Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareStudy of Aetiology, Complications, Prognostic Factors and Mortality Predictors in Acute Liver Failure in a Tertiary Care Hospital of North India English0309Satish KumarEnglish Virendra AtamEnglish Satyendra Kumar SonkarEnglish Ajay KumarEnglish Harish GuptaEnglish Shyam Chand ChaudharyEnglishBackground: Acute liver failure (ALF) is an entity with rapid deterioration of liver functions which is associated with increased morbidity and mortality. Methods: Data recorded in terms of aetiology, complications, prognostic factors and mortality predictors in a defined period of January 2018-January 2019. Univariate analysis was done to compare several parameters of survivors and expired patients and then all significant parameters were fed into a sequential logistic regression analysis to determine independent parameters of prognosis. Results: A total of 100 patients [56 males and 44 females: age (mean ± SD) 30.13 ± 13.32 years] with acute liver failure were enrolled in the study. Among these, 70 (70%) patients died due to the development of complications. In this study acute liver failure was caused by Hepatitis E virus in 44(44%) patients, hepatitis A virus in 19 (19%), hepatitis B virus in 10 (10%), hepatitis C virus in 2 (2%), and hepatitis non A to E in 17(17%). The number of female patients was 44of which, 35 were in childbearing age, 24 (68.57%) were pregnant and 20(83.33%) were in the third trimester. Hepatitis E was found positive in 22 (91.66%) pregnant women. Conclusion: Hepatitis E was found as the commonest cause of acute liver failure and also in most of the pregnant women, mostly in the third trimester were affected. Initial bad prognostic indicators were non-hepatitis E aetiology, prothrombin time >30 s, coma grade >2 and age >40 years. EnglishViral hepatitis, Hepatitis E virus, Pregnancy, Non-hepatitis EIntroduction Acute liver failure (ALF) is a rare clinical syndrome with rapid disease progression causing very high morbidity and mortality within a short interval of time.1 ALF manifests with severe injury and massive necrosis of hepatocytes causing severe liver dysfunction. It is a life-threatening emergency, but a potentially reversible condition, of varied aetiology, featured by jaundice, hepatic encephalopathy and coagulopathy causing multiple organ dysfunction in a patient without previous history of liver disease.1,2 Management is based on the early finding of the aetiology, complications, and general supportive care. But despite the advanced intensive care unit (ICU), mortality in ALF may be up to 40 to 80%.3 These patients have a very poor prognosis and liver transplantation has made a good impact on their survival.4 Chances of spontaneous recovery in these patients are defined by some prognostic criteria used by transplant centres in the West.5 Liver transplantation is newer in developing countries and clinicians there, should know prognostic factors of ALF before managing a patient of acute liver failure. Criteria defining prognosis in western countries may or may not be similar for developing countries like India, because different geographical regions have different aetiology for ALF, hence different prognostic factors.6 The aetiology of ALF also varies according to the age of the patient.7 In the West, aetiology is confined mainly to hepatitis non A to E (Hn A-E), acetaminophen overdose, and idiosyncratic drug reactions8 while on another side in Indian subcontinent main causes for ALF is hepatitis E virus (HEV).9 Pregnant women are prone to get infected with HEV, and progression to ALF will affect the prognosis and thought of liver transplantation.10 Hepatitis C virus is not considered to cause ALF in the absence of a coexisting aetiology. Although, case reports are there. This study was done to study the aetiology, complications, prognostic factors and mortality indicators in 100 patients with ALF in a tertiary care hospital of North India. Patients This study was a retrospective cross-sectional study that enrolled all consecutive patients of ALF admitted to the ICU and high dependency unit (HDU) of the department of medicine at King George’s Medical University, Lucknow during January 2018-January 2019. Consent was taken from all admitted subjects. All patients were given standard supportive care and strict monitoring of clinical, biochemical and hemodynamic status. Women in the age group of 15-45 years who were married were also tested for pregnancy status by human chorionic gonadotropin (HCG) hormone in urine and ultrasonography pelvic region for estimation of gestational age. Pregnant women were managed conservatively and no efforts were made to deliver the pregnancy unless otherwise absolutely indicated by obstetricians. No, any patient was treated by liver transplantation. The most widely accepted definition from the American Association for the Study of Liver Diseases (AASLD) is “evidence of coagulation abnormality, usually an international normalized ratio above 1.5, and any degree of mental alteration (encephalopathy) in a patient without pre-existing liver disease and with an illness of fewer than 26 weeks’ duration.11,12 The prognosis was determined by variables at the time of hospitalization. Complications such as cerebral oedema, renal failure, and gastrointestinal bleeding were noticed within 48 h of admission and were kept for analysis. Methods Data of admitted patients with acute liver failure were collected from Jan 2018 to Jan 2019. A total of 100 patients of acute liver failure were enrolled in the study. Data was collected in terms of clinical, biochemical, aetiology, complications, prognostic factors and mortality predictors. Routine investigations were complete blood count, liver function test (LFT), renal function, serum sodium, serum potassium,prothrombin time, international normalised ratio(INR), and ultrasonography abdomen(USG).[A1] Sera of all acute phase was investigated by enzyme-linked immunosorbent assay (ELISA) for markers of hepatitis A virus (HAV) (IgM anti-HAV), hepatitis B virus (HBV) (HBsAg and IgM anti-HBc), hepatitis C virus (HCV) (anti-HCV second generation) and hepatitis D virus (HDV) (IgG and IgM anti-HDV) with commercially available kits along with ELISA for IgM and IgG antibodies to HEV by a kit using two recombinant HEV antigens. PCR reaction was done when necessary. The patient’s co morbid conditions were noted. Those who had a history or had clinical/imaging/biochemical features of chronic liver disease and a history of significant alcohol ingestion (>20 gm daily) were excluded from the study. Any previous abdominal surgery, malignancies, gallstones, and cardiac diseases were also excluded. Liver biopsy could not be done as none of the patients’ attendants consented for the procedure. On the behalf of positive findings of above viral markers, hepatitis was divided into hepatitis A (presence of IgM anti- HAV), acute hepatitis B (presence of HBsAg and IgM anti- HBc), acute hepatitis on a pre-existing hepatitis B carrier state (presence of HBsAgwith no IgM anti-HBc) and hepatitis D (presence of IgG or IgM anti-HDV and HBsAg). Hepatitis E was confirmed by positivity for IgM anti-HEV in the serum of cases or seroconversion to IgG anti-HEV alone in convalescent sera. Positivity of anti-HCV and HCV RNA diagnosed hepatitis C infection. Aetiology of hepatitis non A to E (HnA-E) was diagnosed in those patients which have clinical, biochemical and radiological features of acute hepatitis, negative aetiologies of viral hepatitis A, B, C, D and E, no history of intake of drugs, hepatotoxins, systemic infections and biliary obstruction/infection. Statistical methods Statistical analysis was performed using SPSS Statistics software. Baseline characteristics were assessed with standard descriptive statistics. Quantitative variables were compared using the independent t-test and Mann–Whitney test (for nonparametric data) between two groups. Qualitative variables were compared using the Chi-square test/Fisher’s exact test. Pearson correlation coefficient was used to find correlation between various variables. Multivariate regression analysis was performed to examine the relationship between various parameters after adjusting for confounders. Results Among all 100 admitted patients of acute liver failure, 70 expired.[A2] Major etiology behind ALF was hepatitis viruses (Table 1). Mortality rates were compared among all viral hepatitis patients, it was 80% in HBV, 100% in HCV, 88.23% in hepatitis non A to E (HnA-E)[A3] and all did not differ significantly. (p=0.45) while the mortality rate in ALF caused by HEV (45.45%) was found lesser than others which were significant (P < 0.001 in almost all). Pre-existing HBV carrier state was found in ten (10%) patients and these had super infection by other hepatitis viruses. Eight (80%) of these died. Cryptic hepatitis B infection was not recorded in any patient. Clinical and hematological parameters of ALF patients with the aetiology of HBV, HCV, and HnA-E were almost similar. All non-E patients of ALF were subgroups and analyzed. Comparison of clinical and haematological parameters of HEV and non- hepatitis E patients are shown in Table 2. ALF patients in the third and fourth decades of life (72% of patients) were highly affected.ALF patients with the aetiology of hepatitis E were younger than the non-hepatitis E related ALF patients. Hepatitis A infection was found in the lower age group of40 years, cerebral oedema, coma grade >2, prothrombin time >30 s, non-hepatitis E aetiology of ALF, sepsis and renal failure at presentation. Among all these seven parameters multivariate analysis signi?cance was found with coma grade >2, age >40 years, non-hepatitis E aetiology and prothrombin time >30 s. The outcome was most significantly associated with etiology.HEV as aetiology of ALF was associated with a good outcome while non-hepatitis E agents were bad prognostic factors. Prothrombin time >30 s was the next signi?cant predictor of outcome which was found in 37 patients and caused 34 (91.89%) of the expiries. In decreasing order age >40 years was the next to affect the outcome. Among 21 patients, 19 (90.47%) deaths occurred. Coma grade>2 was observed in 76 patients and resulted in 60 (78.94%) expiries.[A4] It was concluded that, with more number of bad prognostic factors, the mortality was higher (Table 4). Discussion This study was done on the patients admitted in the intensive care unit and high dependency wards of the medicine department of a tertiary care hospital were all potential patients come to admit. Cause for acute liver failure in our all admitted patients was either known or putative hepatitis viruses. Though ALF could be a result of several aetiological factors, the most common cause in the United Kingdom is concerned with acetaminophen (non-steroidal anti-in?ammatory drugs) poisoning concerning suicidal tendencies13,14 and commonest cause in India was viral hepatitis and it was HEV.15 No one of our patients had ALF with the aetiology of acetaminophen poisoning which may be due to the use of some other agent for the suicidal attempt. Those patients who were having negative viral markers for hepatitis were named Hn A-E in the current study. Among Hn A-E some patients were linked with contact to some unknown ‘herbs’ (drug-induced liver injury-DILI) or toxins and they could not be identified due to lack of reliable biomarkers.16 Remaining liver diseases constituting a very lesser number of cases are liver diseases unique in pregnancy, metabolic and vascular liver diseases, and so many of miscellaneous liver diseases.12 In the current study hepatitis, A and E were the commonest aetiology. In developing countries such as India, HAV[A5] is highly pathogenic and spreads via transmission from one to another person. On the other side HEV is a labile agent that spreads via contaminated water and does not have person-to-person transmission.17 In endemic areas of HEV, anti-HEV seroprevalence ranges from 5-20%, which becomes higher with increasing age and as a result, most of the adults are prone to HEV exposure.18 Due to these conditions, HEV infection is mainly a disease of the adult group.17,19 Many studies from India have concluded hepatitis C in the non-A, non-B group of patients20,21 in causing ALF and also in this study HCV infection was determined in 2% of patients. But this could not be determined that HCV was causing ALF or it was representing pre-existing carrier state and another factor caused ALF. HnA-E constitutes 30–50% of cases of ALF in the West and this putative agent formed 2% of patients in the present study. Maximum 44 patients of ALF were associated with HEV constituting of largest aetiology of ALF. Kashmir state of India is endemic for HEV and it constitutes the commonest aetiology there and in other endemic areas of the world.22 In this study, it was observed that HEV is highly prevalent in pregnant women and there were 22 (91.67%) pregnant women having HEV positivity among a total of 24 pregnant women. It re?ects endemicity of HEV in this state. This finding is the most distinctive epidemiological feature of ALF in the current study. In pregnancy viral hepatitis is a matter of dispute because study data in the West says acute viral hepatitis (AVH) is not prevalent in pregnancy and if occurred it will have a similar disease course as in nonpregnant.20 While in developing nations like India, viral hepatitis is highly prevalent in pregnant with more severity.13,23,24 This is due to the different aetiology of AVH in the West and developing nations. In this study above predilection is consistent. ALF due to non E hepatitis viruses did not have a higher attack rate and fatality in comparison to HEV in pregnancy. In the current study, it was found that HEV has increased prevalence and fatality in pregnancy but pregnancy itself or its gestation didn’t affect mortality in ALF.10 Although ALF is predominant in pregnancy, it means not that there will be higher mortality in comparison to ALF in non-pregnant women and men. Mortality of patients of ALF in pregnancy will depend on all prognostic factors and not on the pregnancy or gestational period.[A6] There was a significant influence of PEP on mortality in our study and it showed that patients with PEP less than 8 days have non signi?cantly lower (63.63%) mortality in comparison to significantly higher mortality in those with PEP more than 8 days (77.78%). While a study was done in New Delhi, India reported that there is no influence of PEP on the prognosis and severity of ALF.9In this study, it was also found that cerebral oedema at presentation was in 56% of patients, which caused fatal results in 89.28% of patients. Late admission to hospital care was responsible for a greater number of patients with cerebral oedema. Finding some more complications such as renal failure, sepsis, and gastrointestinal bleeding was also found in some studies done in western and in India.1 Prognosis in our study was significantly associated with the aetiology of ALF as HEV patients with ALF have a mortality of 45.45% in comparison to higher mortality (88.23%)caused by HBV, HCV, and Hn A-E. While another study from India could not find aetiology as a prognostic indicator in ALF 6 Western studies say Hn A-E and drugs are bad indicators of prognosis.5 ALF due to HEV had a favourable outcome while those due to Hn A-E factors had bad results. The assessment of these parameters separately results in a signi?cant impact on survival. Conclusion In this study of 100 patients, we found that known or putative hepatitis viruses caused ALF in a maximum number of patients. Among all aetiologies of ALF, HEV caused maximum cases. Pregnancy was observed in about one- fourth of ALF patients and, all but two patients were HEV positive. Pregnancy itself or a gestational period not affects results. Early bad prognostic indicators were prothrombin time greater than 30 seconds, age more than 40 years and coma grade more than 2.[A7] Acknowledgment-Authorsare grateful to all patients, clinicians and other medical staff involved in this study. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Conflict of interest-None Financial support- None Englishhttp://ijcrr.com/abstract.php?article_id=2711http://ijcrr.com/article_html.php?did=2711References [1].Hoofnagle JH, Carithers RL Jr, Shapiro C, Ascher N. Ful- minant hepatic failure: summary of a workshop. Hepatology 1995; 21: 240–252. [2]. Bucuvalas J, Yazigi N, Squires R. Acute liver failure in children. Clin Liver Dis. 2006; 10: 149-68. [3]. Gill RQ, Sterling RK. Acute liver failure. J Clin Gastroenterol. 2001 Sep;33(3):191–198. [4]. Bismuth H, Samuel D, Castaing D, Wililams R, Pereira SP. Liver transplantation in Europe for patients with acute liver failure. Semin Liver Dis 1996; 16: 415–425. [5].Bernuau JB, Goudeau A, Poynard T et al. Multivariate analysis of prognostic factors in fulminant hepatitis B. Hepatology 1986; 6: 646–651. [6]. Lee WM, Sorrell MF. Developing a world view toward acute liver failure.Hepatology 1996; 24: 270–271. [7]. Ostapowicz J, Lee WM. Acute hepatic failure: a western perspective. J Gastroenterol Hepatol. 2000;15;480-8. [8].Bernuau J, Rueff B, Benhamou JP. Fulminant and subful- minant liver failure; de?nition and causes.Semin Liver Dis 1986; 6: 97–106. [9].Acharya SK, Dasarathy S, Kumer TL et al. Fulminant hepatitis in a tropical population: clinical course, cause, and early predictors of outcome. Hepatology 1996; 23: 1448– 1455. [10].Khuroo MS, Teli MR, Skidmore S, So? MA, Khuroo MI. Incidence and severity of viral hepatitis in pregnancy. Am J Med 1981; 70: 252–255. [11].Lee WM, Larson AM, Stravitz RT. AASLD position paper: The management of acute liver failure: Update 2011. Association for the Study of Liver Diseases website. http://www.aasld.org/practiceguidelines/Documents/AcuteLiverFailureUpdate2011.pdf. Published 2011. Accessed August 16, 2017. [12].Khuroo MS, Datta DV. Budd–Chiari syndrome following pregnancy.Report of 16 cases with roentgenologichemo- dynamic and histologic studies of the hepatic out?ow tract.Am J Med 1980; 68: 113–121. [13] Riordan SM, Williams R. Treatment of hepatic encephal- opathy. N Eng J Med 1997; 337: 473–478. [14]. O’Grady JG, Schalm SW, Williams R. Acute liver failure: rede?ning the syndromes. Lancet 1993; 352: 273–275. [15].-Acharya SK, Batra Y, Hazari S, Choudhury V, Panda SK, Dattagupta S. Etiopathogenesis of acute hepatic failure: Eastern versus Western countries. J Gastroenteral Hepatol. 2002 Dec 17;(suppl 3):S268-273. [16].Datta DV, Khuroo MS, Mattocks AR, Aikat BK, Chhuttain PN. Herbal medicines and veno-occlusive disease in India.Postgraduate Medical J 1978; 54: 511–515. [17].Khuroo MS. Study of an epidemic of non-A, non-B hepatitis: possibility of another human hepatitis virus distinct from post-transfusion non-A, non-B type. Am J Med 1980; 68: 818–823. [18].Khuroo MS, Khuroo N. Hepatitis E: global epidemiology with special reference to impact of the disease in India and the South East of Asia. In: Rizzetto M, Purcell RH, Gerin JL, Verme G. eds. Viral hepatitis and liver disease, Edizioni Minerva Medica, Turin, 1997: 601–608. [19].Khuroo MS, Rustgi VK, Dawson GJ et al. Spectrum of hepatitisE virus in India. J Med Virol 1994; 43: 281–286. [20].Farci P, Alter H, ShimodaA et al. Hepatitis C virus-associated fulminant hepatic failure. N Engl J Med 1997; 335: 631–634. [21]. Takahashi Y, Shimizu M. Aetiology and prognosis of fulminant[A1] viral hepatitis in Japan: a multicentric study. J Gastroenterol Hepatol 1991; 6: 159–164. [22].Ramaliingaswami V, Purcell RH. Waterborne Non-A, non-B hepatitis.Lancet 1988; 1: 571–573. [23].Arankalle VA, Jha J, Favorov MO, Chaudari A, Fields HA, Bannerjee K. Contribution of HEV and HCV in causing fulminant non-A, non-B hepatitis in western India. Journal of Viral Hepatitis 1995; 2: 189–193. [24].Arankalle VA, Chadha MS, Dama BM, Tsarev SA, Purcell RH, Bannerjee K. Role of immune serum globulins in pregnant women during an epidemic of hepatitis E. J Viral Hepatitis 1998; 5: 199–204.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareAn Ayurvedic Protocol to Manage Rhegmatogenous Retinal Detachment and the Resultant Macular Hole - A Case Report English1016Narayanan Namboothiri NarayananEnglish Aravind KumarEnglish Krishnendu SukumaranEnglishIntroduction: Retinal detachment (RD) is when the neurosensory retina (NSR) separates from the retinal pigment epithelium (RPE). Sometimes it may be associated with a macular hole. The symptom of diminished vision seen in both conditions may be compared with Kacha in Ayurveda. Case: The case of an 8-year-old boy who presented to the OPD of Sreedhareeyam Ayurvedic Eye Hospital with the blurring of vision and who was diagnosed with retinal detachment and the macular hole is presented here. Intervention: The patient underwent two courses of inpatient management, which included Ayurvedic oral medicines, and external therapies for the eyes (Kriyakalpa) and head. Results: Signs of improvement in visual acuity, fundus photography, and optical coherence tomography (OCT) were observed at the end of both treatments. Conclusion: The main aim of management was to preserve and give a better quality of vision for the patient. The results indicate the potential of Ayurvedic treatments to manage and maintain vision in RD and macular hole. EnglishAlternative medicine, Case report, Kacha, KriyakalpaIntroduction RD is classified based on the mechanism of fluid accumulation into rhegmatogenous, tractional, and exudative. From a clinical standpoint, this classification may be modified to group the tractional and exudative varieties under secondary RD and the rhegmatogenous variety under primary RD.1 Rhegmatogenous RD occurs secondary to a full-thickness defect in the sensory retina; tractional RD occurs when the NSR is pulled away from the RPE by contracting vitreo-retinal membranes in the absence of a break; and exudative RD is due to subretinal fluid derived from the vessels of either the NSR, the choroid, or both.2 A macular hole is a full-thickness defect or loss of the neuro-retinal tissue in the macula involving the fovea. Causes include idiopathic (83% of cases, usually in women aged 60-80 years), traumatic (5%), and others (cystoid macular edema, vitreo-macular traction, rhegmatogenous RD, post-surgical myopia, post-LASER treatment).3 Both RD and the macular hole may be considered as Kacha (diminished vision), a Drishtigata Roga (disease of vision) according to Ayurveda, due to their common symptom of profound vision loss. In Kacha, the patient sees objects above but not below, objects are perceived as though covered by a thin cloth, and vision gradually diminishes. Management is repeated administration of Sneha (drinking of fats), Asra-visravana (bloodletting), Reka (purgation), Nasya (nasal medication), Anjana (collyrium), Murdha-Basti (retention of oil over the head), Basti Kriya (enema), Tarpana (retention of fat over the eye), Lepa (application of paste), and Seka (pouring of liquids over the eye). Methodology The efficacy of an Ayurvedic treatment protocol to manage rhegmatogenous RD and the resultant macular hole was assessed in this report. It was prepared according to the Case Report (CARE) guidelines.4 to ensure transparency and effectiveness in reporting. Institutional ethical clearance was not required for this study. As the patient is underage, written informed consent was obtained from his mother prior to detailing his case. Case Presentation An 8-year-old boy presented with a 3-week complaint of blurring of vision and presence of a stationary black spot in his right eye (OD), as revealed by his mother. The patient sustained a sports-related injury 8 months ago when a football collided with his forehead. The trauma was accompanied by bleeding, redness of the eye, and swelling above his right eyelid. 3 weeks ago, he started experiencing a black spot in his visual field and blurring of vision OD. He was diagnosed with retinal detachment with macular hole OD and was advised surgery, which he declined. He came to Sreedhareeyam for alternative options. The child was born into a non-consanguineous family. His height is 139cm and his current weight is 38kg. His personal history readings (bowel, appetite, micturition, and sleep) were also normal. Review of systems and vital signs were normal. Unaided distant visual acuity (DVA) was counting fingers (CF +ve) OD and LogMAR 0 in his left eye (OS); and his near vision was N36 OD and N6 OS. Anterior segment examination revealed normal findings in both eyes (OU). Pupillary examination revealed an afferent pupillary defect OD and normal reflexes OS. Fundus examination OD revealed a macular hole, elongated optic disc, and a subtotal rhegmatogenous retinal detachment (Figure 1a). Optical coherence tomography (OCT) scanning OD showed a dome-shaped elevation under the retina, suggestive of retinal detachment (Figure 1b). Therapeutic Intervention The patient underwent 2 courses of treatment. One was from May 5th, 2019 to May 24th, 2019, and the other was from December 28th, 2019 to January 8th, 2020. He was administered oral medicines such as Kvatha (herbal decoction), Gutika (herbal tablets), and Ghrta (medicated ghee or clarified butter) (Table 1), and external therapies for both the eyes (Netra Kriya Kalpa) and the head (Table 2). As he was under 10, Panchakarma (bio-purification) was not attempted due to his age. All medicines, except Geriforte, were manufactured at Sreedhareeyam Farmherbs India, Pvt. Ltd., the hospital’s GMP-certified drug manufacturing unit. Geriforte was manufactured at The Himalaya Drug Company, based in Bengaluru, India. Outcome Measures The patient was prescribed medicines at discharge after both courses of treatment (Table 3) and advised regular follow-ups. DVA at discharge after the first course of treatment was LogMAR 1.778 OD and LogMAR 0 OS, and NVA was maintained. Pupillary reactions were maintained OD and OS. Fundus examination OD showed a reduction in the macular hole (Figure 2a). OCT scanning OD showed absorption of the vitreous from the retina and lowering of the structure towards its normal position (Figure 2b). The same findings in VA and pupillary reactions were observed at admission for the second course of treatment. Fundus examination and OCT were not done. DVA at discharge after the second course of treatment showed LogMAR 1.477 OD and LogMAR 0 OS. Fundus examination OD showed further reduction of the macular hole, (Figure 3a), and OCT scanning showed further lowering of the retina to its normal position (Figure 3b). A timeline of events for this case is provided in Table 5. Discussion Rhegmatogenous RD is characterized by the presence of a retinal break held open by vitreo-retinal traction.8 Predisposing factors include lattice degeneration, snail-track degeneration, degenerative retinoschisis, and pathological myopia, in which the risk of RD is higher when the refractive error is more. Afferent pupillary defect (Marcus Gunn pupil) is present in eyes with extensive detachment. A causal role of RD attributed to a macular hole can only be made if the detachment involves the posterior pole, or if more extensive, is seen to have advanced from a posterior pole RD.9 This is because it is difficult to determine whether a macular hole is of partial or full-thickness and if the hole is responsible for retinal detachment. This patient’s condition was explored along the lines of Kacha according to Ayurveda. Kacha as an entity unto itself was described by Vagbhata. He considered it as that in which the Doshas afflict the third Patala (layer) of the eye. Gross deterioration of vision is the hallmark symptom of Kacha and, by its nature, is Yapya (controllable). The improvement of the vision of this patient indicated that the Doshas were being expelled from the third Patala. Pathyakshadhatryadi Kashaya, indicated in the Patalagata Rogas (diseases of the layers of vision), is Kapha-Pitta Samaka (relieves Kapha and Pitta) and Cakshushya (healthy for eyes). Sudarsanam Gutika is indicated in all varieties of fever, and hence, helps in restoring proper digestion. Pathya PunarnavadiChurna normalized Vata Dosha in this case by enhancing the expulsion of the waste and movement of Doshas out of the body and eye. Vidaryadi Kvatha is Brmhana (nourishing) and relieves Vata and Pitta, hence it helped to anchor the retina to the rest of the eye. Local therapeutics was employed in this case as the patient was too young for Pancakarma treatments. Purampada or Bidalaka created a counter-pressure gradient that significantly pushes the retina to its original position. Ascyotana enabled the absorption of the medicines to reach the target tissues by such parameters as height and temperature of the medicines. Siroveshtana, Sirolepa, and Talapoticchil enabled absorption of the essential elements through the skin and hair follicles, thus bypassing barriers and reaching the target tissues. Laksha, one of the main ingredients in the medicines for head treatments, helped the retina restore itself to the rest of the eye by its properties of Pitta-Kapha Nasaka (diminishing Pitta and Kapha), Sandhaniya (binding), Balya (strengthening), and Ropana (healing). Vinayakanjana is prepared from Durva, goat’s milk, and goat’s ghee. It is useful as a healing agent and is prescribed in eye diseases. Ananta Ghrta, prepared from Yashtimadhu, Amalaki, Jivanti, and Haritaki, is indicated as a Tarpanain all eye diseases. Sunetra Junior is prepared from Daruharidra, Haridra, and rose water, and is indicated in pediatric eye cases. Vainateya Ghrta is prepared from Draksha, Jivanti, Vasa, and Triphala, is indicated in retinal diseases. Pancatiktaka Guggulu is prepared from Triphala, Pippali, and Guggulu, and is indicated in muscular growths in the eye. Conclusion The main challenge, in this case, was restoring vision and reattaching the retina. It was partially successful in both parameters, as vision marginally improved and the retina showed signs of reattachment. Results were a concerted effort brought about by the combined effect of both oral medicines and external therapies. Repeated courses of treatment may aid to further reattach the retina and give back some eyesight to the patient. The results may be validated and analyzed by large-scale studies and trials. Acknowledgment: The authors thank Sreedhareeyam Ayurvedic Eye Hospital and Research Center, and Sreedhareeyam Farmherbs India Pvt. Ltd., for their help in preparing this case report. The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to the authors/editors/publishers of all those articles, journals, and books from where the literature for this article has been reviewed and discussed. Conflicts of Interest: None declared Sources of Funding: None declared Abbreviations: RD: retinal detachment DVA: distant visual acuity NVA: near visual acuity OD: oculus dexter OS: oculus sinister OU: oculus uterque NSR: neurosensory retina RPE: retinal pigment epithelium Englishhttp://ijcrr.com/abstract.php?article_id=2712http://ijcrr.com/article_html.php?did=2712 Sihota R, Tandon R, Parsons’ Diseases of the Eye, 22nd Edition, Elsevier, a division of Reed Elsevier India, Pvt. Ltd., 2013, pg. 452 Kanski JJ, Bowling B, Clinical Ophthalmology: A Systematic Approach, 7th Edition, Elsevier Saunders, an imprint of Elsevier Limited, 2011,pg. 689 Khurana AK, Comprehensive Ophthalmology, 6th Edition, Jaypee Brothers Medical Publishers, (P) Ltd., New Delhi, 2015, pg. 297 Gagnier J, Kienle G, Altman DG, Moher D, Sox H, Riley DS, CARE group, The CARE guidelines: Consensus-based clinical case-reporting guideline development, Global Advances in Health and Medicine, 2013, Vol. 2, Issue 5, pgs. 38-43 Murthy PHC, Sarngadhara Samhita: Text with English Translation, Chaukhambha Orientalia, Varanasi, 2010, pg. 136 Murthy KRS, Ashtangahrdaya of Vagbhata: Text, English Translation, Notes, Appendices, and Index, Vol. I, Krishnadas Academy, Varanasi, 1999, pg. 201 Murthy PHC, Sarngadhara Samhita: Text with English Translation, Chaukhambha Orientalia, Varanasi, 2010, pg. 240 Kanski JJ, and Bowling B, Clinical Ophthalmology: A Systematic Approach, 7th Edition, Elsevier Saunders, an imprint of Elsevier Limited, 2011,pg. 698 Markham RHC, Chignell AH, Retinal detachment due to macular holes, British Journal of Ophthalmology, 1981, 65, pgs. 423-424

