Intra-articular Steroid alone vs Hydrodilatation with intra-articular Steroid in Frozen Shoulder - A Randomised Control Trial.

Introduction: Various non-operative treatment modalities have been advocated for a frozen shoulder. In the present study we compared the efficacy of single intra-articular steroid injection vs hydrodilatation with intra-articular steroids for frozen shoulder (FS) in the frozen phase. Materials and methods: This was a prospective, randomised control trial (RCT) done at a tertiary care centre. A total of 108 participants were randomised into two groups-one group received intra-articular steroid with hydrodilatation (HDS) and other group received intra-articular steroid injection only (S). Shoulder Pain and Disability Index (SPADI) scores were taken, and statistical analysis was done to measure the outcome at two weeks, six weeks and three-month intervals after the injection. Result: There was significant improvement in symptoms at each interval for both the groups (p=0.0). There was no statistically significant difference in the SPADI score between the two groups at two weeks post injection, however at six weeks (p=0.04) and 3 months (p=0.001) significant difference in the SPADI score was demonstrated with better scores in group S. The mean duration of analgesia required in group HDS was 5.17 days (S.D.=1.73) and for group S was 4.28 days (S.D.=1.01), with a statistical significance (p=0.002). Conclusion: Better clinical results were obtained at six weeks and three months with the group receiving corticosteroid only and also had a lesser requirement of analgesia post-intervention. Thus, intra-articular steroid injection only seems to be a more desirable method of management during the frozen phase of FS than that of hydrodilatation with intra-articular steroid injection.

Empowerment of nurses' knowledge and skills on violence against women with mental illness: A randomized controlled trail.

BACKGROUND: Nurses play a key role in identifying and supporting women with abusive experiences. However, research that evaluated the effectiveness of educational interventions on violence against women is sparse from India. AIM: To evaluate the effectiveness of a training program in improving nurses' knowledge and skills related to the identification and management of abused Women with Mental Illness (WMI). METHODS: A randomized controlled trial design was adopted for the present study. A total of 68 nurses were randomly assigned to either the experimental or control group (34 in each group). The experimental group was provided eight interactive sessions based on a Nursing Module on abuse among women with mental illness. The assessments were done in both groups at baseline, after the intervention, at three months and six months. The data was collected using a self-rated questionnaire and case vignettes. RESULTS: The mean knowledge score increased significantly in the experimental group after the intervention from 12.26 (SD, 2.03) to 23.60 (SD,1.24) and sustained at three months (23.07 ± 0.94) and six months (23.13 ± 1.61). Similarly, there were significant differences in nurses' skills after the training program (t = 13.17, p < 0.001) and at different time points of assessment (p < 0.001). CONCLUSIONS: Results showed that training had a positive impact on nurses' knowledge and skills related to violence against women with mental illness. Therefore, it is necessary to provide continuous training on this issue to help nurses in providing holistic care to this vulnerable population.

Effectiveness of a Module Based Training on Nurses' Attitude Towards Social Norms and Beliefs That Support Abuse Among women with Mental Illness.

Violence against women is a priority public health issue. Women with mental illness are at a double disadvantage. While social norms and beliefs either support or confront violence against women, research is limited on this issue. A randomized controlled design was adopted for the present study. This study was aimed to evaluate the effectiveness of module-based training in changing nurses' attitudes towards norms and beliefs that support violence against women in mental health care settings. In this study, 68 nurses were randomly assigned to either the experimental or control group (34 in each group). After receiving the training program, the mean scores on norms and beliefs and justifiability of abuse scales were significantly higher in the experimental group compared to the control group (p < 0.05). The results confirmed the positive impact of the training program in changing nurses' attitudes. However, further studies are required to draw firm conclusions on the effectiveness of the training intervention.

Is dosimetry still a necessity in current dental practice?

