the lichen epiphyte critical levels and loads with the atmospheric chemistry model projections, we created preliminary estimates of the extent to which Himalayan forests are impacted by excess nitrogen; this equated to c. 80–85% and c. 95–98% with respect to ammonia and total nitrogen deposition, respectively. Recognising that lichens are one of the most sensitive bioindicators for atmospheric nitrogen pollution, our new synthesis of previous studies on this topic generated concern that most Himalayan forests are at risk from excess nitrogen. This is a desk-based study that now requires verification through biological surveillance, for which we provide key recommendations