Traditional approach to predicting trauma-related mortality utilizes scores based on anatomical, physiological, or a combination of both types of criteria. However, several factors are reported in literature to predict mortality independent of severity scores. The objectives of the study were to identify predictors of 1 year mortality and determine their magnitude and significance of association in a resource constrained scenario.
Materials and Methods:
Prospective observational study enrolled 572 patients. Information regarding factors known to affect mortality was recorded. Other factors which may be important in resource constrained settings were also included. This included referral from a peripheral hospital, number of surgeries performed on the patient, and his socioeconomic status (below poverty line (BPL) card). Patients were followed till death or upto a period of 1year. Logistic regression, actuarial survival analysis, and Cox proportionate hazard model were used to identify predictors of 1year mortality. Limited estimate of external validity of the study was obtained using bootstrapping.
Age of patient, Injury Severity Score (ISS), abnormal activated partial thromboplastin time (APTT), Glasgow Coma Scale (GCS) score at admission, and systolic blood pressure (BP) at admission were found to significantly predict mortality on logistic regression and Cox proportionate hazard models. Abnormal respiratory rate at admission was found to significantly predict mortality in the logistic regression model, but no such association was seen in Cox proportionate hazard model. Bootstrapping of the logistic regression model and Cox proportionate hazard model provide us with a set of factors common to both the models. These were age, ISS, APTT, and GCS score at admission.
Multivariate analysis (logistic and Cox proportionate hazard analysis) and subsequent bootstrapping provide us with a set of factors which may be considered as valid predictors universally. However, since bootstrapping only provides limited estimates of external validity, there is a need to test these factors against the well accepted requirements of external validity namely population, ecological, and temporal validity.
Injury Severity Score; mortality predictors; trauma
Recent years have shown an alarming rise in the incidence of diabetes mellitus (DM) all over the world. The present management of DM it not satisfactory. Hence, alternative systems of medicine are also being explored. Prameha as described in Ayurveda is a disease synonymous with today's DM. The patients of Prameha inherently carry the risk of impaired Agni and depleted Ojas status, that is, hypometabolic and immuno-compromised state. Now the primary goal is not merely to achieve normoglycemia, but also to minimize its complications. In this context, many Ayurvedic drugs are undergoing extensive research.
To evaluate the anti-diabetic, immune-enhancer and biofire balancing effects of Naimittika Rasayana drugs viz. Silajatu and Mamajjaka in type-2 DM.
Materials and Methods:
A total of 95 patients of type-2 DM were registered; in which 84 patients turned up for full follow-up. Patients were randomly allocated into three groups; Group-A was treated with Mamajjaka (500mg twice a day) and Group-B with Silajatu (500mg twice a day) and Group-C was treated with modern drug and assessment was done at monthly intervals for three months.
The selected Rasayana drugs have shown good response on subjective and objective parameters. The Mamajjaka treated patients responded better. However, as regards the reduction of post prandial blood sugar, Silajatu was superior.
The Ayurveda-inspired holistic approach seems to have a unique response promoting Agni (biofire) and Ojas (immune strength) status leading to good health and wellness.
Agni; diabetes mellitus; Madhumeha; Mamajjaka; Ojas; Rasayana; Silajatu
Spinal cord injury often results in significant catastrophic disability. Placement of the intact omentum upon a recently traumatized spinal cord was found to be effective. It represents a very suitable organ for revascularization of the ischemic nervous tissue, due to its abundance in blood and lymph vessels and its capability to adhere to the surface of the lesion, with capillary overgrowing in 4-6 h. The traditional method of omentum transposition is a hectic and time-consuming two-stage procedure in which position is changed twice. The major disadvantage of this two-staged procedure is that it takes longer operative time, and there is high risk of infection due to change of position with an open wound. So there is a need for modifications so that the procedure can be made easier and complications can be avoided.
To avoid the complications and to make the procedure easier, a single-staged procedure called ‘chooramani technique’ for omental transposition in spinal cord injury is proposed.
Materials and Methods:
The study was conducted on 16 patients of post-traumatic thoraco-lumbar spinal cord injury with paraplegia.
Complications like wound infection, incisional hernia, and CSF leak were avoided. Operative time reduced to approximately half.
This modification of technique is relatively easy and can be adopted for patients undergoing omental transposition for spinal cord injury.