Today, dentists have a wide range of imaging modalities to choose from, the film based techniques, digital techniques, and the recent introduction of 3D volumetric or cone beam computed tomography (CBCT). The inherent design features of the new generation dental x-ray equipment has significantly improved over the years with no evidence of substandard x-ray units in operation. In dental facilities radiological workload is comparatively low, newer radiation equipments and accessories follow safety guidelines and employ better radiation protection measures for the patient and the operator. Dentists' knowledge and expertise in radiation protection measures is good, enabling them to carry out riskfree radiation procedures in their practice. Therefore, the present study is aimed at assessing the need for dosimeters in current dental scenario. 'Is there currently a significant risk from dental radiography to merit the use of personal dosimetery in dental practice. 'Dental health professionals (Oral radiologists) and radiographic assistants of fourteen dental colleges in Karnataka state participated in this questionnaire study. The questionnaire consisted of the following questions--the make, type, year of manufacture of radiographic machines used in their setup, number of radiographs made per day in the institution, type of receptors used, number of personnel at risk for radiation exposure, radiation protection measures used, regular monitoring by personal dosimeters, equivalent dosage readings for the past 12 months and whether the reading of thermoluminescent dosimeters (TLD) for any personnel had exceeded the recommended exposure value in the last 3 years. Dosimetry records of the radiology staff in the last three years shows doses no more than 1.50 mSv per year. The various institutions' dose (person mSv) was in the range of 3.70 mSv-3.90 mSv. Personal monitoring for Dentists can be omitted in the dental colleges since the estimated dose of oral radiologists contributed less than 0.01 mSv to the total average annual effective dose equivalent. Hence personal monitoring services (TLD Badges) for dentists employed in dental colleges should not be made mandatory.

Setting up a quality assurance model for newborn care to strengthen health system in Bihar, India.

BACKGROUND: A Quality Assurance model was rolled out in Bihar, India. It had two components: external and internal monitoring and giving feedback for action. The parameters included infrastructure and policy, equipment maintenance, stock supply and aseptic measures. METHODS: The performance and gradation into good/average/poor was measured based on the scores translated from the data collected after giving appropriate weights. RESULTS: 12%, 63%, and 25% units were categorized as good, average and poor based on infrastructure. For equipment, 68% of units performed poorly; for stock maintenance 64% and 35% of NBCCs fell under good and average categories respectively; most (54%) NBCCs had average scores for aseptic measures; 30% fell in the poor category. CONCLUSIONS: Involvement of government in monitoring and feedback mechanism, establishing a system of data collection at the grass root level and analysis at the state level were the positive outcomes.

A Prospective Real World Experience of Moxonidine Use in Indian Hypertensive Patients-Prescription beyond Current Guidelines.

OBJECTIVE: The primary objective of this study was to assess the use of moxonidine, a centrally acting anti-hypertensive agent in real world practice. MATERIAL AND METHODS: Patients who attended out-patients clinic with diagnosis of hypertension were enrolled in the study. Demographics with co-morbid illnesses of all patients were recorded. Patient's prescriptions were recorded and anti-hypertensive medications were also analysed. RESULTS: A total of 990 patients were eligible during the study period. Moxonidine was used in 4.54% of patients. Two groups could be identified in moxonidine users - one Group with resistant hypertension (30 patients, 3.03% of total, 66.66% of moxonidine users) on multiple drugs to control BP and another Group with intolerance to conventional, first line drugs (15 patients 1.51% of total, 33.33% of moxonidine users). Moxonidine was not used in newly diagnosed hypertension cases. Resistant hypertension and renal failure predicted the use of moxonidine. Majority of drug used was as per current guidelines. CONCLUSIONS: Our study results reflected real world practice of current anti-hypertensive therapy. Patients generally receive medications in accordance with current recommendations and guidelines. Small but significant proportion of patients may require use of drugs like moxonidine to control high BP. Guidelines need to incorporate these real world practices.

Oral and salivary changes among renal patients undergoing hemodialysis: A cross-sectional study.