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareClinical Profile and Laboratory Investigations of Acute Dyspnea Patients: A Hospital Based Study English1722Kiran Kumar K VEnglishBackground: Dyspnea is a common symptom in hospitalized adult patients and is among the most serious, as it is often a harbinger of severe pathology. Prevalence of dyspnea varies among clinical settings and patient subgroups; in the community 3% to 25%, outpatient clinics 3.7%, emergency rooms 2.7%, and at hospital admissions 15% to 25%. The study of clinical and laboratory profiles of dyspnea patients is essential for a community practice. Objectives: 1. To study the clinical profile of acute dyspnea patients 2. To evaluate the underlying etiopathology of acute dyspnea Materials and Methods: This observational study was be conducted at K.V.G. Medical College & Hospital, Sullia on 150 subjects from March 2016 – Dec 2016. Result: In the present study, 43 patients had fever, 132 patients had cough, 127 patients had sputum, 11 patients had Hemoptysis, 52 patients had PND, 34 patients had chest pain and 8 patients had syncope as a presentational symptom. Mean heart rate was 111.38/min, SBP was 135.36 mmHg, DBP was 88.85 mmHg, Respiratory rate was 29.48/min. Sp02 was 88.91. Analysis of ECG showed, 24 patients (16.00%) had LVH,29 patients (19.33%) had ST Elevation, 12 patients (8.00%) had T wave inversion, 12 patients (8.00%) had LAD, 34 patients (22.67%) had RAD, 6 patients (4.00%) had CHB, 4 patients (4.00%) had LBBB,17 patients (11.33%) had RBBB. 48 patients (32%) had cardiomegaly, 23 patients (15.33%) had pleural effusion,18 patients (12 %) had consolidation. Patients diagnosed with DKA had mean Ph of 7.11, Pco2 of 21.1 mmHg, and HCO3 of 9.62 mEq/Lit. When compared, patients diagnosed with Acute exacerbation of COPD and Asthma had mean pH of 7.21, Pco2 of 60.83 mmHg, and HCO3 of 24.7 mm/l. 30 patients (20.00%) were diagnosed with Acute exacerbation of COPD, 14 patients (9.33%) were diagnosed with Acute exacerbation of Asthma, 22 patients (14.67%) were diagnosed with Pneumonia, 3 patients (2.00%)were diagnosed with Pulmonary embolism, 11 patients (7.33%) were diagnosed with Pleural effusion, 6 patients (4.00%) were diagnosed with Pneumothorax, 24 patients (16.00%) were diagnosed with Acute on chronic CCF, 31 patients (20.67%) were diagnosed with MI with CCF,4 patients (2.67%)were diagnosed with DKA, 2 patients each (1.33%) were diagnosed with Uremic encephalopathy and Hepatic encephalopathy each, 1 patient. (1.33%) was diagnosed with psychogenic dyspnea. Acute exacerbation of COPD had mortality of 11.76%, Acute exacerbation of Asthma had a mortality of 13.33%, Pneumonia had a mortality of 13.64%, Pulmonary embolism had a mortality of 33.33%, Pleural effusion had a mortality of 16.67%, Pneumothorax had a mortality of 50%, Acute on chronic CCF had a mortality of 25.00%, MI with CCF had a mortality of 28.13 %, DKA had a mortality of 25.00%. Overall mortality was 20.67%. Conclusion: The study concluded that Pneumothorax had the highest mortality (50%) followed by pulmonary embolism (33.33%) and MI with CCF (28.13%). Uremic encephalopathy, Hepatic encephalopathy and psychogenic dyspnea had the least mortality. EnglishPneumonia, Clinical profile, PFT, LRTI, DyspneaINTRODUCTION Dyspnea is the clinical term for breathlessness or shortness of breath. Dyspnoea is taken from the Greek word ‘‘dys’’ meaning painful, difficult, or disordered and ‘‘pnoea’’ meaning breathing1. The experience derives from the interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioral responses” as defined by the Consensus statement of the American Thoracic Society2. Dyspnea is one of the common symptoms in admitted patients. It is a subjective experience that may not be always consistent with physical examination. Patients describe their sensations using a variety of terms such as shortness of breath, chest tightness, increased effort of breathing, suffocation, and air hunger3. Dyspnea is the main complaint about 75% of the ambulance service. The prevalence of dyspnea has varied greatly across geographies. The variation is attributed to differences in the distribution of concurrent factors of dyspnea such as aging, gender, and smoking. Dyspnea is extremely common with advancing disease, and at late stages is present in 90-95% of those with COPD, 60-80% of those with CHF and 10-70% of those with cancer, whilst also being common in end-stage kidney disease and most severe in primary lung cancers, affecting 90% 4. Prevalence of dyspnea varies among clinical settings and patient subgroups; in the community 3% to 25%, outpatient clinics 3.7%, emergency rooms 2.7%, and at hospital admissions 15% to 25%. Population-based studies have shown a prevalence of 9 to 13% for mild to moderate dyspnea among community-residing adults, 15% to 18% among community-residing adults aged 40 years or older, and 25 to 37% of adults aged 70 years and older5. AIMS AND OBJECTIVES To study the clinical profile of acute dyspnea patients To evaluate the underlying etiopathology of acute dyspnea MATERIALS AND METHODS This observational study was being conducted at K.V.G. Medical College & Hospital, Sullia STUDY DESIGN: Observational descriptive study STUDY SITE: Emergency ward and ICU, Department of General Medicine, K.V.G. Medical College & Hospital, Sullia DURATION OF STUDY: March 2016 – Dec 2016 SAMPLE SIZE: 150 INCLUSION CRITERIA: Patients aged 18 years or more Dyspnea of < 1week in patients of both sex with age>18 with any one of the following: Respiratory rate >22 SpO2 less than 96% in breathing room air Patients giving informed consent to participate in the study EXCLUSION CRITERIA: Patients aged less than 18 years Patients with dyspnea of >1 week Patients admitted in the hospital who expired in less than 4 hours for whom there was no time period for laboratory evaluation. STUDY PROCEDURE: A detailed history of the patient will be taken and through clinical examination will be done. Routine investigations – Haemoglobin percentage Total count Differential count Random blood sugar Blood urea Serum creatinine Urine routine Liver function test SpO2 monitoring Special investigations – PCXR ECG Cardiac enzymes ABG BNP D-dimer Peak flow Negative inspiratory force/forced vital capacity Pulmonary function testing Chest CT/ VQ scan/ HRCT Echocardiography DISCUSSION The present study was conducted from March 2016 to Dec 2016 with the objective to study the clinical profile of acute dyspnea patients and to evaluate the underlying etiopathology of acute dyspnea at K.V.G. Medical College & Hospital, Sullia. Demography There were 5 patients within 20 years, 24 patients between 20-30 years, 34 patients between 30-40 years, 26 patients between 40-50 years, 32 patients between 50-60 years, 29 patients between 60-70 years. There were 78 male patients and 72 female patients. The mean age of patients was 61.4 years. In the study by Shrestha et al., the mean age of patients was 63.8 years with a minimum of twenty-two and a maximum of eighty-four years. Sixty patients were female and forty were male. Anne Maree Kelly et al. found that elderly patient was represented in higher proportion compared to the younger population. The finding that most patients are older (more than 60% aged > 60 years) is not surprising as the chronic conditions associated with dyspnea including COPD, heart failure, and acute coronary syndrome become more common with age. However, patients with DKA present with type 1 Diabetes mellitus and hence present in younger age. Symptomology In the present study, 43 patients had fever, 132 patients had cough, 127 patients had sputum, 11 patients had Hemoptysis, 52 patients had PND, 34 patients had chest pain, and 8 patients had syncope as presentational symptom. The mean heart rate was 111.38/min, SBP was 135.36 mmHg, DBP was 88.85 mm Hg, Respiratory rate was 29.48/min. Sp02 was 88.91. Anne Maree Kelly et al. observed that Bilateral crepitations were present in 31.5% of patients, Wheeze present in 20.4% patients, Localized rhonchi/bronchial breathing present in 3.7%, Widespread rhonchi present in 6 % of patients presenting with acute dyspnea 6. Various studies have predicted PND has low sensitivity (Englishhttp://ijcrr.com/abstract.php?article_id=2713http://ijcrr.com/article_html.php?did=2713 Yernault JC. Dyspnea in the elderly: a clinical approach to diagnosis. Drugs Aging 2016;18:177–87. Rao AB, Gray D. Breathlessness in hospitalized adult patients. Postgrad Med J 2017;79:681-85. Eagan TM, Bakke PS, Eide GE, Gulsvik A. Incidence of asthma and respiratory symptoms by sex, age and smoking in a community study. EurRespir J. 2016;19:599-605. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012 Mar;59(3):165–175. e161. Walls RM, editor. Manual of Emergency Airway Management. Second ed. Lippincott Williams and Wilkens; Philadelphia: 2014. Currow DC, Clark K, Mitchell GK, Johnson MJ, Abernethy AP. Prospectively Collected Characteristics of Adult Patients, Their Consultations and Outcomes as They Report Breathlessness When Presenting to General Practice in Australia. PLoS One. 2019;8(9):e74814. Frese T, Sobeck C, Herrmann K, Sandholzer H. Dyspnea as the reason for encounter in general practice. J Clin Med Res. 2019;3(5):239–46. Parshall MB. Adult emergency visits for chronic cardiorespiratory disease: does dyspnea matter? Nurs Res. 2016;48(2):62–70. Ekstrom MP, Abernethy AP, Currow DC. The management of chronic breathlessness in patients with advanced and terminal illness. BMJ. 2015;349:g7617. Nishimura K, Izumi T, Tsukino M, Oga T. Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD. CHEST J. 2002;121(5):1434–40. Baker K, Barsamian J, Leone D, Donovan BC, Williams D, Carnevale K, et al. Routine dyspnea assessment on unit admission. Am J Nurs. 2018;113(11):42. Vital FM, Saconato H, Ladeira MT, et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema. Cochrane Database Syst Rev. 2018;(3):CD005351. Silvers SM, Howell JM, Kosowsky JM, Rokos IC, Jagoda AS. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes. Ann Emerg Med. 2017 May;49(5):627–669. Zorbozan, Dharmarajan K, Strait KM, Lagu T, et al. Acute decompensated heart failure is routinely treated as a cardiopulmonary syndrome. Plo Sone. 2018;8(10):e78222. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2018;134(1):117–125. Remes J, Miettinen H, Reunanen A, Pyörälä K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J. 1991;12:315–321.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareA Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi English2327Varsha M. ShindheEnglish Maheshkumar M. ShindheEnglish Neha S. KulkarniEnglish Madiha MehvishEnglish Shivalingappa B. JavaliEnglish Fareeda Banu BalikaiEnglish Kamaruddin JaalamEnglishBackground: Tobacco use is become a public health issue in India and worldwide as well. Due of vigorous efforts towards increasing awareness of the adverse effects of tobacco, smoking has declined and the use of smokeless tobacco has been increased paradoxically among adolescents considering it as safe alternatives of smoking. Through previous studies, it is known that tobacco smoking can adversely affect the respiratory system, yet there are very few studies that have thrown light on the deleterious effects of smokeless tobacco on respiratory system. Objective: To evaluate effect of tobacco chewing on Pulmonary Functions and to compare the results with non-tobacco chewers in class 4 workers of USM KLE International Medical Programme, Belagavi. Methods: Pulmonary function tests were carried out on a total 130 volunteering male and female participants, in the age group of 25-55 years. Spirometric parameters such as Forced Vital Capacity, Forced Expiratory Volume in 1st second, FEV1/FVC ratio, Peak Expiratory Flow Rate, Forced expiratory flow between 0.2 to 1.2 L of expiration, Maximum mid expiratory flow rate or FEF25-75 and Maximal Voluntary Ventilation were compared between 65 tobacco users and 65 apparently healthy, non tobacco users of same socioeconomic status matched for age, sex, height and weight. Results: There was significant reduction in the values of all PFT parameters except FEV1/FVC in tobacco chewers compared to non tobacco chewers (pEnglishOxidative stress, Pulmonary function tests, Restrictive lung disease, Smokeless tobacco (SLT)INTRODUCTION Tobacco use is become a public health issue in India and worldwide as well. Tobacco is mainly consumed in two forms: smoked tobacco and smokeless tobacco. The use of tobacco without burning is referred to as Smokeless tobacco (SLT). Smokeless tobacco is used as chewed, sniffed or sucked form1. Smokeless tobacco (SLT) use has been increased rapidly throughout the world, especially among adolescents by considering it as safe alternative of smoking. Due to vigorous efforts towards increasing awareness of the adverse effects of tobacco, smoking has been declined and paradoxically the use of SLT has been greatly increased.1 Although it is well known that tobacco smoking adversely affects respiratory system causing chronic bronchitis, emphysema, chronic obstructive pulmonary disease and bronchial carcinoma, the deleterious effects of smokeless tobacco on respiratory system are yet to be explored.2 Tobacco contains various chemicals like nicotine, carbon monoxide and tar. In India, tobacco consumption is an important risk factor for development of various cardiovascular diseases and chronic obstructive pulmonary diseases 3. Expenditure on tobacco has been found significantly higher in proportion of their daily income in India. Use of smokeless tobacco indeed represents a health concern of growing magnitude. 4 In contrast to voluminous literatures on the ill effects of smoking, relatively little attention has been directed at smokeless tobacco and the factors that promote its use. This study attempts to find out whether chewing tobacco causes any unfavorable effects to the lungs by using Pulmonary Function tests. AIMS AND OBJECTIVES: 1) To study Pulmonary Function tests by spirometry in tobacco chewers 2) To study Pulmonary Function tests in apparently healthy nontobacco chewers 3) To compare the test results between the two groups MATERIAL AND METHODS The study was conducted at the Department of Physiology, USM KLE International Medical Programme, Belagavi. Study design: This is a comparative, case control study. Duration of study: 8 months (April 2019 to November 2019) POPULATION UNDER STUDY:- Class IV workers of USM KLE International Medical Programme, Belagavi, in the age group of 25-55 years who consume oral tobacco. Age and sex matched controls who do not consume tobacco. Both controls and cases were from same socioeconomic status and were involved in the same occupation. Sample size: A total of 130 subjects were recruited into the study amongst which 70 were males and 60 were females. SELECTION CRITERIA FOR STUDY GROUP Inclusion criteria All apparently healthy volunteering participants of same socioeconomic status Exclusive smokeless tobacco users. Exclusion Criteria History of smoking History of diabetes mellitus and hypertension H/o chronic obstructive pulmonary disease, congenital cardiopulmonary diseases History of Kyphosis, scoliosis History of biomass exposure in females History of occupational hazards. METHOD OF COLLECTION OF DATA: Before initiation of the study ethical approval was taken from the Institutional Ethics Committee of USM KLE International Medical Programme, Belagavi. The details of the procedure was explained to the participants in their vernacular language and an informed written consent was obtained from them. Data on Name, age, sex, occupation, and personal habits of the subjects was recorded using proformas and personal interviews with the subjects. The basic parameters like age, weight, height and BMI of subjects were recorded. Pulmonary function tests were performed by using computerized RMS HELIOS 702-Spirometer. All the tests were conducted between 10 am to 1 pm to avoid effects of diurnal variation. Overnight abstinence from tobacco use in any form was recommended. Subjects were asked to avoid tea, coffee, carbonated drinks or heavy meals at least two hours before the test procedure. During the recording of PFT-The subject was asked to sit comfortably in a chair. Subject was instructed to breathe in fully by deep inspiration with nostrils closed by using nose clips. The lips were sealed around the sterile disposable mouthpiece of spirometer and air was forcefully expired out, as rapidly and deeply as possible. The Pulmonary function tests recorded include Forced Vital Capacity (FVC in litres), Forced Expiratory Volume in first second (FEV1in litres), FEV1/FVC (%), Forced expiratory flow rate 25% -75%, Maximum Voluntary Ventilation (MVV in litres/minute) and Peak expiratory flow rate (PEFR in litres/minute). Best of three technically satisfactory performances as per recommendations of American Thoracic society were considered and interpreted.5 STATISTICAL ANALYSIS The data was statistically analyzed accordingly using SPSS Version 20.00. All the parameter scores were expressed in terms of Mean ±SD Independent ‘t test’ was performed to assess the significant difference between two groups with respective parameters The statistical significance was set at 5% level of significance (pEnglishhttp://ijcrr.com/abstract.php?article_id=2714http://ijcrr.com/article_html.php?did=2714 Pramanik P. Effect of khaini- a form of smokeless chewing tobacco on pulmonary functions. Indian J Physiol Pharmacol 2013; 57(1): 84-6. Gupta G, Goyal K, Gupta R. Pulmonary Functions in Smokeless Tobacco Users in Haryana. International J. of Health Sciences and research 2016; Vol.6(6):106-12. Vijaykumar Nand Badiger S. Effect of acute and chronic nicotine consumption on reaction time. Al Ameen J Med Sci 2015; 8(3) :179-183 4. Devendra Kumar, Binawara B.K., Acharya, Maan B.Effect of chewing tobacco on pulmonary functions in Bikaner city population. IRPMS VOL-2(5), Jan-Mar 2017 Brusasco V, Gapo R, Viegi G. Standardization of spirometry. Series “ATS/ERS task force: Standardization of lung function testing”. Eur Resp J 2005; 26: 319-38. Material and methods American society Ahuja A, Uppe A, Nair G: Study of lung functions in tobacco chewers. International Journal of Current Research. Vol. 8, Issue, 07, pp.34334-34337, July, 2016 World Health Organization. WHO Report on Global Epidemic: Warning about Dangers of Tobacco Geneva. World Health Organization 2011 X Y Li, P S Gilmour, K Donaldson 1996. Free radical activity and pro-inflammatory effects of particulate air pollution (PM10) in vivo and in vitro. Thorax, 51:1216-22. R J Pritchard, A J Ghio, J R Lehmann: 1996. Oxidant generation and lung injury after particulate air pollutant exposure increase with the concentrations of associated metals. Inhal Toxicol., 8:457-77. Bast A, Haenen G R M M, Doelman C J A. 1991. Oxidants and antioxidants: state of the art. Am J Med., 91(suppl):2S-13S. Cantin A, Crystal R G. 1985. Oxidants, antioxidants, and the pathogenesis of emphysema. Eur J Respir Dis., 66:7-17. Crystal R G. 1991. Oxidants and respiratory tract epithelial injury: pathogenesis and strategies for therapeutic intervention. Am J Med., 91(suppl):39S-44S. Lam E W N, Kelly E E, Martin S M, Buettner G R: Tobacco Xenobiotics release nitric oxide. Tob induced Dis 2011;1(3): 207-11. Bagchi M, Balmoori J, Bagchi D, Stohs S J, Chakrabarti J, Das D K: Role of reactive oxygen species in the development of cytotoxicity with various forms of chewing tobacco and pan masala. Toxicology 2002;179:247-55. Patil S S, Patil S. N, Somade P. M.: Comparative study of Pulmonary Function tests in Tobacco chewers and non tobacco chewers. Indian Journal of Basic and Applied Medical Research; December 2018: Vol.-8,Issue- 1, P. 208 - 214