Omental transposition; spinal cord injury; paraplegia
‘What is the ideal way of teaching Ayurveda?’ – has been a debated question since long. The present graduate level curriculum lists out the topics from ‘contemporary medical science’ and ‘Ayurveda’ discretely, placing no emphasis on integration. Most of the textbooks, too, follow the same pattern. This makes learning not only difficult, but also leads to cognitive dissonance.
To develop and evaluate the effectiveness of a few integrative teaching methods.
Materials and Methods:
We introduced three different interventions in the subject Kriya Sharira with special reference to ‘cardiovascular physiology’. The instructional methods that we evaluated were: 1. Integrative module on cardiovascular physiology (IMCP), 2. case-stimulated learning (CSL), and 3. classroom small group discussion (CSGD). In the first two experiments, we subjected the experimental group of graduate students to the integrative instructional methods. The control group of students received the instructions in a conventional, didactic, teacher-centric way. After the experiments were over, the learning outcome was assessed and compared on the basis of the test scores. The groups were crossed over thereafter and the instructional methods were interchanged. Finally, feedback was obtained on different questionnaires. In the third experiment, only student feedback was taken as we could not have a control group.
The test results in the first experiment showed that the integrative method is comparable with the conventional method. In the second experiment, the test results showed that the integrative method is better than the conventional method. The student feedback showed that all the three methods were perceived to be more interesting than the conventional one.
The study shows that the development of testable integrative teaching methods is possible in the context of Ayurveda education. It also shows that students find integrative approaches more interesting than the conventional method.
Ayurveda education; case-stimulated learning; classroom small group discussion; Kriya Sharira; instructional methods; integrative module
Ayurveda prescribes daily and seasonal regimen in maintaining good health. Measures in the preservation of health have been described considering one's own Prakriti, Satva, Vayas, Bala, Agni, Ojus, season, and so on. Depending on the relative predominance of Doshas in various constitutions and seasons, certain regimens have been prescribed. The present study was done to assess the lipid profile in 54 healthy volunteers. It was observed from the present data that winter month is one of the potential risk factors for cardiovascular diseases because more lipid profile level was observed during winter. Among the constitutions, Kapha and Pitta Prakriti are more vulnerable for cardiovascular diseases because more lipid profile level is observed in these constitutions during winter.
Ayurveda; diet; lifestyle; lipid profile; Prakriti; season
Walking is an isotonic aerobic exercise and has been associated with reduced blood sugar level in diabetic patients and other physiological changes in observational studies. A study was conducted to determine the effect of isotonic aerobic exercise (walking) on blood sugar level and other important physiological parameters as per Prakriti. This study was carried out in Department of Kriya Sharira and Kayachikita, S. S. Hospital; Faculty of Ayurveda, IMS, BHU and some cases were enrolled from Kashi Mumukshu Bhawan, Assi, Varanasi. A total 83 (32 diabetic control and 51 diabetic exercise) diabetic cases were included with age ranging from 35 to 65 years during January 2009 to January 2011. Control cases enrolled in this study had not performed any exercise. The results of the study revealed that, there is a strong association in between Prakriti, Blood pressure and certain other Biochemical parameters.
Aerobic exercise; diabetes mellitus; exercise; Prakriti; walking
We report a sporadic case of progressive osseous heteroplasia (POH) in a 10-year-old male child who developed progressive ossification of the skin and deep connective tissue. The condition needs to be distinguished from other causes of childhood heterotopic ossification, such as fibrodysplasia ossificans progressiva, pseudohypoparathyroidism, and pseudopseudohypoparathyroidism. The cause of POH is an inactivating GNAS1 (guanine nucleotide-binding protein alpha-stimulating activity polypeptide 1) mutation caused only by paternal inheritance of the mutant allele. Most cases are sporadic and only 2 instances of familial transmission have been documented, suggesting an autosomal dominant mode of inheritance with possible somatic mosaicism. The condition is associated with progressive superficial to deep ossification, progressive restriction of range of motion, bleak prognosis, and recurrence if excised.
