Background. Poisoning inflicts a considerable economic cost on the health sector. Few cases of poisoning may require intensive management in a critical care unit and thus add to the financial burden. In this study, our primary objective was to analyse the financial burden of poisoning on critical care facilities and the secondary objective was to analyse the critical care needs and treatment outcomes of patients with poisoning. Methods. We did this retrospective study of patients admitted with poisoning in the critical care unit of Government Medical College Hospital, Thiruvananthapuram, Kerala (12- bedded critical care unit of 2500-bedded medical college hospital) from January 2011 to December 2013. Patients <13 years of age were excluded. Cost was estimated using the hospital expenditure data. Results. A total of 118 patients, comprising 2.5% of the total critical care unit admissions, were included in the study. The average cost of providing critical care for cases of poisoning was ₹367 333 per annum. Organophosphorus poison was the most common agent (33.9%) with the highest cost per admission of approximately ₹1 8 500. The highest number of deaths was due to phosphide poisoning with a case fatality rate of 83%. Conclusions. Poisoning imposes a considerable burden on the limited critical care services. Organophosphorus was the most common substance consumed for poisoning and it led to the highest expenditure per admission.

Background. Artemisinin-based combination therapy (ACT) is widely used in India and many generic preparations are available. Delayed response has been reported, suggesting inadequate response to artesunate (AS) or genotypic resistance. We designed a prospective observational study to assess the therapeutic response, elaborate pharmacokinetics of AS and identify Plasmodium falciparum kelch 13 (pfk13) propeller gene polymorphisms among hospitalized Indian patients with severe malaria. Methods. We collected blood samples from adult patients with severe P. falciparum or mixed (P. falciparum and P. vivax) malaria on ACT. We calculated the parasite clearance (CL) half-life using the Worldwide Antimalarial Resistance Network (WWARN) online parasite clearance estimator (PCE). We used the liquid chromatography tandem mass spectrophoto-metry method for simultaneous quantification of AS and dihydroartemisinin. We genotyped longitudinally archived DNA samples obtained pre-treatment (day 0) to study the point mutations in the pfk13 propeller domain. Results. A total of 54 patients with malaria were included, with a majority fulfilling the definitions of severe malaria. The median parasite CL slope half-life was estimated to be 6.44 hours (interquartile range 4.79–10.24). AS pharmacokinetics, assessed in 17 patients, were found to be similar in the groups with rapid (<48 hours) and slow CL (>48 hours) of parasites. No known mutations associated with artemisinin resistance in Southeast Asia were observed in our study participants. Conclusions. Slow parasite CL was seen with a high parasite burden without genotypic evidence of AS resistance. There is a need to standardize definitions of therapeutic efficacy of AS in cases of severe malaria.

Background. Medication errors have an adverse impact on the healthcare system by increasing patient morbidity and mortality. They are preventable, and educational or technology-based interventions are needed to reduce their prevalence and improve medication safety. We aimed to study the impact of a sensitization programme and a blame-free reporting tool for doctors and nurses on the prevalence and reporting of medication errors in the intensive care units (ICUs) of a tertiary care teaching hospital. Methods. This prospective interventional study was conducted in the ICUs of cardiology, medicine, paediatrics and neonatology. Baseline medication errors were detected by prescription order review and direct observation of administration of medication for 30 days. A sensitization programme was conducted for doctors and nurses in these ICUs, the results were discussed, and a blame-free medication error reporting tool was introduced. Medication charts were modified to remove the transcription process in the cardiology and paediatrics ICUs. The follow-up study was conducted for 30 days in each ICU to monitor the impact of the sensitization programme. Results. The prevalence of medication errors was found to be 334.1/1000 patient observation days. Prescription errors were the most common types of errors at 129.1/1000 patient observation days. The interventions significantly reduced the error rate in all four ICUs. The overall number of prescriptions with errors was reduced from 9.1% (177/1944) to 3.5% (48/1373) and no medication error was reported using the tool. Conclusion. The sensitization programme on medication errors for doctors and nurses may be effective in improving medication safety. The impact was more pronounced in prescription errors. Reporting of medication errors did not improve in this study despite the introduction of a blame-free reporting tool.

