Diagnoses and management of adult cough: An Indian Environmental Medical Association (EMA) position paper.

BACKGROUND: Cough is a common yet distressing symptom that results in significant health care costs from outpatient visits and related consultations. OBJECTIVE: The understanding of the pathobiology of cough in recent times has undergone an evolution with Cough hypersensitivity syndrome (CHS) being suggested in most cases of dry cough. However, in the case of productive cough, ancillary mechanisms including impaired Mucociliary clearance, in addition to hypermucosecretory bronchospastic conditions of Smoker's cough, asthma-COPD overlap, bronchiectasis, and allergic bronchopulmonary aspergillosis, need to be critically addressed while optimizing patient care with symptomatic therapy in outpatient settings of India. METHODS: In this review, evidence-based graded recommendations on use of antitussives - & protussives as a Position Paper were developed based on the Level and Quality of Scientific evidence as per Agency for Health Care and Quality (AHRQ) criteria listing and Expert opinions offered by a multidisciplinary EMA panel in India. RESULTS: Management of acute or chronic cough involves addressing common issues of environmental exposures and patient concerns before instituting supportive therapy with antitussives or bronchodilatory cough formulations containing mucoactives, anti-inflammatory, or short-acting beta-2 agonist agents. CONCLUSION: The analyses provides a real world approach to the management of acute or chronic cough in various clinical conditions with pro- or antitussive agents while avoiding their misuse in empirical settings.

Hydroxyethylamine derivatives as HIV-1 protease inhibitors: a predictive QSAR modelling study based on Monte Carlo optimization.

Application of HIV-1 protease inhibitors (as an anti-HIV regimen) may serve as an attractive strategy for anti-HIV drug development. Several investigations suggest that there is a crucial need to develop a novel protease inhibitor with higher potency and reduced toxicity. Monte Carlo optimized QSAR study was performed on 200 hydroxyethylamine derivatives with antiprotease activity. Twenty-one QSAR models with good statistical qualities were developed from three different splits with various combinations of SMILES and GRAPH based descriptors. The best models from different splits were selected on the basis of statistically validated characteristics of the test set and have the following statistical parameters: r2 = 0.806, Q2 = 0.788 (split 1); r2 = 0.842, Q2 = 0.826 (split 2); r2 = 0.774, Q2 = 0.755 (split 3). The structural attributes obtained from the best models were analysed to understand the structural requirements of the selected series for HIV-1 protease inhibitory activity. On the basis of obtained structural attributes, 11 new compounds were designed, out of which five compounds were found to have better activity than the best active compound in the series.

Assessment of urban air pollution and it's probable health impact.

The present study deals with the quantitative effect of vehicular emission on ambient air quality during May 2006 in urban area of Lucknow city. In this study SPM, RSPM, SO2, NOx and 7 trace metals associated with RSPM were estimated at 10 representative locations in urban area and one village area for control. Beside this, air quality index (AQI), health effects of different metals and mortality were assessed. The 24 hr average concentration of SPM, RSPM, SO2 and NOx was found to be 382.3, 171.5, 24.3 and 33.8 microg m(-3) respectively in urban area and these concentrations were found to be significantly (p < 0.01) higher by 94.8, 134.8, 107.4 and 129.6% than control site respectively The 24 hr mean of SPM and RSPM at each location of urban area were found to be higher than prescribed limit of National Ambient Air Quality Standard (NAAQS) except SPM for industrial area. The 24 hr mean concentration of metals associated with RSPM was found to be higher than the control site by 52.3, 271.8, 408.9, 75.81, 62.7, 487.54 and 189.5% for Fe, Cu, Pb, Zn, Ni, Mn and Cr respectively. The inter correlation of metals Pb with Mn, Fe and Cr; Zn with Ni and Cr; Ni with Cr; Mn with Fe and Cu with Cr showed significant positive relation either at p < 0.05 or p < 0.01 level. Metals Pb, Mn and Cr (p < 0.01) and Cu (p < 0.05) showed significant positive correlation with RSPM. These results indicate that ambient air quality in the urban area is affected adversely due to emission and accumulation of SPM, RSPM, SO2, NOx and trace metals. These pollutants may pose detrimental effect on human health, as exposure of these are associated with cardiovascular and respiratory diseases, neurological impairments, increased risk of preterm birth and even mortality and morbidity.

Assessment of industrial effluent and its impact on soil and plants.

