Churg-Strauss syndrome (CSS) is an uncommon systemic disorder leading to inflammation of small and medium vessels by an immunological mechanism. Lungs are the most frequent organ affected. It is an allergic granulomatosis with polyangiitis associated with the presence of perinuclear antineutrophil cytoplasmic antibody. We describe a rare presentation of CSS as bilateral multiple cavitating nodules in a 50-year-old man with diabetes.

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The currently available methods of screening for diabetic retinopathy (DR) depend on the availability of healthcare professionals and technology. The high prevalence of diabetes in India, and the need to repeatedly screen such patients for DR and treat them, places an enormous economic and logistic burden. We introduce the concept of screening for DR with ‘selfie retinal imaging’ through this report of 3 patients. The patients can themselves capture retinal images and transfer to a grading centre for further deliberation. If incorporated into the current technological revolution of smartphones, this futuristic concept is likely to be of huge benefit in preventing loss of vision due to diabetes.

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Mild hypokalaemia is a common electrolyte abnormality following therapeutic doses of diuretics such as torsemide. If undiagnosed and untreated, hypokalaemia progresses and smooth muscle, skeletal muscle and the heart are affected. Potassium-sparing diuretics such as spironolactone are commonly added to loop diuretics to prevent symptomatic hypokalaemia. We present a patient with moderate hypokal-aemia associated with the use of torsemide and spironolactone, resulting in quadriparesis, hospitalization and electrophysio-logical abnormalities.

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Defensive medicine is the deliberate departure by doctors from standard operating procedures with a view to safeguard themselves against possible medical malpractice litigation. It is on the rise in both developed and developing nations and across all fields of medicine. Different aspects of this practice are evident and many new are unfolding by the day. It is silently encroaching on the healthcare systems and could be detrimental for patients, doctors and healthcare systems. We probe the determinants of defensive medicine, the possible implications and the recommendations for addressing it.

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Background. Sparse data are available on service utilization, pattern and profile of mental and behavioural emergencies in India. We explored the pattern and clinical profile of consecutively referred psychiatric emergencies at a premier tertiary healthcare centre in India. Methods. We reviewed the consecutive referrals for acute mental and behavioural problems made by the emergency department and recorded in an emergency psychiatry register between January 2015 and January 2016. Results. Over a 1 3-month period, 666 patients were assessed; of whom 473 (71 %) had no prior/known psychiatric history and 84 (12.6%) had a comorbid medical condition. Nearly one-third of patients had potential legal issues associated with their emergency. The most common reasons for presentation were: an attempt at self-harm (130; 19.5%), aggression/agitation ( 122; 18.3%) and psychoactive substance use-related problems (69; 10.3%). Schizophrenia and other psychotic disorders (89; 13.4%) and mood disorders (87; 1 3.1%) formed the 2 most common diagnostic groups seen in emergency. Most commonly prescribed medications were benzodiazepines (296; 44.4%) followed by antipsychotics (187; 28.1%) and antidepressants (90; 13.5%). Notably, 11% of patients (76) were advised immediate admission under psychiatry, half of whom could be admitted directly from the emergency. Conclusion. Our findings suggest that there is a need to optimize emergency mental healthcare and develop service delivery models for common psychiatric emergencies in India.

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The assessment of the suitability of an individual for the profession of medical science is carried out worldwide on the basis of several yardsticks. While a few methods assess domain knowledge of sciences, others focus on evaluating the cognitive aptitude skills of the candidate, while few others assess communicative skills. Though it has been considered that the possession of an aptitude for the profession is a prerequisite, considering its strenuous demands from the candidate, a comprehensive assessment of these areas under the construct of medical aptitude has not been analysed so far, though medical aptitude has been socially defined. This article attempts to develop a comprehensive construct to ‘Medical aptitude’, meant for the pre-medical student, which has been encapsulated with respect to the areas of its assessment. We did an extensive survey of the literature pertaining to the mode of selection of students towards medical profession and analysed their areas of assessments for admittance. This enabled to identify similarities in the areas of assessment which were then classified under several domains of assessment. Special reference to the keywords involving ‘Aptitude’ and ‘Medical Aptitude’ was made. We analysed the definitions to the construct of aptitude from the literature with respect to its relevance in the profession of medical science to be possessed by the pre-medical aspirant—in context. From this, a new construct of medical aptitude was formulated incorporating the existing construct of medical aptitude. Medical aptitude is a comprehensive construct that encompasses the dimensions of a consistent core, a peripheral content and the support of a scaffold. Each of these dimensions have their importance and distinct objective in being assessed in the pre-medical student. A perfect intertwining of these 3 dimensions can prove beneficial in assessing individuals to be fit for the profession of medical science.