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareTo examine Clinical Characteristics for the Detection of Cervical Cancer, According to a Checkup in Andijan Region English2832Dilnoza IsakovaEnglish Oltinoy YakubovaEnglish Yorkinoy FarmankulovaEnglish Matkarimov BakhtiyorjonEnglish Ranokhon SolievaEnglish Dilfuzahon MamarasulovaEnglishPrecancerous and background processes are characterized by the proliferation of epithelial cells leading to the subsequent glandular polyps, true and false cervical erosion, endocervicitis, ectropion, papillion, and foci of leukoplakia. The greatest clinical importance in the area of the junction of the stratified squamous epithelium of the vaginal portion of the cervix and the columnar epithelium of the cervical canal, as in this zone most often develop pathological processes. Depending on the age of the woman and the state of hormonal balance the junction of two epithelial cells can be located at different levels. From the neonatal period until the end of puberty, the joint may be below the level of the external uterine OS, leaving the vaginal portion of the cervix. In the reproductive age (from 20-22 to 40-45 years old) place of transition epithelia is at the level of the external pharynx, and in pre climate period or post-menopausal condition can be displaced into the cervical canal, becoming inaccessible for visual inspection, making it difficult to identify pathological processes. EnglishCervical cancer, Screening, Pregnancy, Diseaseshttp://ijcrr.com/abstract.php?article_id=2715http://ijcrr.com/article_html.php?did=2715