The present study deals with the assessment of industrial water of an electronic component manufacturing unit with electroplating and its subsequent effects on soil and plants receiving the effluent. The physico-chemical parameters of the effluent samples showed higher value than that of ground water. The treated effluent was within the permissible limit. Microtox test was conducted and determined the degree of toxicity of untreated, treated effluents as well as the water sample collected at effluent discharge point of receiving river (confluence point). The physico- mechanical parameters of the soil samples were not changed due to irrigation of the treated effluent, but the concentration of metals were comparatively higher than the control soil. Higher accumulation of metals was found in the plant parts in naturally growing weeds and cultivated crop plant irrigated with treated effluent. Elevated accumulation of metals in Eichhornia crassipes and Marsilea sp. growing along the effluent channel has been identified as a potential source of biomonitoring of metals particularly for Cu and Ca and can be utilised for the removal of heavy metal from wastewater.

Utility of coaxial technique for renal angioplasty in patients with a difficult-to-cross stenosis.

The aim of this study was to evaluate the feasibility of coaxial approach in difficult-to-cross lesions in patients with failed percutaneous transluminal renal angioplasty by conventional over-the-wire exchange technique. Twelve stenoses in 10 patients (six women and four men; age range 19 +/- 7 years) with uncontrolled hypertension were treated by this method. The stenosis was caused by nonspecific aortoarteritis in 8 patients and fibromuscular dysplasia in 2 patients. It was ostial in seven and post-ostial in five vessels. Conventional exchange technique was unsuccessful in all of them. All procedures were done by femoral route. Technical success was seen in 11 (92%), without complication. The stenosis improved from 90 +/- 2.1% (range 80-100%) to 6 +/- 7% (range 0-20%), blood pressure decreased from 198 +/- 12.3 mm Hg (range 180-220 mm Hg)/130 +/- 6.7 mm Hg (range 120-140 mm Hg) to 119 +/- 5.7 mm Hg (range 110-130 mm Hg)/83 +/- 3.9 mm Hg (range 80-90 mm Hg), and number of drug treatments for hypertension fell from 3.6 +/- 0.52 (range 3-4) to 1 +/- 0.94 (range 0-3; p < 0.01). Percutaneous transluminal renal angioplasty resulted in "cure" in 3 patients and "improvement" in 7 patients. Follow-up period was 3-21 months (mean 6.4 months). No restenosis was detected. Coaxial approach is safe and effective in treating difficult-to-cross lesions in which renal angioplasty by conventional exchange technique is unsuccessful.

Current status of neonatal care and alternate strategies for reduction of neonatal mortality in the decade of nineties.

PIP: Improvement in neonatal care in India is needed in order to fulfill the National Health Policy to reduce infant and perinatal mortality and low birth weight babies. 50-60% of perinatal and infant mortality is due to neonatal mortality, specifically low birth weight. There have been no declines in any of the states even though there are literacy, fertility, poverty and health personnel differences between states. The health delivery system is described. Basic facilities are lacking in subcenters and primary health centers: weighing scales, blood pressure recorder, urine analysis, and blood transfusion capability; pregnancy registration is 40%. 40% of women believe that the female multipurpose worker (ANM) is a maternal and child health worker; Dais made postnatal visits to 25% of the women and infants, while physicians and ANM's visited 10%. The most frequent method of delivery is home delivery with a Dai or relative in attendance. Information on temperature control at birth, hand washing, feeding, and identification of high risk infants by health personnel is inadequate. There are no neonatal units in the entire country even though there are 8 million low birth weight babies/year and 1 million neonatal deaths/year. Neonatal causes are primarily birth injuries, aspiration syndrome, and neonatal infections (tetanus, pneumonia, and diarrhea). Studies have identified health service improvements to reduce neonatal mortality. In India, the priority should be to 1) establish delivery of neonatal and perinatal care at all 3 levels of care, 2) train and educate all health personnel in perinatal and neonatal care, and 3) improve community participation by involving the community in decision making on kind of care, perinatal care, and health education and by monitoring such services. Infant care must extend from prenatal through postnatal care, which is currently fragmented, through a 3-tiered system. 80-85% of all infants need care at Level I; 15-20% require Level II care; and 1-5% need Level III care. Health services and supplies may need to be provided at the village rather than the subcenter level and in postpartum services. Other possibilities are to include neonatal care within the Integrated Child Development Program or the Universal Immunization Program. Community leaders could monitor neonatal services. Regional institutes could provide training for all health personnel.^ieng

ICMR Task Force National Collaborative Study on Identification of High Risk Families, Mothers and Outcome of their Off-springs with particular reference to the problem of maternal nutrition, low birth weight, perinatal and infant morbidity and mortality in rural and urban slum communities. Summary, conclusions and recommendations.

