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Prajitha KC, Rahul A, Chintha S, Soumya G, Maheswari Suresh M, Nalina Kumari Kesavan Nair A, Valamparampil MJ, Reghukumar A, Venkitaraman S, Anish TSN. Strategies and challenges in Kerala's response to the initial phase of COVID-19 pandemic: a qualitative descriptive study. BMJ Open 2021; 11:e051410. [PMID: 34244285 PMCID: PMC8275365 DOI: 10.1136/bmjopen-2021-051410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To understand the structures and strategies that helped Kerala in fighting the COVID-19 pandemic, the challenges faced by the state and how it was tackled. DESIGN Qualitative descriptive study using focus group discussions and in-depth interviews. SETTING State of Kerala, India. PARTICIPANTS 29 participants: four focus group discussions and eight in-depth interviews. Participants were chosen purposively based on their involvement in decision-making and implementation of COVID-19 control activities, from the department of health and family welfare, police, revenue, local self-government and community-based organisations. Districts, panchayats (local bodies) and primary health centres (PHCs) were selected based on epidemiological features of the area like the intensity of disease transmission and preventive/containment activities carried out in that particular area to capture the wide range of activities undertaken in the state. RESULTS The study identified five major themes that can inform best practices viz social capital, robust public health system, participation and volunteerism, health system preparedness, and challenges. This study was a real-time exploration of the intricacies of COVID-19 management in a low/middle-income country and the model can serve as an example for other states and nations to emulate or adjust accordingly. CONCLUSION The study shows the impact of synergy of these themes towards more effective solutions; however, further research is much needed in examining the relationship between these factors and their relevance in policy decisions.
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Affiliation(s)
| | - Arya Rahul
- Community Medicine, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Sujatha Chintha
- Community Medicine, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Gopakumar Soumya
- Community Medicine, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Meenu Maheswari Suresh
- Community Medicine, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | | | | | - Aravind Reghukumar
- Infectious Disease, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Sriram Venkitaraman
- Department of Health and Family Welfare, Government of Kerala, Thiruvananthapuram, Kerala, India
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Prasad N, Jabbar PK, Jayakumari C, John M, Haridasan RK, Surendran Nair Anish T, Gomez R, Das DV, Sreenath R, George GS, Nair A. Late-Night Salivary Cortisol in Healthy, Community-Dwelling Asian Indians Assessed by Second-Generation ECLIA. J Clin Endocrinol Metab 2020; 105:5840379. [PMID: 32424408 DOI: 10.1210/clinem/dgaa269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/08/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Late-night salivary cortisol (LNSC) is used as a screening test for Cushing syndrome (CS), but there is no community-derived normative data for the normal upper limit in the South Asian population. This study aimed to determine the upper limit of normal (97.5th percentile) for LNSC in an Asian Indian population using a commercially available second-generation electrochemiluminiscence immunoassay (ECLIA). METHODS LNSC in apparently healthy community-dwelling individuals was assessed by multistage cluster sampling. Healthy individuals age 18 to 60 years from 8 urban and 8 rural clusters of Thiruvananthapuram district were studied. Thirty people from an approximate population of 1000 individuals from each cluster participated in the study. A saliva sample was collected between 11 PM and 12 midnight and analyzed using Roche COBAS-e-411 and ultrasensitive Cortisol II kits the next day. RESULTS Cortisol values from 474 salivary samples were available for final analysis after exclusion of improperly collected samples. The 97.5th percentile of the LNSC concentrations was 0.25 μg/dL (6.89 nmol/L) (90% CI, 0.23-0.27 μg/dL; ie, 6.34-7.45 nmol/L). In postmenopausal women, median LNSC was significantly higher but the 90% CI for the upper limit of their LNSC (0.28μg/dL or 7.72 nmol/L) overlapped with that of premenopausal women. CONCLUSIONS This study establishes the normal value of LNSC estimated by second-generation ECLIA in healthy community-dwelling Asian Indian individuals for the first time. Salivary cortisol at 11 pm to 12 am is less than 0.25μg/dL (6.89 nmol/L) in the general Asian Indian population. Menopause causes a significant increase in LNSC and may lead to overdiagnosis of CS if not interpreted carefully.