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareTreatment of Knee Osteoarthritis with Orthoped Points English3335M. E. IrismetovEnglish N. B. SafarovEnglishThe purpose of this scientific work was to determine the tactics of treatment depending on the degree of osteoarthritis and the characteristics of the disease. 196 patients with different severity of osteoarthritis and osteoarthrosis of the knee, treated in the department of Sports Traumatology of RSSPMC TO in the period from 2014 to 2019 were included in the study material. All patients underwent standard examination methods. Patients were treated with surgical methods according to our proposed 5 types, depending on the severity and characteristics of the disease, in addition they received physiotherapy and exercise therapy. The results of treatment were evaluated by the Lysholm score taking into account certain indicators with the summation of the ball scales. In the majority of patients (188 patients), an improvement in the condition of the knee joint was noted. Only in 4 patients after the arthroscopic intervention, a short-term remission occurred for only a few months, which was associated with the severity of the pathological process - osteoarthritis IV stage. The use of an individual approach depending on the severity and characteristics of the disease and the complex treatment of gonarthrosis is reasonable with many benefits and positive consequences in the postoperative period. EnglishOsteoarthritis, Knee joint, Arthroscopy, Treatment, Subchondral tunneling, Debridementhttp://ijcrr.com/abstract.php?article_id=2716http://ijcrr.com/article_html.php?did=2716