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Background. We compared the neonatal outcomes between 2 methods of shoulder delivery: 2-step and 1-step. Methods. We did a comprehensive search of 7 electronic databases up to 31 October 2016. Two of the authors independently identified relevant studies for inclusion in the review, assessed their quality and extracted data. The primary outcome was the rate of neonatal asphyxia; secondary outcomes were neonatal brachial plexus injury and clavicular fracture of newborns. Review Manager 5.3 was used for the metaanalysis. The pooled relative risk (RR) was estimated by the fixed or random effect model, based on heterogeneity. Seven cohort studies were included in the meta-analysis. Results. A total of 14 627 women had successful vaginal delivery; 7212 women had 2-step and 7415 women had 1-step delivery. The rate of neonatal asphyxia (RR 0.55; 95% confidence interval [CI] 0.35–0.86; p = 0.008) and occurrence of neonatal clavicular fracture (RR 0.19; 95% CI 0.07–0.51; p = 0.001 ) were lower in the 2-step group than in the 1-step group. The neonatal brachial plexus injury rate was not statistically significant between the 2 groups (RR 0.2; 95% CI 0.04–1.10; p = 0.06). Conclusions. Current evidence supports the use of 2-step method of shoulder delivery with no major adverse neonatal outcomes, lower incidence of neonatal asphyxia rate, and neonatal clavicular fracture rate than delivery by the 1-step method. The clinical value is high for the adoption of 2-step method for better neonatal outcomes.

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Background. Fall is a common morbidity in older persons. In India, the number of old age homes and persons living in them are increasing. We studied the prevalence of fall among older persons living in old age homes. Methods. We did a cross-sectional survey among persons aged 60 years or above, living in old age homes of Delhi, India. Information on location, type and bed-strength was collected for old age homes, and using their combination, 28 clusters of almost equal sizes (25–35) were created, of which, 13 were selected randomly to meet an estimated sample size of 340. All residents of the selected old age homes were recruited for the study. A self-developed, semi-structured interview schedule was used for recording the sociodemographic profile and history of fall in the past 6 months. Logistic regression was used to explore factors that might be associated with fall. Poisson regression was used to model the frequency of incidents of fall. Results. A total of 335 older persons, with mean (SD) age of 75.2 (8.6) years were studied. At least 1 episode of fall was reported by 55 (16.4%), of whom, injury and disability were sustained by 54.5% and 23.3%, respectively. On multivariate logistic regression, for each additional morbidity, odds ratio of fall was 1.5 (95% confidence interval [CI] 1.09–1.95). Multivariate Poisson regression showed that age and tobacco use were significantly associated with the incidents of fall. For each unit increase in age, the incident rate ratio increased by 1.02 times (95% CI 1.01–1.03). Being a past user of tobacco had a statistically significant incident rate of 1.57 times (95% CI 1.01-2.45) compared to non-users of tobacco. Conclusion. One-sixth of individuals living in old age homes had experienced a fall in the past 6 months. Measures should be taken to prevent falls in old age home settings in India.

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Background. An ‘informed consent’ is a legal and ethical requirement for research involving human subjects. Studies assessing the validity of informed consent and determinants of its quality have highlighted problems in consent delivery and comprehension by trial participants. We report the findings of a questionnaire-based survey conducted to understand the quality of informed consent (QuIC) in cancer clinical trials. Methods. The survey was conducted in a single tertiary care cancer centre in India. Patients enrolled in phase 1, 2 or 3 interventional studies were administered the QuIC questionnaire by a trained study coordinator. The QuIC, expressed as knowledge score, was calculated from the proportion of correct responses expressed as a percentage. Results. The mean (SD) knowledge score was 60.46% (1 5.21%). It was considerably higher in industry-sponsored trials compared to investigator-initiated trials (65.32% v. 52.21%, respectively; p<0.001). Faith in the treating oncologist positively influenced the patients’ decision to participate in a trial. Nearly 97% of the respondents anticipated better care, while 85% felt that the new drug/procedure would be better than the existing treatment. Free treatment emerged as a strong inducement for patients to take part in clinical trials. Patients were aware of their autonomy, and responses showed that none of the patients were coerced or unduly influenced to participate in clinical trials. Conclusion. Our study revealed important deficiencies in research participants’ understanding of essential elements of informed consent. Thorough patient counselling is crucial to minimize ‘therapeutic misconception’ to preserve the validity of informed consent in cancer trials.

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Community-based research is an excellent opportunity for medical students to learn outside the boundaries of a medical college, where health-related conditions and factors can be studied in a larger social context. It also brings a variety of other educational and social learning with it. The research question is usually a community-driven issue. There are multiple ways to arrive at a research question. Sampling poses a unique challenge, especially in terms of availability of a sampling frame. However, accessing electoral rolls, census data and approaching community leaders of voluntary agencies working in a particular area can be a suitable way. The interview schedule should be culturally and socially appropriate and locally validated if possible. Prior preparation of a timetable of activities is much needed, including slack time and contingency plans to fall back on as some social situations might make the area inaccessible. An important team member in these situations is a chaperone from the community who can facilitate these social interactions, including negotiations for the time of the participant. There may be sociocultural problems, which plague the research as much as they affect the community, which the researcher has to be sensitized to. Extra effort is needed to achieve a high response rate in community-based studies. Refusals by selected participants and their nonavailability despite 2–3 household visits need to be addressed with patience and perseverance. Several ethical issues arise during the research, and careful thought has to be given to avoid exploitation of the communities.

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