We wanted to assess oral and salivary changes in end stage renal disease (ESRD) patients undergoing hemodialysis (HD) and to understand the correlation of such changes with renal insufficiency. The cross-sectional study was performed among 100 ESRD patients undergoing HD. Among these, 25 patients were randomly selected to assess the salivary changes and compared with 25 apparently healthy individuals who formed the control group. Total duration of the study was 15 months. Oral malodor, dry mouth, taste change, increased caries incidence, calculus formation, and gingival bleeding were the common oral manifestations. The flow rates of both unstimulated as well as stimulated whole saliva were decreased in the study group. The pH and buffer capacity of unstimulated whole saliva was increased in the study group, but stimulated whole saliva did not show any difference. ESRD patients undergoing HD require special considerations during dental treatment because of the various conditions inherent to the disease, their multiple oral manifestations and the treatment side-effects.

NT-proBNP in Myocarditis after a Scorpion Sting Envenomation.

OBJECTIVE: This study was to evaluate the levels of NT-proBNP in patients with myocarditis which occurred after a scorpion sting envenomation. MATERIAL AND METHODS: A total of 30 patients with scorpion sting envenomation and 21 patients with heart failure which was caused by cardiomyopathy, were prospectively studied. The data included the patient demographics, clinical features, echocardiography and the NT-proBNP levels. RESULTS: An echocardiographic evidence of myocarditis with a left ventricular ejection fraction of less than 50%, was found in 22 patients. In all the 22 patients, NT-proBNP was significantly elevated. The NT-proBNP levels were very high in the patients with severe LV dysfunction. However, it was in the normal range in the patients without an evidence of myocarditis. The elevated NT-proBNP levels were correlated with the LV dysfunction and myocarditis. When they were compared with the patients with heart failure which was caused by cardiomyopathy, the NTproBNP levels were found to be significantly more elevated in scorpion sting myocarditis. CONCLUSIONS: The NT-proBNP levels were significantly elevated in myocarditis which occurred after a scorpion sting envenomation.

Echocardiography guided therapy for myocarditis after scorpion sting envenomation.

OBJECTIVE: This study was to evaluate echocardiographic findings and its usefulness in clinical management of patients with scorpion sting envenomation. MATERIAL AND METHODS: A total of 84 consecutive patients were prospectively studied. The data included demographics, at the time of presentation to the hospital, the clinical features, echocardiographic findings, admission to intensive care unit, use of inotropic medication, time to discharge, and mortality. RESULTS: Out of 84 patients studied 60 patients (71.4%) had echocardiographic evidence of myocarditis (LVEF <50%). Majority of patients had LVEF <40% (50 patients, 83.3%). Severe LV dysfunction (LVEF <30%) was noted in 20 patients (33.3%). No patient had significant valvular regurgitation. RV dysfunction was noted in half of the patients who had LV dysfunction. RV dysfunction was not seen in isolation. Twenty four patients without evidence of myocarditis on echocardiography were observed in general wards and were discharged in 24 to 48 hours of admission. Ten patients with mild LV dysfunction (LVEF 50-40%) and 20 patients with moderate LV dysfunction were observed in high dependency units with regular monitoring for 24 to 48 hours. Only 3 patients were put on inotropics support and others could be discharged in 72 to 96 hours. All the patients with severe LV dysfunction and moderate LV dysfunction with significant RV dysfunction were admitted in intensive care unit irrespective of symptoms (Total 30 patients). These patients were put on inotropics support. Among severe LV dysfunction group, 4 patients required ventilator support and 2 (2.3%) patients died with refractory shock and multi-organ failure. Tachycardia, muffled and or gallop heart sounds and hypertension didn't predict presence of LV dysfunction. Persistent hypotension requiring inotropics support was a marker of severe LV dysfunction. CONCLUSION: Echocardiography is a useful tool in emergency to assess LV function in patients with scorpion sting envenomation. It can guide therapy by identifying patients with severe LV dysfunction.

Elevated Cardiac Troponin (cTnI) Levels Correlate with the Clinical and Echocardiographic Evidences of Severe Myocarditis in Scorpion Sting Envenomation.