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareThe Influence of Dysfunction of the Autonomic System and the Thyroid Gland on the Course of Bronchial Asthma (BA) in Children English3639Mavjuda AbdullaevaEnglish Gulnorakhon KasimovaEnglish Esan YaxudayevEnglish Mavlyuda SakhibovaEnglish Zamira BakhavadinovaEnglishResearch on BA, not carried out a comparison of changes in indicators of thyroid function at different severity of the disease, has, in our opinion, extremely important to persons living in regions of endemic goiter, one of which is the Fergana Valley of Uzbekistan. On the other hand, thyroid hormones have a significant impact on the respiratory system. Thus, the influence of thyroid hormones on the formation of the respiratory system revealed already at the stage of fetal development. The inner piece of the embryo forms the respiratory organs and the main part of the thyroid. Its hormones affect the synthesis of receptors and the production of surfactant. Autonomic dysfunction is one of the urgent problems of modern medicine. The nature of the body's response to stress depends on the initial state of the regulatory mechanisms of VNS. An imbalance of the links of the VNS is one of the pathogenetic mechanisms of the occurrence of various somatic diseases or complications of infectious diseases. No diseases in which the ANS was not involved. Over the last decade, studies of autonomic dysregulate in norm and pathology, as a result of perceived need, has a significant place in clinical and experimental medicine. EnglishAutonomic dysfunction, Asthma, Thyroid gland, Vegetative statushttp://ijcrr.com/abstract.php?article_id=2717http://ijcrr.com/article_html.php?did=2717

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareA Reliability Study of Shuttle Walk Test on Field and Treadmill in Healthy Individuals – Are the Responses Interchangeable? English4648Sayli D. RaneEnglish Razia NagarwalaEnglish Ashok ShyamEnglish Parag SanchetiEnglishBackground: In healthy individuals, to achieve a favourable physical training response and enable the appropriate prescription of physical activities, functional physical capacity should be established. Shuttle walk test (SWT) is a standardized incremental field walking test which provokes a symptom-limited maximal performance and provides an objective measurement of disability and allows direct comparison of the individual performance. Objective: To examine responses of SWT on the field and treadmill in healthy individuals. Materials and methods: A reliability study was conducted to examine the responses of SWT performed on the field and on the treadmill for age group 18 – 50 yrs of both gender. Result: Outcomes measured were distance covered, VO2 max, HR, BP, RPE (6-20) after performing shuttle walk test on field and on treadmill. The distance covered between the 2 testsshows no correlation with insignificant p-value and with poor reliability (Cronbach’s α: 0.221) whereas the other responses shows good correlation. Conclusion: Shuttle walk test carried on field can be interchangeably used with SWT on treadmill in case of a healthy individual. EnglishField, Shuttle walk test, Treadmill, VO2 maxINTRODUCTION: Inactive lifestyle results in the development of chronic disabling conditions such as diabetes, obesity, coronary artery disease, and hypertension, which becomes the primary cause of mortality. To prescribe, monitor, and evaluate exercise programs, a reliable and valid exercise assessment is required1 In the development of individual exercise programs, cardio-respiratory fitness assessment, be it maximal or submaximal plays an important role. There are a number of laboratory and field-based tests currently used for the assessment of exercise capacity. Incremental shuttle walk test is an externally paced (i.e. walking speed is dictated to the patient) in which there is a gradual increase in speed and useful for quantifying the benefits of the walking program designed for healthy individuals and appears to induce a maximal exercise response that is appropriate for assessing exercise capacity and for designing a walking program.2 The American College of Sports Medicine (ACSM; 1995) generally recommends exercising at a minimum intensity of 60% of maximal HR (50% of VO2 max or HR reserve) for improving cardio respiratory endurance. In the treadmill test, there is an increase in the speed and inclination. Thus, as compared to field test we can appreciate the relative physiological demands required to assess cardio-respiratory responses. Shuttle walk test is usually carried on the field which determines maximal performance but requires larger area and individual needs to judge pace correctly, whereas if the same test protocol is performed on a treadmill, speed will be fixed on the treadmill so that individual need not judge the speed. It will require less space and can be monitored efficiently. In addition, the need for continuous monitoring and oxygen supplementation in some of these patients makes performing the test difficult.3 Hence, the aim of the study is to assess whether the responses on the shuttle walk test carried in the corridor and on the treadmill are the same. MATERIALS and METHODS: This reliability study was conducted on 30 patients of either sex, age between 18 to 50 years in physiotherapy OPD. Ethical clearance was received from the institutional ethical board and informed consent was obtained from the patients before the start of the study. Subjects with BMI Englishhttp://ijcrr.com/abstract.php?article_id=2718http://ijcrr.com/article_html.php?did=2718 Stork, M., Novak, J., and Zeman, V. (2016). Cardiopulmonary exercise testing for vo2max determining in subjects of different physical activity. Léka? a technika-Clinician and Technology, 46(4), 91-101. Singh, S. J., Morgan, M. D., Scott, S., Walters, D., and Hardman, A. E. (1992). Development of a shuttle walking test of disability in patients with chronic airways obstruction. Thorax, 47(12), 1019-1024. Singh, S. J., Morgan, M. D., Scott, S., Walters, D., and Hardman, A. E. (1992). Development of a shuttle walking test of disability in patients with chronic airways obstruction. Thorax, 47(12), 1019-1024. Stevens, D., Elpern, E., Sharma, K., Szidon, P., Ankin, M., and Kesten, S. (1999). Comparison of hallway and treadmill six-minute walk tests. American journal of respiratory and critical care medicine, 160(5), 1540-1543. Woolf-May, K., and Meadows, S. (2013). Exploring adaptations to the modified shuttle walking test. BMJ open, 3(5), e002821. Lindsay, T. R., Noakes, T. D., and McGregor, S. J. (2014). Effect of treadmill versus overground running on the structure of variability of stride timing. Perceptual and motor skills, 118(2), 331-346. Meyer, T., Welter, J. P., Scharhag, J., and Kindermann, W. (2003). Maximal oxygen uptake during field running does not exceed that measured during treadmill exercise. European journal of applied physiology, 88(4-5), 387-389. Woolf-May, K., and Meadows, S. (2013). Exploring adaptations to the modified shuttle walking test. BMJ open, 3(5), e002821. Dourado, V. Z., and Guerra, R. L. F. (2013). Reliability and validity of heart rate variability threshold assessment during an incremental shuttle-walk test in middle-aged and older adults. Brazilian Journal of Medical and Biological Research, 46(2), 194-199. Bousquet-Santos, K., Soares, P. P. S., andNóbrega, A. C. L. (2005). Subacute effects of a maximal exercise bout on endothelium-mediated vasodilation in healthy subjects. Brazilian journal of medical and biological research, 38(4), 621-627.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareEffect of Partial Sleep Deprivation on Neurocognitive Functions in Female Nursing Students: An observational study in India English4955Manisha UppalEnglish Sujata GautamEnglish Mary Vibha LakraEnglish Anupama V BetigeriEnglish Asha GandhiEnglish Sunita MondalEnglishAim: The objective of this study was to evaluate the effects of cumulative partial sleep deprivation (i.e. restricted sleep EnglishPartial sleep deprivation, Neurocognitive function tests, Pittsburgh Quality of Sleep IndexINTRODUCTION Sleep is a complex and dynamic physiological process essential for human survival. Although the exact sleep requirements may differ for individuals based on age, genetics, social and environmental factors1, it is recommended that adults should sleep seven or more hours per night on a regular basis to promote optimal health2. Unfortunately, compromising on one’s sleep to meet one’s daily responsibilities has become an increasingly common practice amongst people nowadays, in particular among young adults3. Good quality of sleep is a must for nursing students learning and acquiring clinical skills at a professional level. Poor quality of sleep in students can have an impact on various areas such as efficacy, mental health, stability, physical health, and activity4. While total sleep deprivation is a useful model for studying the neurocognitive effects of sleep deprivation, it is a much less representative form of sleep loss than chronic partial sleep deprivation5. Chronic partial sleep deprivation(sleep restriction to Englishhttp://ijcrr.com/abstract.php?article_id=2719http://ijcrr.com/article_html.php?did=2719 Chaput JP, Dutil C, Sampasa-Kanyinga H. Sleeping hours: what is the ideal number and how does age impact this. Nat Sci Sleep. 2018;10:421–430. Watson NF, Badr MS, Belenky G, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep. 2015;38(6):843–844 Zitting KM, Münch MY, Cain SW, et al. Young adults are more vulnerable to chronic sleep deficiency and recurrent circadian disruption than older adults. Sci Rep. 2018;8(1):11052. Ryu SH. Quality of life and quality of sleep in medical college students. Korean Soc Biol TherPsychiatr 2009; 15:29-36. Goel N, Rao H, Durmer JS, Dinges DF. Neurocognitive consequences of sleep deprivation. Semin Neurol. 2009;29(4):320–339. doi:10.1055/s-0029-1237117 Banks S, Dinges DF. Behavioral and physiological con- sequences of sleep restriction. J Clin Sleep Med 2007;3(5): 519–528 Killgore WD. Effects of sleep deprivation on cognition. Prog Brain Res. 2010;185:105-129. Randazzo AC, Muehlbach MJ, Schweitzer PK, Walsh JK. Cognitive function following acute sleep restriction in children ages 10-14. Sleep 1998;21:861–8. Sadeh A, Gruber R, Raviv A. The effects of sleep restriction and extension on school-age children: what a difference an hour makes. Child Dev 2003;74:444–55. Carskadon MA, Harvey K, Dement WC. Acute restriction of nocturnal sleep in children. Percept Mot Skills 1981;53:103–12. Fallone G, Acebo C, Arnedt JT, Seifer R, Carskadon MA. Effects of acute sleep restriction on behavior, sustained attention, and response inhibition in children. Percept Mot Skills 2001;93:213–29. Kopasz M, Loessl B, Valerius G, et al. No persisting effect of partial sleep curtailment on cognitive performance and declarative memory recall in adolescents. J Sleep Res 2010;19:71–9. Van Dongen HPA, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003;26(2):117–126 Dinges DF, Pack F, Williams K, et al. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep 1997;20(4):267–277 Belenky G, Wesensten NJ, Thorne DR, et al. Patterns of performance degradation and restoration during sleep restriction and subsequent recovery: a sleep dose-response study. J Sleep Res 2003;12(1):1–12 Carpenter JS, Andrykowski MA. Psychometric evaluation of the Pittsburgh Sleep Quality Index. J Psychosom Res1998;45(1 Spec No):5-13. Buysse DJ, Reynolds CF, III, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiat Res. 1989;28:193–213 Maura M, Boone KB, Razani J, DElia LF. Handbook of Normative data for Neuropsychological Assessment. 2nd edition. USA: Oxford University Press;2005. Lezak MD, Howieson DB, Loring DW. Neuropsychological assessment. 4th ed. New York: Oxford University Press; 2004. pp. 337–74. Jaiswal A, Bhavsar V, Jaykaran, Kantharia ND. Effect of antihypertensive therapy on cognitive functions of patients with hypertension. Annals of Indian Academy of Neurology 2010; 13(3): 180–183. Sharma VK, Das S, Mondal S, Goswami U, Gandhi A. Effect of Sahaj Yoga on neuro-cognitive functions in patients suffering from major depression. Indian J Physiol Pharmacol. 2006 Oct-Dec;50(4):375-83. Finelli LA, Baumann H, Borbély AA, Achermann P. Dual electroencephalogram markers of human sleep homeostasis: correlation between theta activity in waking and slow-wave activity in sleep. Neuroscience. 2000; 101:523–529. Thomas M, Sing H, Belenky G, Holcomb H, Mayberg H, Dannals R, Wagner H, Thorne D, Popp K, Rowland L, Welsh A, Balwinski S, Redmond D. Neural basis of alertness and cognitive performance impairments during sleepiness. I. Effects of 24 h of sleep deprivation on waking human regional brain activity. Journal of Sleep Research. 2000; 9:335–352. Harrison Y, Horne JA, Rothwell A. Prefrontal neuropsychological effects of sleep deprivation in young adults- a model for healthy aging? Sleep. 2000; 23:1067–1073. Harrison Y, Horne JA. One Night of Sleep Loss Impairs Innovative Thinking and Flexible Decision Making. Organ Behav. Hum. Decis. Process. 1999; 78:128–145. Harrison Y, Horne JA. Sleep loss impairs short and novel language tasks having a prefrontal focus. Journal of Sleep Research. 1998; 7:95–100. Horne JA. Sleep loss and "divergent" thinking ability. Sleep. 1988; 11:528–536. Tucker AM, Whitney P, Belenky G, Hinson JM, Van Dongen HPA. Effects of sleep deprivation on dissociated components of executive functioning. Sleep. 2010; 33:47–57. Sagaspe P, Sanchez-Ortuno M, Charles A, Taillard J, Valtat C, Bioulac B, Philip P. Effects of sleep deprivation on Color-Word, Emotional, and Specific Stroop interference and on self-reported anxiety. Brain Cogn. 2006; 60:76–87. Fallone G, Acebo C, Arnedt JT, Seifer R, Carskadon MA. Effects of acute sleep restriction on behavior, sustained attention, and response inhibition in children. Perceptual Mot Skills. 2001; 93:213–229. Samatra, Dpg and Kesanda, I Made andAdnyana, Oka and Widyadharma, Eka. (2017). The Effect of Partial Sleep Deprivation in Decrease of Cognitive Function in Resident Doctors of Udayana University/Sanglah General Hospital. International Journal of Science and Research (IJSR). 6. 215-218. 10.21275/ART20172233. Santisteban Lopez, Jose and Brown, Thomas and Ouimet, Marie and Gruber, Reut. (2018). Cumulative mild partial sleep deprivation negatively impacts working memory capacity but not sustained attention, response inhibition, or decision making: a randomized controlled trial. Sleep Health. 10.1016/j.sleh.2018.09.007. Glynda Kinsella and John R. Crawford: Chapter -7: Executive function and its assessment. Neurology and Clinical Neuroscience, 2007, Pages 83-95. Mosby. James A. Holdnack. Chapter -4: The development, expansion, and future of the WAIS-IV as a cornerstone in comprehensive cognitive assessments. Handbook of Psychological Assessment (Fourth Edition)2019, Pages 103-139. Academic Press. Glenville M, Broughton R, Wing AM, Wilkinson RT. Effects of sleep deprivation on short duration performance measures compared to the Wilkinson auditory vigilance task. Sleep. 1978; 1:169– 176. Jewett ME, Dijk D-J, Kronauer RE, Dinges DF. Dose-response relationship between sleep duration and human psychomotor vigilance and subjective alertness. Sleep. 1999; 22:171–179. Jeffrey M. E. Cognitive benefits of sleep and their loss due to sleep deprivation. Neurology. April 12, 2005; 64 (7) E25-E27

