Shooting shadows: India's struggle to reduce the burden of anaemia.

Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015-2016 and 2019-2021) is concerning to India's public health system. This article reviews existing food-based and clinical strategies to mitigate the anaemia burden and why they are premature and insufficient. In a context where multiple anaemia control programmes are in play, this article proposes a threefold strategy for consideration. First, except the Comprehensive National Nutrition Survey, 2016-2018, which measured Hb concentration among children and adolescents aged 1-19 years using venous blood samples, all national surveys use capillary blood samples to determine Hb levels, which could be erroneous. The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples. Second, without deciding the appropriate dose of Fe needed for an individual, food fortification programmes that are often compounded with layering of other micronutrients could be harmful and further research on this issue is needed. Same is true for the pharmacological intervention of Fe tablet or syrup supplementation programmes, which is given to individuals without assessing its need. In addition, there is a dire need for robust research to understand both the long-term benefit and side effects of Fe supplementation programmes. Third and final, the WHO is in process of reviewing the Hb threshold for defining anaemia, therefore the introduction of new anaemia control programmes should be restrained.

Strategies and challenges in Kerala's response to the initial phase of COVID-19 pandemic: a qualitative descriptive study.

OBJECTIVE: To understand the structures and strategies that helped Kerala in fighting the COVID-19 pandemic, the challenges faced by the state and how it was tackled. DESIGN: Qualitative descriptive study using focus group discussions and in-depth interviews. SETTING: State of Kerala, India. PARTICIPANTS: 29 participants: four focus group discussions and eight in-depth interviews. Participants were chosen purposively based on their involvement in decision-making and implementation of COVID-19 control activities, from the department of health and family welfare, police, revenue, local self-government and community-based organisations. Districts, panchayats (local bodies) and primary health centres (PHCs) were selected based on epidemiological features of the area like the intensity of disease transmission and preventive/containment activities carried out in that particular area to capture the wide range of activities undertaken in the state. RESULTS: The study identified five major themes that can inform best practices viz social capital, robust public health system, participation and volunteerism, health system preparedness, and challenges. This study was a real-time exploration of the intricacies of COVID-19 management in a low/middle-income country and the model can serve as an example for other states and nations to emulate or adjust accordingly. CONCLUSION: The study shows the impact of synergy of these themes towards more effective solutions; however, further research is much needed in examining the relationship between these factors and their relevance in policy decisions.

Manifestations and risk factors of post COVID syndrome among COVID-19 patients presented with minimal symptoms - A study from Kerala, India.

BACKGROUND: COVID 19 is associated with the development of post COVID syndrome usually manifested as fatigue, anxiety, joint pain, headache, chest pain, dementia, depression, and dyspnea. Documented evidence of post COVID syndrome among patients with asymptomatic or mild infections, especially from India is less. METHODOLOGY: A community based prospective cohort study was conducted among 154 patients admitted in CFLTCs of coastal Thiruvananthapuram, Kerala during May-August 2020. They were enrolled at the time of their admission to CFLTCs and were followed up for three months after discharge. The discharged patients were followed up at regular intervals of three weeks and three months by telephonic interview using a structured proforma. RESULTS: Out of the 154 patients followed up, 57 (37%) were men and 97 (63%) were women. The mean (SD) age of study participants was 31.49 (18.4) years. At least one symptom was present in 120 (78.0%) patients at the time of admission. Cough (29, 18.8%), fever (26, 16.8%), headache (25, 16.2%), rhinitis (23,14.9%) and sore throat (18, 11.7%) were the major symptoms reported at the time of admission. At the end of three weeks, 11 (7.1%) patients and at the end of three months 18 (11.7%) patients reported to have symptoms. Fatigue (5.8%), headache (5.8%) myalgia (3.2%) joint pain (2.5%) and exertional dyspnea (2.5%) were the predominant symptoms. Presence of fatigue, cough and breathlessness at the time of admission, and presence of another COVID positive family member were significantly associated with the appearance of post COVID symptoms. CONCLUSION: Post COVID syndrome is not uncommon in COVID 19 patients with minimal symptoms. Understanding long term consequences of COVID 19 is as important as management of acute COVID 19 due to its multisystem involvement and its implications on health and well-being.

Overcoming Barriers in a Traditional Medical Education System by the Stepwise, Evidence-Based Introduction of a Modern Learning Technology.

INTRODUCTION: Histology teaching in India and in other developing countries has not changed much over the past decades and has not joined the global movement of using virtual microscopy (VM). Many factors may have contributed to this academic inertia-including curricular requirements for traditional microscopy (TM) skills, assessments that are heavily based on TM, and unfamiliarity with modern technology among faculty, as well as infrastructural shortcomings. This study is aimed at overcoming these roadblocks by using a blended approach combining VM with TM in a tradition-centered curricular setting. METHODS: For validation of this approach, the authors conducted a non-randomized controlled trial with a crossover design on first year medical students at the Government Medical College, Thiruvananthapuram, India. Examination scores and responses of a student group taught with VM as an adjunct to TM were compared with a student group taught with TM only. RESULTS: The test group had significantly better results when compared to the control group for knowledge-based tests (p = 0.012; analysis of co-variance) and for an unannounced visual-based test conducted 1 month later (p = 0.001; Mann-Whitney U test). Feedback collected from students showed highly favorable responses to the use of VM for teaching histology. CONCLUSION: This study should encourage Indian medical colleges and schools in other developing countries to start using VM as a supplementary approach for their histology education programs. Furthermore, as the Medical Council of India recommends the introduction of new competency-based integrated curriculum in India starting in 2019, the use of VM may facilitate more effective learning in the new scenario. TRIAL REGISTRATION: CTRI/2018/04/012928.