OBJECTIVE: This study was to evaluate the predictive value of the cardiac troponins in scorpion sting myocarditis at a tertiary care hospital in Raichur, (Karnataka state) India. METHODS: A total of 84 consecutive patients were prospectively studied. The data included the demographics, the time of presentation to the hospital, the clinical features, the cardiac troponin levels and the echocardiographic findings. RESULTS: 12 patients with only local symptoms had troponin levels of less than 0.01µg/L. 12 patients with local and systemic symptoms without an echocardiac evidence of myocarditis had troponin values of 0.01 to 0.11 µg/L. 60 patients with an echocardiographic evidence of myocarditis had troponin levels of above 0.11 µg/L. 6 patients with severe myocarditis who required ventilator support or which led to death had troponin values which were higher than 10 µg/L. CONCLUSIONS: High cardiac troponin levels predict myocarditis in scorpion sting envenomation and they can be a useful tool in guiding the therapy early.

A simple screening method for individuals at risk of developing type 1 diabetes: measurement of islet cell autoantibodies (GADA, IA-2A, and IAA) on dried capillary blood spots collected on filter paper.

There is limited information regarding the use of dried capillary blood spots collected on a filter paper (FP) to test for islet cell antibodies. The aim of this study was to validate the use of dried capillary blood spots collected on a FP for the analysis of islet cell antibodies. FP eluates were tested using both single and combined assay for antibodies to glutamic acid decarboxylase (GADA) and/or to the protein tyrosine phosphatase like IA-2 (IA-2A), and a single assay for antibodies to insulin (IAA). The results were compared with those of serum assays. Ninety-one subjects were studied. Forty had Type 1 diabetes mellitus (T1DM) and 51 were first-degree relatives (FDR) of patients with T1DM. The GADA and IA-2A were measured by radio-binding assays, which utilize 35S-labeled GAD65 and IA-2. IAA was measured by a microtiter plate assay using 125I-labeled insulin. Twenty-six of those with T1DM (65%) and 5 of the FDRs (10%) had at least 1 positive test on the single serum assays. The FP combi-assay for GADA and IA-2A had 97.8% concordance rate when compared with serum single assays for GADA and IA-2A. The concordance rate for individual assays were 96.7% for GADA, and 100% for both IA-2A and IAA There was significant correlation of the antibody levels between FP and serum specimen for all 3 antibodies. We conclude that antibody screening performed using dried capillary blood spots collected on a FP correlates well with serum assays, and provides an easy alternative for population screening.

Genetic diversity of Macrophomina phaseolina isolates from certain agro-climatic regions of India by using RAPD markers.

Genetic diversity analysis of Macrophomina phaseolina isolates obtained from different host range and diverse geographical locations in India was carried out using RAPD fingerprinting. Of the thirteen 10-mer random primers used, primer OPB-08 gave the maximum polymorphism and the UPGMA clustering could separate 50 isolates in to ten groups at more than 65% similarity level. The ten clusters correlated well with the geographical locations with exceptions for isolates obtained from Eastern and Western Ghats. There was a segregation of isolates from these two geographical locations in to two clusters thus, distributing 10 genotypes in to eight geographical locations. All the isolates M. phaseolina irrespective of their host and geographical origin, exhibited two representative monomorphic bands at 250 bp and 1 kb, presence of these bands suggests that isolates might have evolved from a common ancestor but due to geographical isolation fallowed by natural selection and genetic drift might have segregated in to subpopulations. Genetic similarity in the pathogenic population reflects the dispersal of single lineage in all locations in India.

Carbon dioxide efflux from soil with poultry litter applications in conventional and conservation tillage systems in northern Alabama.