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Affiliation(s)
- Nandini Prasad
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Puthiyaveettil Khadar Jabbar
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Chellamma Jayakumari
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Mathew John
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
- Providence Endocrine and Diabetes Specialty Centre, Thiruvananthapuram, Kerala, India
| | | | - Thekkumkara Surendran Nair Anish
- Providence Endocrine and Diabetes Specialty Centre, Thiruvananthapuram, Kerala, India
- Department of Community Medicine, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Ramesh Gomez
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Darvin Vamadevan Das
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Ravindranath Sreenath
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Geena Susan George
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Abilash Nair
- Department of Endocrinology & Metabolism, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
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Yohannan DG, Oommen AM, Umesan KG, Raveendran VL, Sreedhar LSL, Anish TSN, Hortsch M, Krishnapillai R. Overcoming Barriers in a Traditional Medical Education System by the Stepwise, Evidence-Based Introduction of a Modern Learning Technology. Med Sci Educ 2019; 29:803-817. [PMID: 34457545 PMCID: PMC8368117 DOI: 10.1007/s40670-019-00759-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Histology teaching in India and in other developing countries has not changed much over the past decades and has not joined the global movement of using virtual microscopy (VM). Many factors may have contributed to this academic inertia-including curricular requirements for traditional microscopy (TM) skills, assessments that are heavily based on TM, and unfamiliarity with modern technology among faculty, as well as infrastructural shortcomings. This study is aimed at overcoming these roadblocks by using a blended approach combining VM with TM in a tradition-centered curricular setting. METHODS For validation of this approach, the authors conducted a non-randomized controlled trial with a crossover design on first year medical students at the Government Medical College, Thiruvananthapuram, India. Examination scores and responses of a student group taught with VM as an adjunct to TM were compared with a student group taught with TM only. RESULTS The test group had significantly better results when compared to the control group for knowledge-based tests (p = 0.012; analysis of co-variance) and for an unannounced visual-based test conducted 1 month later (p = 0.001; Mann-Whitney U test). Feedback collected from students showed highly favorable responses to the use of VM for teaching histology. CONCLUSION This study should encourage Indian medical colleges and schools in other developing countries to start using VM as a supplementary approach for their histology education programs. Furthermore, as the Medical Council of India recommends the introduction of new competency-based integrated curriculum in India starting in 2019, the use of VM may facilitate more effective learning in the new scenario. TRIAL REGISTRATION CTRI/2018/04/012928.
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Affiliation(s)
| | - Aswathy Maria Oommen
- Department of Anatomy, Government Medical College, Thiruvananthapuram, Kerala India
| | | | | | | | | | - Michael Hortsch
- Department of Cell and Developmental Biology, University of Michigan Medical School, Ann Arbor, MI USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI USA
| | - Renuka Krishnapillai
- Department of Anatomy, Government Medical College, Thiruvananthapuram, Kerala India
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Nair SS, Sarasamma S, Gracious N, George J, Anish TSN, Radhakrishnan R. Polymorphism of the CYP3A5 gene and its effect on tacrolimus blood level. EXP CLIN TRANSPLANT 2015; 13 Suppl 1:197-200. [PMID: 25894154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Tacrolimus is the cornerstone for immunosuppression in renal transplant and is metabolized by the cytochrome P 450 3A (CYP3A) subfamily of enzymes in the liver and small intestine. A polymorphism in intron 3 of the CYP3A5 gene affects the expression of this enzyme and tacrolimus trough blood levels. The purpose of this study was to identify the proportion of CYP3A5 gene polymorphisms in South Indian renal transplant patients and determine the effect of CYP3A5 gene polymorphisms on tacrolimus trough blood levels in patients with and without CYP3A5 expression. MATERIALS AND METHODS We included 25 adult patients who underwent renal transplant at Government Medical College, Trivandrum. All patients received tacrolimus (dose, 0.1 mg/kg/body weight, in 2 divided doses). Tacrolimus trough blood levels were determined on postoperative day 6. The CYP3A5 genotype analysis was performed by polymerase chain reaction amplification of target and detection by restriction fragment length polymorphism analysis. RESULTS The CYP3A5*1/*1 genotype was detected in 5 recipients (20%), *1/*3 genotype in 5 recipients (20%), and *3/*3 genotypes in 15 recipients (60%) of the total 25 graft recipients. Mean tacrolimus level in the CYP3A5*1/*1 group was 5.154 ng/mL (range, 4.42 to 6.5 ng/mL), CYP3A5*1/*3 group was 5.348 ng/mL (range, 3.1 to 9.87 ng/mL), and CYP3A5*3/*3 group was 9.483 ng/mL (range, 4.5 to14.1 ng/mL). Acute rejection episodes were significantly more frequent for CYP3A5*1/*1 homozygous patients (40%) than patients with CYP3A5*1/*3 (20%) or CYP3A5*3/*3 (13%) genotypes. CONCLUSIONS Most patients carried the mutant allele CYP3A5*3 (A6986G). Tacrolimus drug level correlated well with presence or absence of CYP3A5 polymorphisms. Acute rejection episodes were more frequent in expressors, and they may require higher doses of tacrolimus. Similarly, tacrolimus nephrotoxicity was more frequent in non-expressors. Therefore, CYP3A5 polymorphism analysis before renal transplant may help determine the optimal dose of tacrolimus in this population and prevent acute rejection episodes or tacrolimus toxicity.
