Background. Growing evidence suggests that non-communicable diseases (NCDs) result in considerable economic burden for individuals and households. With the poor facing a greater burden of NCDs than the rich in India, we undertook this study to analyse the horizontal equity in utilization and vertical equity in out-of-pocket expenditure for NCD care. Methods. We used data of 1 4 large Indian states from the National Sample Survey 60th round to compute hospitalization rates for NCDs. Mean per capita consumption expenditure (MPCE) was computed and used as a proxy measure for socioeconomic status. Out-of-pocket payment as a proportion of MPCE was estimated by wealth quintile (Q) to assess the vertical equity in payments. Concentration index (CoI) was computed to measure the extent of equity, and its 95% confidence interval was estimated to assess statistical significance. Results. Overall, NCD hospitalizations in public facilities in India were used more by the poor (Col –0.041 ), while the rich used proportionately more services in the private sector (CoI 0.174). Out-of-pocket expenditure in public facilities was consistently lower than that in private facilities in urban and rural areas. The mean out-of-pocket expenditure for inpatient services for NCDs was found to be more among the rich in both public (Q5 ₹13 016, Q1 ₹4197) and private (Q5 ₹22 974, Q1 ₹8225) facilities. Conclusion. Public facilities are utilized more by poorer individuals. Strengthening the capacity of the public sector to deliver NCD care is required to meet equitable outcomes.

Background. Inappropriate footwear may be a major cause of foot ulceration among patients with diabetic neuropathy in India. No study has specifically examined the types of footwear or its components in patients with diabetes mellitus and their role in causing foot ulcers. We analysed the role of commonly used footwear in India in inducing first foot ulcers (FFU) in people with diabetes. Methods. Of 4800 patients with diabetes attending our centre over 1 year, 301 had FFU from different causes. Sixty-six patients with diabetic neuro-/vasculopathy presenting with ulcers due to footwear were included as cases. An equal number of patients with diabetes but without foot ulcers were enrolled as controls. Cases and controls were matched demographically and clinically for type of diabetes, metabolic control, duration of diabetes, comorbid conditions and foot neurovascular status. We did a detailed foot examination for neurological, vascular and wound status. We also evaluated the footwear in both groups. Results. In one-fifth of 335 limbs (301 patients), the primary cause for the FFU was use of inappropriate footwear. The patients used seven different models of footwear, six of which were found to be inappropriate. The straps of footwear caused over 50% of ulcers. Another one-third were due to penetration of sharp objects through the outer sole of footwear; among these cases, 1 3.6% of ulcers were caused by not using soft inner soles. Conclusions. The use of softer insole is least effective in preventing foot ulcers. Similarly, straps contribute to a higher percentage of foot ulcers. Foot ulcers can be prevented by a combination of soft insole, with midsole and hard outsole with proper back counter and adjustable front and back straps.

Background. The Central Standard Drugs Control Organization (CDSCO) issued an administrative order in November 201 3 mandating audiovisual (AV) recording of the informed consent process for all regulatory studies. At this point, a phase 2/3 trial ongoing at our centre had recruited 45 participants using the written, informed consent process. Another 40 participants were recruited after the order and underwent AV recording of the consent process. We assessed the difference in participants’ understanding between the two consenting processes as the trial fortuitously had both forms of consent. Methods. A 16-item questionnaire with six domains (purpose, study procedures, risks, benefits, payment for participation, and rights and confidentiality) was designed and validated. It was administered to the participants after approval of the institutional ethics committee and written informed consent. Answers given were matched with a template of model answers. The responses were scored as fully correct (3), partially correct (2), ‘don't remember’ (1 ), and incorrect (0) with a total possible score of 48. Between-group analysis was done for total scores and domain-specific scores. Domain-wise analysis was done for the proportion of all categories of responses. The impact of potential confounders on participants’ understanding was also factored in. Results. A total of 38 respondents—21 in the AV consent group and 1 7 in the written consent group—agreed to participate. The total mean (SD) score of the AV consent group was significantly higher (40.3 [5.9]) compared to that of the written consent group (34.8 [7.94]; p = 0.01). Between the groups the score was significant in the domains of rights and confidentiality (p = 0.01). The proportion of participants who gave fully correct answers was statistically significant in the domain of purpose (p = 0.04). The time elapsed between the original consent and this study showed a weak inverse correlation (ρ = -0.3, p = 0.01). Conclusion. AV recording of the informed consent process in a clinical trial appears to improve the understanding of participants relative to the written informed consent alone.

Light chain myeloma (LCM) is an unusual neoplasm accounting for about 1 8% of all plasma cell myelomas. It is characterized by the absence of a detectable M protein in the serum and urine protein electrophoresis, altered free light chain ratio, bone marrow plasmacytosis and related organ or tissue damage. We report a 60-year-old man with LCM presenting with pancytopenia. Urine Bence Jones proteins were negative and serum protein electrophoresis did not reveal an M-band. However, bone marrow biopsy showed plasmablastic morphology. Subsequent immunohistochemistry showed lambda restriction and cells positive for CD138 and IgM.