Background. Prothrombin (PT) G20210A is one of the genetic polymorphisms associated with thrombophilia. Studies show a low prevalence for this polymorphism in Asian populations with only one subject reported from India. We studied the prevalence and association of this polymorphism in patients with arterial and venous strokes and their matched controls in south and north India. Methods. We recruited patients with cerebral venous thrombosis (mean age 37.2 years) and cryptogenic ischaemic stroke (mean age 36.7 years), and age- and sex-matched controls (mean age 37.6 years) from south and north India. Genotyping was carried out using polymerase chain reaction followed by restriction fragment length polymorphism, and the prevalence of the variants among the patients and controls was compared. Results. The heterozygous allele of the polymorphism was detected in both groups with significantly higher prevalence among north Indians (5/154; 3.2%) compared with south Indians (4/516; 0.8%; p = 0.026). Thrombosis as a manifestation of this polymorphism was more among north Indians with 4/82 (4.9%) of patients with ischaemic stroke and cerebral venous thrombosis having this polymorphism compared with south Indian patients 1/72 (1.4%), p = 0.003. Conclusion. PT G20210A is prevalent in India, especially among those from north India. Its role in predisposition to thrombosis needs to be studied further along with other known risk factors.

Salmonella infection causes a wide range of intestinal and extraintestinal manifestations as well as a lifetime carrier state. Untreated patients may develop complications, which can be life-threatening. Electrocardiogram (ECG) changes are a common occurrence in enteric fever and may be helpful in predicting myocarditis. Common ECG changes are decreased amplitude of QRS complexes, QTc prolongation and right bundle branch block. Ventricular bigeminy in enteric fever is a rare phenomenon. We report its occurrence in a patient.

Administration of intravenous fluids is the most common therapy given to patients admitted to a hospital. Evidence suggests that the use of normal saline (NS) in large quantities is not without adverse effects. Balanced salt solutions (BSS) contain bicarbonate or one of its precursors that act as a buffer, and the electrolyte composition resembles that of plasma. We reviewed studies across different setups such as intensive care units (ICUs), major surgeries, renal transplants and emergency departments to identify the effect(s) of NS and to find evidence favouring the use of BSS over NS. The use of NS is strongly associated with hyperchloraemic acidosis in almost all the studies. In the largest and latest trial in ICUs, it was found that higher chloride levels were associated with renal injury. No significant difference was found in mortality in any of the trials. In surgical patients, studies found only transient hyperchloraemia and increase in the base deficit in patients receiving NS. Systematic reviews and meta-analyses did not find any significant differences in adverse outcomes such as the need for renal replacement therapy or mortality with the use of saline; however, blood chloride levels were consistently higher with saline compared to BSS. There is a need for larger trials with better methodology to determine if the physiological benefits of BSS translate into better clinical outcomes.

Background. Knowledge of cognition and its regulation are important meta-cognitive activities, which are crucial for enhancement of learning. Their explicit teaching is meaningful and necessary yet seldom undertaken systematically in medical education programmes. Methods. We aimed to identify the cognitive styles using the Alert Scale of Cognitive Style among our undergraduate students. Students were also sensitized about different cognitive styles, their implications in strategic learning and the importance of meta-cognitive approach in education. Feedback from students was obtained to understand their awareness, perspectives and relevance of meta-cognitive concepts. Results. The intervention enhanced awareness of students about their own cognitive style and its implications to learning processes. The middle brain cognitive style was the most common (51.2%), followed by the right and the left brain cognitive styles (29.5% and 19.4%, respectively). A significant shift from the left towards the middle or the right cognitive style was observed in clinical years. No significant association was observed between a cognitive style and various variables such as age, gender and handedness. Conclusion. Incorporation of meta-cognitive learning practices in medical education offers a basis for enhancing classroom teaching, thereby making it learner-centric. The study helped students in identifying the way they process information and in identifying their preferred methods of assimilating knowledge. Identification of cognitive diversity is a primary pedagogic act for improving competence in learning. Meta-cognitive skills can be harnessed to bring about consonance of the left, right and middle brain cognitive styles to achieve better learning outcomes.

Doctors are duty bound to assist the delivery of justice by providing expert opinion/evidence in a court of law. However, the time spent in doing so comes at the cost of patient care. The healthcare sector and the judiciary are seized of the matter, and the use of technology as an avenue to ease the process is desirable. Tele-evidence or testimony through video conference can be that breakthrough. The Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, has institutionalized the mechanism of tele-evidence with the concurrence of the High Court of Punjab and Haryana. This was made possible after many permutations and combinations were tried, because the existing information technology infrastructure of the stakeholders was not compatible. The desired solution was achieved, and other institutions working to establish similar facilities can learn from the experience of PGIMER to achieve faster results.