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareIntroduction of Key Feature Problem Based Questions in Assessment of Dental Students English5661Preethi SharmaEnglish Punit FulzeleEnglish Minal ChaudharyEnglish Madhuri GawandeEnglish Swati PatilEnglish Alka HandeEnglishObjectives: The aim of the study was to assess the individual’s clinical decision-making ability through Key feature problems and to compare Key feature problems with conventional level II based questions among third-year undergraduate dental students in the subject Oral Pathology. Study design: The study is an interventional educational research. Results: Comparisons between groups A and B were carried out by using descriptive and inferential statistics using Student’s unpaired t-test and Cronbach’s alpha method of reliability. The software used in the analysis was SPSS 26.0 version and p < 0.05 is considered as the level of significance. The mean score being 8.93±0.93 for group A-Key feature problem and 7.05±1.28 for group B- Conventional Level II. The difference between the two scores was found to be statistically significant with p-value less than 0.05. The reliability of Key feature problems was 0.98. Conclusion: It was observed in our study that students who were exposed to Key feature problem performed better in decision making skills. The Key feature problems do not entirely rely on the factual knowledge but it has the ability to apply the knowledge within case-based scenarios comprising of crucial elements and requiring critical decisions at specific decision points during the judgement and management of the problem. EnglishClinical decision-making, Key features, Key feature problemhttp://ijcrr.com/abstract.php?article_id=2720http://ijcrr.com/article_html.php?did=2720

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22Life SciencesCytosporosis Diseases of Apple Trees (Reinette Simirenkomalus) and It’s Distribution in the Lower Amudarya Region English6267Rasul RuzmetovEnglish Yulduz MatyakubovaEnglish Ikram AbdullaevEnglishThis study analyzed the morphological properties of cytosporosis disease in the Reinette Simirenko variety (Malus) of apple trees and nature of its damage to the causative agents in the Lower Amudarya region (Uzbekistan). The region is characterized with dry climate and shallow groundwater tables which can effect on the spread of the disease. For determining the causes of the disease, the apple trees and the groundwater level were monitored in orchards where the cytosporosis diseaseis widespread. Based on thismonitoring and additional correlation analysis, we found out considerable influence of the groundwater level in the expansion of cytosporosis in apple orchards. EnglishReinette Simirenko, Cytosporosis, Ground-water level, Picnium, Conidium, Irrigation systemhttp://ijcrr.com/abstract.php?article_id=2721http://ijcrr.com/article_html.php?did=2721

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareModern Hypolipidemic Therapy in Patients with Arterial Hypertension with High Cardiovascular Risk Under Conditions of Long-Term Ambulatory Observation English6872Ruziyeva Amira AsrorovnaEnglish Muradova Railya RustamovnaEnglish Turaev Khikmatulla NegmatovichEnglish Nuralieva Rano MatyakubovnaEnglishGlobally, more human beings die from cardiovascular sickness (CVD) than from another motive. An envisioned 17.5 million humans died from CVD in 2012. Eighty % of those deaths are because of coronary heart assaults and strokes; greater than three-quarters of all deaths occurred in low- and center-earnings countries. In 2012, 34% of all deaths from CVD befell earlier than the age of 70 years. CVD disproportionately impacts low- and middle-earnings nations; in many nations, the financial and social burden is maximum a few of the negative and socially deprived. EnglishAtorvastatin, Rosuvastatin, Atherosclerosis, Hypercholesterolemia, Endothelial dysfunction, Arterial stiffness, Cardiovascular riskhttp://ijcrr.com/abstract.php?article_id=2722http://ijcrr.com/article_html.php?did=2722

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareThe Rate and Structure of Causes in Development of Secondary Metabolic Nephropathy in Children English7376Sharipov Alisher MirkhamidovichEnglish Artikova Magina AkmalovnaEnglish Akhmatalieva Mayram AkhmatalievnaEnglishMetabolic disorders nephropathy (MDN) is a large group of kidney diseases with various etiologies and pathogenesis, but combined in that their development is associated with metabolic disorders that can lead to changes in the functional state of the kidneys or structural changes at the level of various structures of the nephron. Statistical variation in the registration of MDN ranges from 27% to 64% in the structure of the incidence of the urinary system in children, and in everyday practice of a pediatrician, almost every third patient has a syndrome of metabolic disorders in the urine. Establishing the nature of crystalluria as the cause of metabolic nephropathy, at what age the manifestations of MDN most often debut, the gender characteristics of this pathology, and finally, the determination of the genealogical relationship is a widely discussed focus of research on this field. Therefore, our results showed that oxalate-calcium crystalluria accounted for the majority of cases of crystalluria, especially from 6 months to 7 years of age, which predetermined the majority of cases of secondary oxalate nephropathy, especially in boys who had a longer course of oxaluria. Genealogical analysis of anamnestic data reflected the high incidence of kidney stones diseases and dysuric syndrome, which correlated with a hereditary burden in the gastrointestinal tract, among parents and immediate relatives of the studied children with SMN. EnglishMetabolic disorders nephropathy, Secondary oxalate nephropathy, Crystalluria, Oxalate-calcium crystalluria.http://ijcrr.com/abstract.php?article_id=2723http://ijcrr.com/article_html.php?did=2723

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareCOVID-19 – A Pandemic & a Policy Driver to Healthcare System in India English7782Narahari KVEnglish Sowjanya MEnglish Vishwanath BAEnglish Saravanan JEnglishThe present article provides a brief review on sources of health disparities, pandemic risks and burdens, various impact factors (such as political disruptions, state-centre imbalance, lack of trained health professionals) hindering policy-making on pandemics. Further, factors responsible for outbreak mismanagement with strategies for effective preparedness is focused. It also highlights the age-old colonial law, so-called the backbone of Indian healthcare policy in strategizing healthcare emergencies. The gaps in the present policy indicate an immediate requirement for an overarching law that governs public health care. The review also envisages the safety and security measures taken by the Indian government against COVID-19, prioritising health over the economy. Finally, flagship changes required in national healthcare policy to prepare the country to fight against any upcoming pandemic outbreaks are suggested. EnglishHealthcare policy, Indian government, Pandemic risks, Preparednesshttp://ijcrr.com/abstract.php?article_id=2724http://ijcrr.com/article_html.php?did=2724