PIP: The objectives was to assess the determinants of and rates of abortion, stillbirth, and infant mortality for a cohort of pregnant women from slums in New Delhi, Calcutta, and Madras, India and rural slums in Hyderabad, Varanasi, and Chandigarh, India in 1981. The relationship of low birthweight (LBW) and high risk pregnancies to social, environmental, nutritional, cultural, and biological factors was of interest. The results showed variation both between and within urban and rural areas. Rural pregnancy outcome showed fewer LBWs and perinatal and neonatal mortality. Perinatal, neonatal, and infant mortality rates were consistent with prior findings. There was a demonstrated need for prenatal care and referral due to the 10-12% with a poor obstetric history and the significant number with anemia, bleeding, hypertension, toxemia, and urinary tract infections during this pregnancy. Many women were malnourished (body weight 40 kg, height 145 cm, and midarm circumference of 22.5 cm. These women can be identified as high risk. Other risk factors identified were women with disadvantageous personal habits: smoking, alcohol use, tobacco chewing, and working. 10-25% of pregnancies were not registered even though the prenatal clinic was accessible and outreach was provided. 20% completed the recommended number of prenatal visits. 75-85% visited at least once and sometimes more often. Screening for high risk must be done at the 1st visit. Women had strong feelings about the preference for a Dai during delivery and for place of delivery. Poor training of health workers was reflected in the lack of adequate sanitation during the birthing process. Neonatal units were lacking and primary care absent. 10-14% of births were preterm of which 50% occurred at 36 weeks. Multiple regression identified risk factors for fetal and neonatal mortality and LBW as maternal age, preterm birth, maternal anemia, previous preterm or LBW, birth interval, and previous fetal and neonatal mortality. Recommendations are for improving sanitation, hygiene, and water supplies, promoting community awareness of the adverse effects of early marriage and close birth spacing, improving the delivery of health care, allocating health resources based on morality rates, using an intersectoral approach for dealing with the complex social and personal habits adversely affecting childbearing and 7 other suggestions. Existing services and their use are inadequate.^ieng

Breast feeding best for the babies.

PIP: Recent information on breastfeeding has confirmed almost all the facts and beliefs known for centuries about mother's milk, i.e., it protects an infant and helps him/her grow optimally both physically and emotionally. Yet, no other child health promotional effort has been threatened in recent times as the practice of breastfeeding. It is not uncommon to find both rural and urban mothers who believe that infants fed on formula grow to be bonnier and healthier. Coupled with this belief is often their feeling that is is difficult to introduce semisolids, solids and top milk to an infant if the infant is unaccustomed to a bottle or a commercially available infant food in earlier weeks of life. 1 reason for this situation is the publicity blitz aimed at promotion of commercially available infant foods and the feeding bottle. In contrast to the aggressive promotion of formula feeding, there is a lack of information on breastfeeding and its promotion through the mass media. There is no food which has been invented to replace the mother's love or its suitability in terms of a child's physiological, nutritional, and emotional needs. The mammary gland allows mammals to nurture their offspring with their own milk, milk that is constituted in such a way that it optimally meets the needs of the offspring. This is evident from the comparison of milk from human and various animal sources. Each animal produces milk which is best suited for its survival and growth and which vastly differs from human milk. Breast milk is richer in carbohydrates, qualitatively superior in proteins and minerals, and is low in solute load. It is thus easily digestible by infants whether of low or normal birth weight or premature. Milk from animal sources is unsuitable for infants in the 1st few weeks. At least in terms of composition, breast milk is the most suitable milk among all the available milk for infants. It does not need money for purchase, fuel for warming, water for dilution, and reconstitution or utensils for preparations of feeds and bottles for feeding. It is well established that infants who are not breastfed have higher mortality rate, suffer from significantly higher morbidity, are hospitalized 10 times more often, and if they survive these hazards, suffer from moderate to severe malnutrition. Breastfeeding enhances the bond between the mother and her child and is a satisfying experience for the mother. Breastfeeding aids in the natural fall of the mother's body weight and provides a contraceptive effect^ieng