GNAS1 mutation; heterotopic ossification; subcutaneous ossification
Poor maternal nutritional status and substandard antenatal care, which result in increased women's risk, low birth weight and stillbirth, afflict many countries with weak or emerging economies even today. Studies that address the effect of extending nutrition awareness among pregnant women to the net outcome of pregnancy remain scarce. We aimed to compare and contrast the effect of a pragmatic nutrition awareness program for expectant mothers (NAPEM) on birth weight of the newborn with a control group who received no such nutrition awareness activity. The effect of variables of mode of newborn delivery, associated complications at birth, and APGAR score of the newborn were also assessed. A pragmatic intervention trial of an antenatal care (ANC) program that consisted in nutrition awareness was conducted involving 53 pregnant women. Awareness was given through one-to-one interview and through informational literature provided to the participants in the local language. A hospital registry for deliveries undertaken during the study period was screened for identification of variables. A control group of matched pregnant women (n = 53) was obtained from the same hospital registry from preceding years, when the nutrition awareness program was not executed. A statistically significant improvement in birth weight of the newborn was observed in the intervention group, where expectant mothers were made aware about desired nutrition during pregnancy. A reduced incidence of complications associated with pregnancy was also observed in the intervention group. Providing awareness about nutritional requirements during pregnancy and suggesting the pragmatic ways to meet them was shown to be one possible effective measure to deal with pregnancy-related undernutrition. We show the efficacy of the intervention for underprivileged regions of India marked by inadequate health care delivery and lower socio-economical standards. We discuss our findings in the context of available evidence-based guidelines.
“Ayurveda” is an ancient system of healthcare that is native to India. At present, in India, there are more than 240 colleges that offer a graduate-level degree (Bachelor of Ayurvedic Medicine and Surgery—BAMS) in Ayurveda. Even though the Central Council of Indian Medicine, the governing body that monitors the matters related to Ayurveda education, has imposed various educational norms and regulations, the standard of education has been a cause of concern in recent years. The mushrooming of substandard Ayurvedic colleges is the most important factor that is being held responsible for this kind of erosion in the standards. The present study is a mailed survey, which was carried out to evaluate the “Extent of exposure to basic clinical skills during BAMS course” as perceived by the sample groups of students and teachers drawn from 32 Ayurvedic educational institutions spread all over India. A methodically validated questionnaire was used as the tool in the study, to which 1022 participants responded. The study indicates that there are some serious flaws in the existing system of the graduate-level Ayurveda education. Since the Ayurvedic graduates play an important role in the primary healthcare delivery system of the country, governing bodies are required to take necessary steps to ensure the adequate exposure of the students to basic clinical skills. Along with the strict implementation of all the regulatory norms during the process of recognition of the colleges, introducing some changes in the policy model may also be required to tackle the situation.
According to Ayurveda, the native Indian system of healthcare, three Doshas, namely, Vata, Pitta, and Kapha, are the basic mutually reciprocal mechanisms that are responsible for the maintenance of homeostasis in human beings. Ayurveda classifies entire human population into seven constitutional types (Prakriti), based on the dominance of any single or a combination of two or three Doshas. Considering the fact that, in the recent past there have been several studies that have proposed some important genetic, biochemical and haematological bases for Prakriti, we conducted the present study in 90 randomly selected clinically healthy volunteers belonging to dual constitutional types (Dvandvaja Prakriti) to evaluate the variability of heart rate and arterial blood pressure in response to specific postural changes, exercise, and cold pressor test. The results of this study, in general, suggest that these basic cardiovascular responses do not vary significantly as per the dual constitutional types. However, we noted a significant fall in the diastolic blood pressure immediately after performing the isotonic exercise for five minutes, in Vata-Kapha individuals in comparison to the other two groups, namely, Pitta-Kapha and Vata-Pitta.
The manipulation and corrective cast application for club foot was known to be done by Kite's method. The Kite's method of manipulation (center of rotation of malaligned foot and fulcrum on cuboid) was modified by Ponseti (fulcrum on head of talus). Recently, Ponseti's method has gained popularity and vastly improved results are reported. We report randomized controlled trial where manipulation of club foot was done by Ponseti's and Kite's method and correction evaluated by Pirani score to compare the outcome of treatment.
Materials and Methods:
Sixty feet in 38 patients, 22 with bilateral and 16 with unilateral clubfeet in children less than two years of age and without any prior manipulation or surgical treatment were randomly allocated to the Ponseti (30 feet) and Kite (30 feet) methods of manipulation. This process resulted in the right and left feet of the same patient in 12 bilateral cases being compared with one another (Paired analysis). In the remaining 10 bilateral cases, four patients had both feet treated by Ponseti and six had both feet treated by Kite (unpaired analysis). Finally, in 16 unilateral cases, 10 feet were allocated to the Ponseti and six to Kite methods of manipulation (unpaired analysis). Feet were followed up weekly for 10 weeks for change of cast and recording of hindfoot, midfoot and total Pirani scores. Correction was measured as a difference between hindfoot, mid foot and total Pirani scores weekly from weeks 1 to 10 and corresponding baseline scores. Absolute correction and rate of correction in (i) bilateral clubfeet treated by Ponseti's method on one side and Kite's method on the other side in the same patient were compared using paired Student's t test and (ii) patients with unilateral clubfoot (where either of the methods was used) or those with bilateral clubfoot (where both feet treated by either of the two methods on both the sides) were compared using difference between means (mean correction by Ponseti minus mean correction by Kite) for magnitude of difference and unpaired Student's t test (if data was normally distributed) or Mann Whitney U statistics (otherwise) for significance of difference.