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareRadiological Study of Posterior Cerebral Artery Variations and its Influence on Cerebral Stroke English8386Dravya JayakumarEnglish Radhika P.M.English Shailaja ShettyEnglishBackground: The posterior cerebral artery (PCA) is the terminal branch of the basilar artery. The fetal variant of PCA (fPCA) arises directly from the internal carotid artery. A fPCA can be either complete or partial with a hypoplastic segment connecting to the basilar artery. Individuals with fPCA could be more prone to ischemic strokes. Aims: This study aims to analyze the posterior cerebral artery variations on Magnetic resonance (MR) angiogram and its influence on ischemic strokes. Materials and Mmethods: The MR angiogram images of 150 patients - 75 with evidence stroke and 75 without evidence of stroke were analyzed for the presence of fPCA. The origin, diameter, and variations of PCA and posterior communicating artery were analysed for evidence of the presence of fPCA. Results: There were 20 individuals with fPCA out of 75 individuals with evidence of stroke and 9 individuals with fPCA among 75 individuals without evidence of stroke. The presence of fPCA associated with stroke is statistically significant with P-value of 0.0375. Conclusions: The presence of fPCA in an individual is one of the predisposing factors to stroke. EnglishFetal posterior cerebral artery, Angiography, Strokehttp://ijcrr.com/abstract.php?article_id=2725http://ijcrr.com/article_html.php?did=2725

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcarePerception, Attitude and Experience of Lady Medical Representatives towards Sales Profession: A Quantitative Study English8790Priyadarsani SaswothiEnglish Ajay PiseEnglish Shilpa PiseEnglish Ligade VirendraEnglishIntroduction: Personal selling is a crucial determinant factor of success in pharmaceutical marketing. In pharmaceutical selling, the sales personnel are known as a medical representative or detail men. Objective: The objective of the study was to analyse the perception, attitude and experience of lady medical representative towards the sales profession. Methods: Total sample size used for the study was fifty from various pharmaceutical companies. Nonprobability convenience sampling method was used for the study. Results: From the above survey it was noted that lady medical representatives were working as full time for the company. Majority of the respondents believe that there is no differential treatment given to them in comparison to male medical representatives. Conclusion: According to respondents there are lots of advantages like a good job with good package and with flexible timings. Further concept of Lady Medical Representative is at a nascent stage in India and may become more popular in future according to the majority of the respondents. EnglishLady Medical Representatives, Medical Representatives, Personal selling.http://ijcrr.com/abstract.php?article_id=2726http://ijcrr.com/article_html.php?did=2726

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareAcute Myocardial Infarction English9195Shodieva Gulzoda RabimmkulovnaEnglish Ruziyeva Amira AsrorovnaEnglish Nizamov Bakhtiyor UrokovichEnglishThe article describes practical cases of unrecognized acute myocardial infarction, which debuted in a man at 24 years old and woman 60 years old, with a different syndrome with an ST-segment elevation with an outcome in anterior transmural myocardial infarction (MI) wall of the left ventricle. The diagnosis and treatment of MI with the justification of medical appointments are described. The emergence of MI at a young age encourages cardiologists to search for new links in the pathogenesis of this pathology. EnglishMyocardial infarction, Diagnosis, Treatment, Acute myocardial infarction, Cardiovascular disease diagnosis, Mortality.http://ijcrr.com/abstract.php?article_id=2727http://ijcrr.com/article_html.php?did=2727

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22Life SciencesThe Social WASP Fauna of Riparian Tuqai Forest in Khorezm Region of Uzbekistan (HYMENOPTERA, VESPIDAE) English9699Ulmasbek AbdullaevEnglish Ikram AbdullaevEnglish Lola GandjaevaEnglishAn inventory of social wasps was carried from March 2019 to September 2019 in a section of riparian tuqai forest along the Amu Darya River in Cholish Urgench district, Khorezm region, Uzbekistan. Two dynamic collecting strategies (dynamic collecting and point examining employing afluidsnare) and one inactive strategy (teased PET bottle trap) were utilized. Thirteen species having a place to six genera were recorded. The foremostcopious were Polistesdominula and Vespulagermanica. These species have a place to the genus Polistes and Vespula, which was prevailing within the test. Concerning inspecting strategies, the dynamic collecting ones examined the most prominent abundance esteem. EnglishWasps, Turanga, Attractive, Species, Ethanol, Polistine, Vegetation, Tuqay.http://ijcrr.com/abstract.php?article_id=2728http://ijcrr.com/article_html.php?did=2728

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22Life SciencesPhilophthalmus Lucipetus (Trematoda, Philophthalmidae) Cercariae in Molluscs Melanoides Kainarensis English100104Ulugbek Abdulakimovich ShakarbaevEnglish Firuza Djalaliddinovna AkramovaEnglish Djalaliddin Azimovich AzimovEnglishCercariae of Philophthalmus lucipetus (Rudolphi, 1819) were detected in molluscs Melanoides kainarensis Starobogatov et Izzatullaev, 1980. Of the 4,629 examined individuals of M. kainarensis from Boshkhovuz, a warm body of water in the Karnabchul steppe (Nurabad District, Samarkand Province), 407 individuals (9.01%) were infected with cercariae and parthenitae of flukes from the genus Philophthalmus Looss, 1899, whose species was identified as Ph. lucipetus. EnglishMelanoides kainarensis, Philophthalmus lucipetus, Parthenitae, Cercariae, Molluscs.http://ijcrr.com/abstract.php?article_id=2729http://ijcrr.com/article_html.php?did=2729