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Affiliation(s)
- Sreeja S Nair
- From the Department of Nephrology, Government Medical College, India
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Kuriakose A, Nair Anish TS, Soman B, Varghese RT, Sreelal TP, Mendez AM, Abraham A. Rate and Risk of All Cause Mortality among People with Known Hypertension in a Rural Community of Southern Kerala, India: The Results from the Prolife Cohort. Int J Prev Med 2014; 5:596-603. [PMID: 24932391 PMCID: PMC4050680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 01/01/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Hypertension is one of the most important determinants of death due to vascular damage and is fast emerging as a high burden disease in India. However, its documentation is poor in the country. This study aims to estimate the rate and the causal pattern of mortality in a cohort of people with high blood pressure as compared to normotensives. METHODS The study setting is Varkkala, a rural village in southern Kerala, India, and the study design was that of a prospective cohort. A total of 77,881 participants of age 20 years and above were considered for analysis. The rate and risk of all cause mortality (death due to any cause) among hypertensives were quantified and compared against the normotensives. The causes of death were also analyzedin both the groups. Cox proportional hazard models were created to estimate the hazard ratios of death among hypertensives adjusted for sociodemographic factors, behaviors, and comorbidities. RESULTS The incidence proportion of deaths in the study was 4.28% during the follow-up period of 6 years. The relative risk of mortality was 3.13 (CI: 2.91-3.37) in the high BP group. The age-adjusted hazard ratio of all cause mortality for the high BP group was 2.96 (2.56-3.42). Coronary artery disease was the major cause of death among the subjects with high BP. CONCLUSIONS The study revealed high prevalence of hypertension in the study population. A person with hypertension is at three times higher risk of death due to any cause compared to a normotensive individual even after adjustment for age.
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Affiliation(s)
- Anu Kuriakose
- Health Action by People (HAP), Thiruvananthapuram, Kerala, India,Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Thekkumkara Surendran Nair Anish
- Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India,Correspondence to: Dr. Thekkumkara Surendran Nair Anish, Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala - 695 011, India. E-mail:
| | - Biju Soman
- Health Action by People (HAP), Thiruvananthapuram, Kerala, India
| | | | | | - Alice Matilda Mendez
- Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Anitha Abraham
- Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India
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Anish TSN, Ramachandran R, Sivaram P, Mohandas S, Sasidharan A, Sreelakshmi PRN. Elementary school enrolment and its determinants among children with cerebral palsy in Thiruvananthapuram district, Kerala, India. J Neurosci Rural Pract 2013; 4:S40-4. [PMID: 24174798 PMCID: PMC3808060 DOI: 10.4103/0976-3147.116446] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Context: There is enough documented evidence to prove the benefits of early and appropriate initiation of education among children with cerebral palsy (CP). Aim: To find out the proportion of children with CP who are enrolled for some kind of formal education and to study the determinants of the same. Setting and Design: This cross sectional study was done among children, attending the special clinics at government medical college, Thiruvananthapuram. Materials and Methods: Children between 3 and 12 years of age diagnosed with CP were subjects for the study. Statistical Analysis Used: Enrollment for any form of formal education was the major outcome variable. The factors associated with initiation of formal education were tested using Chi-square test or Fischer's exact test. Independent association of each factor was evaluated through binary logistic Regression analysis. Results and Conclusions: The mean (SD) age of the children (n = 86) was 5.7 (2.3) years with forty-six (53.5%) of them being girls. Diplegia was the commonest limb abnormality found. Fifty-two (60.5%) children were undergoing some kind of schooling. Those children who were less dependent physically and those who had achieved better language development were regular school goers. After binary logistic regression the ability of a child to speak in sentences (P = 0.008) and ambulatory level of the child (P = 0.019) were factors which favored, whereas delay in attaining the adaptive developmental milestone of transferring objects from one hand to another (P = 0.014) was found to be detrimental for school enrollment.