In 12 bilateral clubfeet, where one foot received Kite's method and the other Ponseti's manipulation, feet treated by Ponseti's technique showed faster rates of decrease in Pirani score (improvement) as compared to feet treated by Kite's method with the mean of difference between baseline and follow up scores showing significantly greater (P<0.05) difference from zero from fourth week onwards to up to 10 weeks. In unpaired analysis, both for unilateral or bilateral clubfeet, regardless of side, mean Pirani scores in Ponseti feet improved much faster than Kite feet but the difference achieved statistical significance only at the 10th week from the start of treatment.
Hind foot, midfoot and total Pirani scores reduce much faster with Ponseti than the Kite's method of manipulation of clubfoot. In paired analysis the difference becomes statistically significant at fourth week and in unpaired analysis at 10th week from the start of treatment.
Clubfoot; kite; Ponseti; manipulation; Pirani score
In the present day scenario, Ayurveda is globally being perceived in several contradictory ways. Poor quality of Ayurveda graduates produced as a result of poorly structured and poorly regulated education system is at least one of the important factors responsible for this scenario. The present study was carried out to evaluate the ‘Global challenges of graduate level Ayurvedic education’ and is based on the responses of Ayurvedic students and Ayurvedic teachers from various educational institutions of India to a methodically validated questionnaire. As the study indicates, the poor standard of Ayurvedic education in India is definitely a cause of concern. The curriculum of Bachelor of Ayurvedic Medicine and Surgery (BAMS) course of studies is required to be reviewed and restructured. The syllabi are required to be updated with certain relevant topics like laws governing the intellectual property rights, basic procedures of standardization of medicinal products, fundamental methods of evaluating the toxicity of the medicinal products, essentials of healthcare management and the basics of cultivation and marketing of medicinal plants. Furthermore, the study suggests that the Ayurvedic academicians are required to be trained in standard methods of research and documentation skills, and the educational institutions are required to be encouraged to contribute their share in building up the evidence base for Ayurveda in the form of quality education and research.
Ayurveda education; global challenges; India; mailed survey
A clinico-epidemiological study helps to plan future preventive measures and management strategies for spinal trauma. This is a 10 years' retrospective review of spinal-injury patients treated at a tertiary health center in the eastern of Nepal to determine clinico-epidemiological aspects of spinal-injury patients in a predominantly rural population of eastern Nepal.
Materials and Methods:
All medical record files of patients with spinal injury from 1996 to 2005 in the Medical Record Section of BPKIHS (B. P. Koirala Institute of Health Sciences) were studied. The preformed pro forma consisting age, sex, place of living, mode of injury, hospital stay level of injury, site of injury, associated injury, Frankel grading of neural deficit and treatment modality was filled from the record files of patients. These parameters were entered in Excel 8 and analyzed by EPI INFO 2002. Details of 896 patients of spinal injury were recorded in the 10-year period of review.
684 (76.35%) male and 212 (23.66%) female patients with mean age of 41.74 ± 16.53 years and 38.56 ± 15.86 years respectively were studied. Two hundred forty-two (27%) patients were from hilly districts of eastern Nepal. Fall from height [in 350 (39%) patients] was the commonest mode of spinal injury. Six hundred thirty-six (71%) patients presented with a neurological deficit. Seven hundred thirty-three (85%) patients were treated conservatively, compared to 163 (15%) surgically treated patients. One hundred forty-six (22%) patients were treated with operative interventions in the last five years.
The study shows that the most vulnerable group for spine injury was the group of patients of productive age with late presentation (i.e., injury hospital duration − 41.64 ± 54.24 hours) without proper prehospital management. The treatment modalities have changed (from conservative to surgical) in this part of the world. These specific observations help us in further planning for preventive measures and management in our setting.
Clinico-epidemiological study; retrospective review; spinal injuries; treatment of spinal injuries