Increased CO2 release from soils resulting from agricultural practices such as tillage has generated concerns about contributions to global warming. Maintaining current levels of soil C and/or sequestering additional C in soils are important mechanisms to reduce CO2 in the atmosphere through production agriculture. We conducted a study in northern Alabama from 2003 to 2006 to measure CO2 efflux and C storage in long-term tilled and non-tilled cotton (Gossypium hirsutum L.) plots receiving poultry litter or ammonium nitrate (AN). Treatments were established in 1996 on a Decatur silt loam (clayey, kaolinitic thermic, Typic Paleudults) and consisted of conventional-tillage (CT), mulch-tillage (MT), and no-tillage (NT) systems with winter rye [Secale cereale (L.)] cover cropping and AN and poultry litter (PL) as nitrogen sources. Cotton was planted in 2003, 2004, and 2006. Corn was planted in 2005 as a rotation crop using a no-till planter in all plots, and no fertilizer was applied. Poultry litter application resulted in higher CO2 emission from soil compared with AN application regardless of tillage system. In 2003 and 2006, CT (4.39 and 3.40 micromol m(-2) s(-1), respectively) and MT (4.17 and 3.39 micromol m(-2) s(-1), respectively) with PL at 100 kg N ha(-1) (100 PLN) recorded significantly higher CO2 efflux compared with NT with 100 PLN (2.84 and 2.47 micromol m(-2) s(-1), respectively). Total soil C at 0- to 15-cm depth was not affected by tillage but significantly increased with PL application and winter rye cover cropping. In general, cotton produced with NT conservation tillage in conjunction with PL and winter rye cover cropping reduced CO2 emissions and sequestered more soil C compared with control treatments.

Prevention of insulin resistance by ingesting aqueous extract of Ocimum sanctum to fructose-fed rats.

The study was aimed to examine if oral administration of the aqueous extract of the whole plant OCIMUM SANCTUM (OS) protects against the development of insulin resistance in fructose fed rats. Male Wister rats were randomly divided into four groups of eight animals each: group-S (starch diet), group-F (fructose diet), group-F+OS (fructose diet along with OCIMUM SANCTUM extract at a dose of 200 mg/kg), group-S+OS (starch diet along with OCIMUM SANCTUM). During the experimental period of 60 days body weight, plasma glucose, insulin, and triglycerides were measured at an interval of 15 days. Insulin sensitivity was assessed at the end of experimental period by measuring glucose-insulin index, which is the product of the areas under the curve of glucose and insulin during oral glucose tolerance test. The nontoxic nature of OS was revealed by unaltered body weight, plasma glucose, insulin, and triglyceride levels in group-S+OS when compared with group-S. A significant gain in body weight, hyperglycemia, hyperinsulinemia, hypertriglyceridemia, and insulin resistance were observed in group-F when compared with group-S. OS treatment prevented the observed fructose induced alterations in group-F+OS. In conclusion, our results suggests that oral administration of OS aqueous extract could delay the development of insulin resistance in rats and may be used as an adjuvant therapy for treating diabetic patients with insulin resistance.

Health outcomes in type 2 diabetes.

Outcome evaluation is of great interest throughout the healthcare field, but which outcomes are important depends on the viewpoint one holds. For the healthcare organisation costs and resource utilisation are paramount, whereas patients may be interested in being able to work and lead a productive life without long-term complications. Healthcare policy decisions are influenced by varying degrees of social forces, existing regulations and outcome research findings. Ideally, all three are in agreement but often they may be competitive or may not even be included in policy decision making. With respect to improving outcomes, much energy has been spent on developing diabetes care guidelines. However, these have had minimal impact on physician behaviour. Soon after onset or diagnosis of diabetes, we are most concerned with process measures such as micro-albumin levels, blood pressure monitoring, routine eye and foot examinations and lipid profiles. These process measures are related to the development of intermediate outcomes--proteinuria, retinopathy, foot ulcers and dyslipidaemia. Diabetes is an expensive disease but there is accumulating evidence that improved care can lead to better quality of life and reduction in health care resource utilisation. The UKPDS demonstrated that for one percentage point decrease in HbA1c there was a 35% reduction in the risk of complications. Preliminary data from various diabetes management programmes indicate that instituting standardised care may lead to cost savings and improved health. Rationing health care resources wisely requires consideration of multiple factors including quality of life years (QALYs) and healthy year equivalents (HYEs). Formal quantitative methods are used to measure overall desirability of a medical intervention. Questions to be answered include predictability of responsiveness or adverse events to drug therapy. Outcomes research will have a key role in future development of models of diabetes care.