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Anish TSN, Sreelakshmi PRN, Medhavan S, Babu S, Sugathan S. Efficacy of Canadian computed tomography head rule in predicting the need for a computed-axial tomography scans among patients with suspected head injuries. Int J Crit Illn Inj Sci 2012. [PMID: 23181211 PMCID: PMC3500009 DOI: 10.4103/2229-5151.100904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Context: The use of imaging modalities is crucial in the diagnostic field of critical medicine. However, the ethical and economic use of these techniques has become a major concern especially in resource-poor settings. The Canadian computed tomography Head Rule (CCHR) is being increasingly used all over the world to evaluate the necessity of a Computer-assisted Tomography (CT) scan in patients with suspected head injury. Aim: The aim of the current study is to evaluate the efficacy of CCHR to predict the occurrence of head injury, as evidenced radiologically by a CT Head, at a government tertiary care clinical setting in south India. Setting and Design: The design was that of a hospital-based cross-sectional survey conducted at the Medical College Hospital, Thiruvananthapuram (Kerala, India). Materials and Methods: The study subjects were patients with suspected head injury evaluated at the Surgical Casualty Department of the study setting. Fifty consecutive patients with suspected head injury were enrolled in the study. Statistical Analysis: The Chi-square test was used to assess the statistical significance of association between the outcome variable and the exposure characteristics. The diagnostic ability of the Glasgow Coma Scale (GCS) and CCHR were expressed in terms of sensitivity and specificity by considering CT diagnosed Head injury as the gold standard diagnostic tool. Results: Clinical manifestations as measured by a GCS score < 13 failed to significantly predict a head injury in the CT scan. However, the same became statistically significant when the CCHR was added to the GCS score as a predictor (P value < 0.001). The sensitivity of the tool in predicting a head injury rose from 23.3 to 96.7%. Conclusion: The current study suggested that the CCHR could act as an excellent decision rule to indicate the need of a CT scan. The need of a decision rule was warranted in the context of the growth of newer diagnostic imaging facilities in India.
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Vijayakumar KP, Nair Anish TS, George B, Lawrence T, Muthukkutty SC, Ramachandran R. Clinical Profile of Chikungunya Patients during the Epidemic of 2007 in Kerala, India. J Glob Infect Dis 2011; 3:221-6. [PMID: 21887052 PMCID: PMC3162807 DOI: 10.4103/0974-777x.83526] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: The association of the present Chikungunya pandemic with a mutation in the Chik virus is already established in many parts of the world, including Kerala. Kerala was one of the worst-affected states of India in the Chikungunya epidemic of 2006–2007. It is important to discuss the clinical features of patients affected by Chikungunya fever in the context of this change in the epidemiology of the disease. Aim: This study tries to analyze the clinical picture of the Chikungunya patients in Kerala during the epidemic of 2007. Setting and Design: A cross-sectional survey was carried out in five of the most affected districts in Kerala, India. Materials and Methods: A two-stage cluster sampling technique was used to collect the information. Ten clusters each were selected from all the five districts, and the size of the clusters were 18 houses each. A structured interview schedule was used for data collection. Diagnosis based on clinical signs and symptoms was the major case-finding strategy. Results and Conclusion: Of the 3623 residents in the surveyed households, 1913 (52.8%) had Chikungunya clinically. Most of the affected were in the adult age group (73.4%). Swelling of the joints was seen in 69.9% of the patients, followed by headache (64.1%) and itching (50.3%). The knee joint was the most common joint affected (52%). The number of patients with persistence of any of the symptoms even after 1 month of illness was 1388 (72.6%). Taking bed rest till the relief of joint pain was found to be a protective factor for the persistence of the symptoms. Recurrence of symptoms with a period of disease-free interval was complained by 669 (35.0%) people. Older age (>40 years), a presentation of high-grade fever with shivering, involvement of the small joints of the hand, presence of rashes or joint swelling during the first week of fever and fever lasting for more than 1 week were the significant risk factors for recurrence of symptoms predicted by a binary logistic regression model. In conclusion, we found that there is substantial acute and chronic morbidity associated with the Chikungunya epidemic of 2007.
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Affiliation(s)
- Krishna Pillai Vijayakumar
- Department of Community Medicine, Government Medical College, Thiruvananthapuram, Calicut, Kerala, India
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