Ischaemic stroke is among the leading causes of disability and death. Despite extensive vascular, cardiac and serological evaluations, the cause remains unknown in 20%-40% of patients. These are classified as cryptogenic stroke. Paradoxical embolism is one of the many causes of cryptogenic stroke. The term paradoxical embolism is used to describe an embolus of venous origin entering the systemic circulation through a patent foramen ovale (PFO), atrial septal defect (ASD), ventricular septal defect or extracardiac communication such as pulmonary arteriovenous malformation. PFO is present in about 25% of the population. PFO is seen more commonly in patients with cryptogenic stroke. Secondary prevention of stroke in such patients includes the prevention of formation of a thrombus with antiplatelets, vitamin K antagonists or closure of the PFO by either surgery or the percutaneous route. Percutaneous closure using devices has been shown to be safe and beneficial in preventing secondary stroke. Data from randomized trials have shown device closure to be superior to medical management in the secondary prevention of cryptogenic stroke due to PFO.

Nijssen EC, Rennenberg RJ, Nelemans PJ, Essers BA, Janssen MM, Vermeeren MA, van Ommen V, Wildberger JE. (Departments of Radiology and Nuclear Medicine, Internal Medicine, Epidemiology, Clinical Epidemiology and Medical Technology Assessment, and Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands.) Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): A prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Lancet 2017;389:1312-22.

Aljitawi OS, Paul S, Ganguly A, Lin TL, Ganguly S, Vielhauer G, Capitano ML, Cantilena A, Lipe B, Mahnken JD, Wise A, Berry A, Singh AK, Shune L, Lominska C, Abhyankar S, Allin D, Laughlin M, McGuirk JP, Broxmeyer HE. (Division of Hematologic Malignancies and Cellular Therapy; Hematology and Transplantation Translational Research Laboratory ; Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas; Division of Hematology/Oncology and Bone Marrow Transplantation Program, University of Rochester Medical Center, Rochester, New York; Department of Urology, University of Kansas Medical Center, Kansas City, Kansas; Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana; Cardiovascular Research Institute, Department of Biostatistics, Department of Radiation Oncology, Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, Kansas; Cleveland Cord Blood Center, Cleveland, Ohio; Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA.) Erythropoietin modulation is associated with improved homing and engraftment after umbilical cord blood transplantation. Blood 2016;128:3000-10

A multiple choice-based National Eligibility-cum-Entrance Test for admission to postgraduate courses (NEET-PG) for 201 7 was conducted by the National Board of Examinations of India. It was widely reported in the media and through gazette notifications that the government is going to use this NEET examination as a licentiate examination in the near future. Medical students will be certified to practise in India only if they qualify in this examination. We discuss the pros and cons of such an end-of-term examination, its utility and educational impact besides proposing a comprehensive framework for implementing formative assessment in medical colleges.

Background. Family studies are an integral part of teaching of community medicine to all undergraduate medical and nursing students. It enhances the understanding of students about social determinants and multifactorial causation of disease. However, there is no standard approach towards it and it is seen as a clinical presentation with some elements of family included. We describe a systematic and comprehensive approach to a family study. Methods. Based on the existing literature and personal experience, we identified 11 domains under the acronym Family ASSESSMENT—Structure, Socioeconomic, Sickness, Nutritional, Educational, Environmental, Affordability, System (health), Mental, Family influence, Threats. Under each domain, we present indicative diagnoses and possible solutions. We also suggest that these domain diagnoses can be integrated into a single ‘web of interaction’ which provides a comprehensive understanding of the issues and guides us towards identifying the solutions. Results. We use a worked out example of a case of tuberculosis to demonstrate the use of this approach and develop a rich web of interaction, which is then linked to identification of possible approaches towards mitigating the impact of disease on the individual and the family. Some suggestions to the departments of community medicine on organizing family studies are also provided. Conclusion. Availability of a systematic and comprehensive approach would improve students’ understanding of the social model of disease and multifactorial causation of disease. It will also provide a standardized method of teaching this important component of community medicine nationally.

Since 201 4, there is a shift in terror targets, with a 1 72% increase in the deaths of common citizens. India ranks fourth in the global terrorism index. Intelligence, security and counter-terrorism conjointly form the contours of priority for governance and public engagement but the attendant aspects of health system remain neglected. Recurring acts of global terrorism have given rise to unique medical requirements that can be termed as ‘terror medicine’, geared towards managing health impacts of terrorism and not just a single patient. Health impacts of terrorism that affect vulnerable and non-combative citizens will need a well-developed healthcare delivery mechanism consisting of four components: medical preparedness, incident management, care of injuries and body functions, and intervention for psychological consequences. Terror medicine should not be considered a ‘dangerous territory’, as it can provide opportunities for healthcare to gain new strengths of knowledge and research, similar to the medical outcomes from the two world wars.