Polymorphism of the CYP3A5 gene and its effect on tacrolimus blood level.

OBJECTIVES: Tacrolimus is the cornerstone for immunosuppression in renal transplant and is metabolized by the cytochrome P 450 3A (CYP3A) subfamily of enzymes in the liver and small intestine. A polymorphism in intron 3 of the CYP3A5 gene affects the expression of this enzyme and tacrolimus trough blood levels. The purpose of this study was to identify the proportion of CYP3A5 gene polymorphisms in South Indian renal transplant patients and determine the effect of CYP3A5 gene polymorphisms on tacrolimus trough blood levels in patients with and without CYP3A5 expression. MATERIALS AND METHODS: We included 25 adult patients who underwent renal transplant at Government Medical College, Trivandrum. All patients received tacrolimus (dose, 0.1 mg/kg/body weight, in 2 divided doses). Tacrolimus trough blood levels were determined on postoperative day 6. The CYP3A5 genotype analysis was performed by polymerase chain reaction amplification of target and detection by restriction fragment length polymorphism analysis. RESULTS: The CYP3A5*1/*1 genotype was detected in 5 recipients (20%), *1/*3 genotype in 5 recipients (20%), and *3/*3 genotypes in 15 recipients (60%) of the total 25 graft recipients. Mean tacrolimus level in the CYP3A5*1/*1 group was 5.154 ng/mL (range, 4.42 to 6.5 ng/mL), CYP3A5*1/*3 group was 5.348 ng/mL (range, 3.1 to 9.87 ng/mL), and CYP3A5*3/*3 group was 9.483 ng/mL (range, 4.5 to14.1 ng/mL). Acute rejection episodes were significantly more frequent for CYP3A5*1/*1 homozygous patients (40%) than patients with CYP3A5*1/*3 (20%) or CYP3A5*3/*3 (13%) genotypes. CONCLUSIONS: Most patients carried the mutant allele CYP3A5*3 (A6986G). Tacrolimus drug level correlated well with presence or absence of CYP3A5 polymorphisms. Acute rejection episodes were more frequent in expressors, and they may require higher doses of tacrolimus. Similarly, tacrolimus nephrotoxicity was more frequent in non-expressors. Therefore, CYP3A5 polymorphism analysis before renal transplant may help determine the optimal dose of tacrolimus in this population and prevent acute rejection episodes or tacrolimus toxicity.

Elementary school enrolment and its determinants among children with cerebral palsy in Thiruvananthapuram district, Kerala, India.

CONTEXT: There is enough documented evidence to prove the benefits of early and appropriate initiation of education among children with cerebral palsy (CP). AIM: To find out the proportion of children with CP who are enrolled for some kind of formal education and to study the determinants of the same. SETTING AND DESIGN: This cross sectional study was done among children, attending the special clinics at government medical college, Thiruvananthapuram. MATERIALS AND METHODS: Children between 3 and 12 years of age diagnosed with CP were subjects for the study. STATISTICAL ANALYSIS USED: Enrollment for any form of formal education was the major outcome variable. The factors associated with initiation of formal education were tested using Chi-square test or Fischer's exact test. Independent association of each factor was evaluated through binary logistic Regression analysis. RESULTS AND CONCLUSIONS: The mean (SD) age of the children (n = 86) was 5.7 (2.3) years with forty-six (53.5%) of them being girls. Diplegia was the commonest limb abnormality found. Fifty-two (60.5%) children were undergoing some kind of schooling. Those children who were less dependent physically and those who had achieved better language development were regular school goers. After binary logistic regression the ability of a child to speak in sentences (P = 0.008) and ambulatory level of the child (P = 0.019) were factors which favored, whereas delay in attaining the adaptive developmental milestone of transferring objects from one hand to another (P = 0.014) was found to be detrimental for school enrollment.

Efficacy of Canadian computed tomography head rule in predicting the need for a computed-axial tomography scans among patients with suspected head injuries.

CONTEXT: The use of imaging modalities is crucial in the diagnostic field of critical medicine. However, the ethical and economic use of these techniques has become a major concern especially in resource-poor settings. The Canadian computed tomography Head Rule (CCHR) is being increasingly used all over the world to evaluate the necessity of a Computer-assisted Tomography (CT) scan in patients with suspected head injury. AIM: The aim of the current study is to evaluate the efficacy of CCHR to predict the occurrence of head injury, as evidenced radiologically by a CT Head, at a government tertiary care clinical setting in south India. SETTING AND DESIGN: The design was that of a hospital-based cross-sectional survey conducted at the Medical College Hospital, Thiruvananthapuram (Kerala, India). MATERIALS AND METHODS: The study subjects were patients with suspected head injury evaluated at the Surgical Casualty Department of the study setting. Fifty consecutive patients with suspected head injury were enrolled in the study. STATISTICAL ANALYSIS: The Chi-square test was used to assess the statistical significance of association between the outcome variable and the exposure characteristics. The diagnostic ability of the Glasgow Coma Scale (GCS) and CCHR were expressed in terms of sensitivity and specificity by considering CT diagnosed Head injury as the gold standard diagnostic tool. RESULTS: Clinical manifestations as measured by a GCS score < 13 failed to significantly predict a head injury in the CT scan. However, the same became statistically significant when the CCHR was added to the GCS score as a predictor (P value < 0.001). The sensitivity of the tool in predicting a head injury rose from 23.3 to 96.7%. CONCLUSION: The current study suggested that the CCHR could act as an excellent decision rule to indicate the need of a CT scan. The need of a decision rule was warranted in the context of the growth of newer diagnostic imaging facilities in India.