A controlled evaluation of a national continuing medical education programme designed to improve family physicians' implementation of diabetes-specific clinical practice guidelines.

AIMS: New approaches to continuing medical education will facilitate the implementation of clinical practice guidelines. This study assessed the short and long-term impact of a 7-h, small group workshop on family physicians' attitude, knowledge and self-reported practice patterns regarding diabetes mellitus. METHODS: One hundred and seventy-seven of 1807 family physicians who participated in this nationwide workshop, and 113 non-participant controls completed two validated questionnaires. Participants completed one questionnaire before the workshop and a second equivalent questionnaire 1 month later. Non-participant controls also completed the two questionnaires 1 month apart. Between 8 and 24 months later, these individuals were mailed the same questionnaire they completed on the first occasion; 143 participants and 50 controls returned this third questionnaire. RESULTS: Participants were more likely to be female (P = 0.03), not certified in family practice (P = 0.02), in a smaller centre (P = 0.0005), recent medical graduates (P = 0.001) and seeing fewer patients per month (P = 0.01) than controls. Compared to controls, participants had improved their attitude (P<0.0001), knowledge (P = 0.04) and self-reported practice patterns (P<0.002) regarding diabetes after 1 month but not after 1 year. CONCLUSIONS: An interactive, small group, diabetes continuing education programme effectively disseminates practice guidelines to family physicians. The impact of such a programme declines after 1 year.

United Kingdom Prospective Diabetes Study (UKPDS). Effects of glucose and blood pressure control on complications of type 2 diabetes mellitus.

The United Kingdom Prospective Diabetes Study (UKPDS) showed that intensive treatment (i.e., glucose-lowering drugs, with a goal fasting blood glucose level of 108 mg/dL) decreases the microvascular complications of type 2 diabetes mellitus. We summarize the key study results and their implications for clinical management of type 2 diabetes mellitus.

Nocardiosis in a recently transplanted renal patient.

Opportunistic infections are common after renal transplantation because of the use of immunosuppression. Nocardiosis is a rare but important cause of morbidity and mortality among renal transplant recipients. Depending upon the transplant center, the estimated incidence of nocardiosis among renal transplant recipients varies widely from 0 to 20%. We report the first case of nocardiosis in a recently transplanted renal patient maintained on tacrolimus, prednisone, and mycophenolate mofetil. It is likely that the nocardial infection in our patient was related to the development of her diabetes mellitus, and to her early episode of rejection and treatment which included high-dose steroids, and the addition of mycophenolate mofetil. Our case illustrates the importance of maintaining a heightened awareness so that nocardiosis may be diagnosed early and treated successfully.

Pulmonary embolus in pregnant patients: survey of ventilation-perfusion imaging policies and practices.

PURPOSE: To assess the policies and practices of nuclear medicine facilities as regards ventilation-perfusion (V-P) imaging in pregnant patients suspected of having pulmonary embolus. MATERIALS AND METHODS: Surveys were mailed to physician-directors of 1,000 randomly selected facilities at which nuclear imaging studies are performed. Information gathered included use of V-P imaging in pregnant patients, written policies, informed consent procedures, and modifications of standard protocols. RESULTS: Of the 1,000 surveys mailed, 327 (33%) completed surveys were returned. Of these 327 respondents, 220 (67%) reported that they perform V-P imaging in pregnant patients suspected of having pulmonary embolus. Of these 220 respondents, 115 (52%) routinely obtain informed consent, and 170 (77%) modify their standard V-P imaging protocol for pregnant patients. The most common modification (135 [79%] of 170 respondents) was reduction of the perfusion agent dose. Reported practice patterns for written policies, informed consent, and modifications did not show statistically significant trends among respondents in varying practice settings or geographic locations. CONCLUSION: Most respondents perform V-P imaging in pregnant patients suspected of having pulmonary embolus, with considerable variability in their policies and practices.