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareEvaluation of Anterior and Posterior Cruciate Ligament Injuries of the Knee on Magnetic Resonance Imaging: A Cross-sectional Study English105108Shirish V VaidyaEnglish Harshal S DhongadeEnglish Shital M MahajanEnglish Aneesh MKEnglishBackground: The knee joint is complex with a variety of structures; signs/symptoms of knee injuries may all be caused by them. In the reign of Magnetic Resonance Imaging (MRI) the most landmark advances were made in knee joint imaging. A non-invasive modality, it has replaced traditional arthrography in the menisci and cruciate ligaments evaluation and has reduced both the morbidity and expense associated with the arthroscopic examination which yields negative results. Aim: The present research was performed on MRI for evaluation of ligamentous knee injuries. Material: This research was performed in 100 subjects (63 malesand37 females), aged between 12 and 73 years. Results: The findings obtained showed that medial meniscal tears/degeneration (64 %) followed by anterior cruciate ligament tear (49 %) were the most frequently found pathology of all subjects. Conclusion: Magnetic resonance imaging has high sensitivity, precision and accuracy in the identification of posterior cruciate ligament and full anterior cruciate ligament tears; however, it has no adequate sensitivity in the detection of partial anterior cruciate tears. EnglishMagnetic resonance imaging (MRI), Anterior cruciate ligament (ACL), Posterior cruciate ligament (PCL)Introduction: Magnetic resonance imaging has been useful in the identification of subjects, preoperative preparation, diagnosis, and better contact with the patient-doctor.1 The decline in the cost of MRI knee studies has also helped the orthopaedic community embrace them as a non-invasive alternative for arthrography and non-therapeutic arthroscopy.2,3 The anatomic and pathologic interpretation of the soft tissue, ligaments, fibrocartilage and articular cartilage with MRI is superior to that seen with computed tomography (CT).4,5,6 Fast spin-echo imaging, used in combination with MR fat suppression technique, has increased MR 's sensitivity and precision to detect injuries to the articular cartilage. Besides, three-dimensional (3D) volume techniques have shown MR imaging 's flexibility in measuring meniscal tears. These can be used to reformat pictures of orthogonal and non-orthogonal planes with meniscal tears. Aims and Objectives: Evaluation of ligamentous injuries of the knee on MRI Material and Methods: SELECTION CRITERIA: Subjects reporting knee injury history and consenting to report. Some those can comply with the MRI test, e.g. the willingness to lie immobile during the testing process. EXCLUSION CRITERIA: Subjects with cardiac pacemakers, metallic implants in the body, foreign body in the eye or with claustrophobia. MRI SCANNER: MRI was performed with a PHILIPS ACHIEVA 1.5 T MR Scanner. A dedicated knee coil (FLEX M) was used. PATIENT POSITIONING: The MRI examination was conducted after ruling out the presence of any metallic implants or prosthesis in all the subjects. The patient was placed in a supine position with the knee in a closely coupled extremity coil. The knee was externally rotated 15-20°, to facilitate the visualization of ACL completely on sagittal images as it realigns the ACL parallel with the sagittal imaging plane. The knee was flexed slightly 5-10°, to increase the accuracy of assessing the patella-femoral compartment and patellar alignment. IMAGING PROTOCOL: Standard surface phased array (FLEX M) coil was used for the identification of knee injury. In subsequent sagittal and coronal plane photos, an axial acquisition by patella-femoral joint was used as an initial localiser. The coronal plane tests the menisci collateral ligaments and body in an ideal manner. The sagittal plane exposes particularly the suprapatellar pouch, the cruciate ligaments, menisci and synovial anatomy. Through the incorporation of all three planes the bones, muscles, tendons, neurovascular structures have been thoroughly assessed. Results: In this present study of 100 subjects, 63 were men and 37 women. The youngest patient in the study was of 12 yrs, while the oldest patient was of 73 years. Most of the subjects were in the age group of 21- 50 yrs with those in the age group of 41-50 yrs. being highest. Out of 100 subjects, 52 had derangements of the right knee while 48 had left-sided derangements. Out of 100 subjects in the study, 49 cases showed ACL tears and 9 subjects showed PCL tears. A. ANTERIOR CRUCIATE LIGAMENT (ACL) TEARS: Out of 49 subjects of ACL tears, 20 subjects (40.8%) had full-thickness tears while 29 subjects (59.2%) had partial thickness tear. On MRI, 29 subjects (59.2%) had mid substance tears, 13 subjects (26.5%) had tears at the femoral attachment and 7(14.3%) at the tibial attachment were detected. ASSOCIATED INJURIES WITH ACL: Out Of the 49 cases of ACL tears, 42 have been related to Meniscal Tears. Of these, 22 were associated with medial meniscal tears and 20 cases of lateral meniscal tears were associated. Medial meniscal tears were thus associated with ACL tears more frequently than others. In 22 (44.8 per cent) cases of an ACL tear, Marrow contusions and Bone Edema of the femoral condyle and tibial plateau were seen. In combination with ACL, chondral and osseous fractures in both medial and lateral compartments were also noted for 4 (8 per cent) cases. Collateral Ligament Tears accounted for ACL injuries in 4(8 %) situations. Tibial Spine Avulsion was noted in 1(2%) case of an ACL tear. In our study, meniscal tears with marrow oedema and contusions off emoral and tibial condyles were most commonly associated with ACL tears. B. POSTERIOR CRUCIATE LIGAMENT TEARS: PCL tears amounted for a small number of cases 9(9%) out of 100 subjects. All 9 subjects had partial-thickness tears along with 5 subjects having low-grade partial-thickness tears while 4 subjects having high-grade partial-thickness tears. Strain in PCL was found in another 9 subjects. ASSOCIATED INJURIES WITH PCL: Out of 9 cases of PCL tears, 3(33.33 %) were associated with ACL tears. Meniscal injuries were associated with 2 cases (22.22%) of PCL tears. Collateral ligament tears were associated with 2 cases (22.22%) of PCL tears. Out of 9 patients of PCL tear, 1(11.11%) pt. also had an avulsion fracture of the tibial plateau. Bone Contusion existed in 1 (11.11%) of the case of PCL injuries. Discussion: In our analysis we found that it was best to position the knee with 5 – 10° flexionand15 – 20° external rotation. When ACL has been seen incompletely replicate oblique images have been obtained. T2WI and PDW FS images were preferred, as acute lesions were interpreted as high signal strength with high precision. ANTERIOR CRUCIATE LIGAMENT TEARS: In our study Anterior cruciate ligament (ACL) tears were more common than posterior cruciate ligament (PCL). Lakhar et al.1 in their study on 173 subjects also reported ACL tear (45.08%) to be more common than PCL tear(5.78%). The most common tear location was at mid-substance. Lakhar et al.7 in their study reported mid substance tear as the most common type. Another study done by Berquist et al.8 showed a similar result. ASSOCIATED INJURIES WITH ACL: Meniscal tears were the most common finding associated with ACL tear in our research. 42 (85.7 per cent) of the 49 cases of ACL tears were associated with meniscal tears. Of those 42 cases of meniscal tears, 22 subjects suffered medial meniscal tears while 20 subjects had lateral meniscal tears. In their research, McDaniel et al.9 recorded that 85 to 91 % of chronic ACL-deficient knees are associated with meniscal tears. In 22 (44.8%) cases of ACL tear, Marrow contusions and bone oedema of the lateral femoral condyle and lateral tibial plateau were seen. Murphy et al.10 considered subchondral bone impactions posterolateral tibial plateau (94%) and lateral femoral condyle (91 %) to be relatively common indicators of an acute ACL tear. Fractures in both the medial and lateral compartments were also reported for 4 (22.22 %) cases in connection with ACL. Indelicato et al.11 in their study found that erosions and chondral fractures in both medial and lateral compartments were associated with ACL tears but in 23 per cent in acuteand54 per cent of chronic injuries, they observed these chondral fractures. In our analysis, the triad of damage to the ACL by the classic O'Donoghue, MCL and medial meniscus was less severe in just 1 (2.77%) case. In any case, ACL tear was not seen in Segond's fracture. Tibial spine avulsion was noted in ACL tear case 1(2.77 %). Kezdi-Rogus et al.12 found that Segond's fracture is associated with ACL rupture in 75% to 100% of cases and tibial spine avulsion is a rare but common finding for ACL injury. They also claimed that distal ACL injuries are often associated with avulsion injuries due to the comparatively stronger distal ACL fibres than adjacent tissue. POSTERIOR CRUCIATE LIGAMENT TEARS: PCL tears accounted for 9(9 %) of small cases. D S Shetty et al. 13 observed PCL tears in only a small percentage of subjects in their sample of 115 subjects (4.34 %)and the symptoms were hyperintensity in 3 subjects and discontinuity in 2 subjects. In their analysis, Sonnin et al.14 found a 2-23 % occurrence as PCL injury. ACL tears 49 (49 %) were much more common in our sample of 100 subjects than the PCL tears 9 (9 %). Chernye et al.15 reported that PCL is twice as strong as ACL, with a wider cross-sectional area and higher tensile strength resulting in lower PCL rupture incidence. ASSOCIATED INJURIES WITH PCL: Out of 9 cases of PCL tears, 3(33.33%) were associated with ACL tears. The meniscal tear was seen to coexist with PCL tear in 2(22.22%) case. Collateral ligament tears accounted for 2(22.22%) cases in PCL injuries. Avulsion tear-off of tibial plateau accounted for 1(11.11%) cases. Bone contusion existed in 1(11.11%) case in PCL injuries. Niitsu et al.16 found 12(30.7%) subjects of isolated PCL tear among 39 subjects with PCL tears. The remaining 27 subjects showed evidence of other coexistent knee injuries, such as meniscal tears and ligamentous injuries. Of coexistent knee injuries, meniscal tears (18 subjects, 46.2%) were most common. 4 (10.3%) subjects had avulsion tear-off of the tibial plateau. Conclusion: The primary signs of ACL tear, including discontinuity, non-visualization and irregular increased signal strength, were adequately established on FSE T2W and PDW FS and mid-substance was the most common tear position for the anterior cruciate ligament. Often noted were secondary symptoms, including bone contusions of the lateral femoral condyle and lateral tibia, anterior tibial translation, lateral meniscus rear horn uncovering, and PCL buckling. As in other research, FSE T2 and PD FS sequences are most prone to the spectrum of menisci land cruciate ligament tears and the related injuries like osteochondral fractures, while SE T1 sequence was useful to correlate pathology other than ligament tears. PD FS sequences were useful to evaluate associated bone contusions. The high degree of precision in MRI evaluation in various planes and positioning of the knee in 15-20° of external rotation and 5-10° of flexion helped to delineate the location and the full range of lesions. Magnetic resonance imaging has high sensitivity, precision, and accuracy in the diagnosis of meniscal, posterior cruciate ligament, and full anterior cruciate ligament tears; however, there is inadequate sensitivity to detect partial anterior cruciate tears. Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Ethical clearance-Taken from the institutional ethics committee. Source of funding- Self. Conflict of Interest- Nil. Englishhttp://ijcrr.com/abstract.php?article_id=2730http://ijcrr.com/article_html.php?did=2730 Kean DM, Worthington BS, Preston BJ. Nuclear MRI of knee: examples of normal anatomy and pathology. Br J Radiol 1983; 56: 355-36 Nikken JJ, Oei EHG, Ginai AZ, et al. Acute peripheral joint injury: cost and effectiveness of low-field-strength MR imaging—results of r&omized controlled trail. Radiology 2005; 236:958–967. Nagrale N, Barmate N. Age determination by radiological assessment of epiphyseal union of bones at knee joint in chhattisgarh region. Journal of South India Medicolegal Association. 2019; 11 (1): 30-35. Moon KL, Genant HK, Helms CA, Chafetz NI, Crooks LE, Kaufman L. Musculoskeletal applications of nuclear MR. Radiology 1983; 147: 161-171. Mahato R, Panchal D, Vyas N. Exercise interventions in Knee Osteoarthritis in Aging adults: A Systematic Review of Randomized Clinical Trials International Journal of Current Research and Review. 2011; 23(11) 01-0 Kumar P, Kumar A, Venkatesh D. Healthy Gait: Review of Anatomy and Physiology of Knee Joint International Journal of Current Research and Review. 2005;12(6): 01-08 B N Lakhkar, K V Rajagopal, P Rai. MR Imaging of Knee with Arthroscopic Correlation in Twisting Injuries. Ind J Radiol Imag. 2004; 14:1:33-40. Berquist TH. Magnetic resonance techniques in musculoskeletal diseases. Rheum Clin North Am 1991; 17: 599-615. McDaniel WJ. Untreated ruptures of the anterior cruciate ligament. J Bone Joint Surg [Am] 1980; 62:696. Murphy BJ, Smith RL, et al. Bone signal abnormalities in the posterolateral tibia and lateral femoral condyle in complete tears of the anterior cruciate ligament: a specific sign? Radiology 1992; 182:221. Indelicato PA, et al. A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases. Clin Orthop 1985; 198:77. Kezdi-Rogus PC, Lomasney LM. Plain film manifestations of ACL injury. Orthopaedics 1994; 17:969. Shetty D, Lakhkar B, Krishna G. Magnetic Resonance Imaging in Pathologic Conditions of Knee. Ind J Radiol Imag 2002 12:3:375-381. Sonin AH, Fitzgerald SW, Friedman H, Hoff FL, Hendrix RW, Rogers LF. PCL injury: MR imaging diagnosis and pattern of injury. Radiology 1994; 190: 455-458. Chernye S. Disorders of the knee. In: Deer, et al, eds. Principles of orthopaedic practice, vol 2. New York: McGraw-Hill, 1989:1283. Takahashi N, Niitsu M et al. MR imaging of posterior cruciate ligament injuries. Nippon Igaku Hoshasen Gakkai Zasshi. 2001; 61(8):421-6.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareTo Study the Histopathological Forms of Thyroid Lesions Observed in Tertiary Care Hospital English109112Naresh GurbaniEnglish Prince LokwaniEnglish Rajneesh BerdiaEnglishIntroduction: The thyroid organ is a butterfly-model organ made out of globular right and left flaps associated in the midline by a meagre organisation named isthmus. Disorder related to thyroid consists of a group of disease of endocrines. All of these disorders may be associated with clinical conditions of hyper as well as hypo thyroids. Surgical excision and pathological evaluation are vital to establish a proper diagnosis. Aim: The study to show the histopathological forms of thyroid lesions observed in a tertiary care hospital. Materials and Methods: The present cross-sectional study was conducted for 2 years. Inclusion criteria: The test population included patients with thyroid pathology in a specified period. Thyroidectomy specimens including lobectomy, partial thyroidectomy, subtotal thyroidectomy and total thyroidectomy. Exclusion criteria: Patients with other disorder than thyroid were excluded. Results: The total number of studied cases was 225 cases (table 1). The reviewed cases were classically categorized into two main groups; Non- neoplastic (132; 58.5%) and Neoplastic (93; 41.5%). Papillary carcinoma was the most frequent thyroid cancer accounting for most of the thyroid cancers. Conclusion: Thus, in conclusion, females accounted for a higher number of patients with neoplastic thyroid lesions and the prevalence peaked at a younger age. Present study finding suggests that papillary carcinoma appears much before development so diagnosis should be fastened. EnglishHistopathological, Thyroid, Papillary carcinoma, Neoplastic thyroid lesionshttp://ijcrr.com/abstract.php?article_id=2731http://ijcrr.com/article_html.php?did=2731

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareBan of Cosmetic Testing on Animals: A Brief Overview English113116Sreedhar D.English Manjula N.English Ajay PiseEnglish Shilpa PiseEnglish Ligade VSEnglishIntroduction: Animals have been used in biomedical researchfor many years because they are considered as important experimental subjects due to their physiological similarity to human beings. Cosmetics are considered to be luxury products; they are not part of the essential commodity. Testing cosmetic ingredients on animals is primarily to check whether the product is safe for human use. Due to the increased concern for animals, to protect them from unnecessary pain and injuries many countries have passed,enacted Act made Rules and Regulations. Objective: In the present study an attempt was made to explore various country statuses that have banned, in the progress of cosmetic testing on animals. Methodology: The required information was obtained through secondary data sources, which were available onthe public domain. Discussion: The first ban on animal testing of cosmetics products was started by the European Union.A full ban on both the sale and import of cosmetics that are tested on an animal was done in March 2013 by the European Union. India banned cosmetic testing on animals in 2014. New Zealand prohibited the use of animals for tests of cosmetic products since May 2015. Countries like Israel, Norway, Brazil, South Korea also banned cosmetic testing on animals. Conclusion: This move from manycountries may protect cosmetic testing on animals from unnecessary pain and injuries. EnglishBiomedical Research, Animal Testing, Cosmetics Products.http://ijcrr.com/abstract.php?article_id=2732http://ijcrr.com/article_html.php?did=2732

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareGandhian Values in Health Science Education: Need for Global Revamp in Higher Education English4045Siddharth P. DubhashiEnglish Shashank D. DalviEnglish RB GoelEnglish Nitin N. KadamEnglish Sudhir N. KadamEnglish P.M. JadhavEnglishThe 21st century has drifted away from the Gandhian postulates, with lust for power, disrespect for religion, misuse of science and technology, unfair competition, thereby leading to ill-health. Only a healthy mind can build a healthy Nation. Our Institution strongly advocates the implementation of Gandhian values with the motto, “Wipe every tear from every eye.” The paper highlights the outcome of various initiatives undertaken by the University to implement the Gandhian Values in Health Science education. The Institution Model of Integrated Curriculum aims at the holistic development of the budding health care professional, doing away with the fragmented approach to teaching-learning. We as health professionals, need to be role models for the community. The paper strongly recommends that Health Science institutions need to foster a cultural ethos, imbibing the philosophy of the Mahatma in the true sense. EnglishGandhian values, Healthy mind-healthy nation, Integrated curriculum, Holistic developmentIntroduction Student-centred, patient-oriented education is the need of the hour. Higher Education Institutions should recognize the importance of integrating social and cultural values into the formal curriculum. Mahatma Gandhi, a symbol of world peace, spent his entire life in the pursuit of non-violence and truth. He believed that every human being has good in him, and that no one is born evil. He advocated that it is the bond of Ahimsa and love that unites human beings. He used this as a universal method for dealing with conflicts. The 21st century has drifted away from the Gandhian postulates, with lust for power, disrespect for religion, misuse of science and technology, unfair competition, thereby leading to ill-health. Only a healthy mind can build a healthy Nation. Gandhiji said that our body sends several signals to indicate the effects of wrong habits and lifestyles. However, modern medicine is used to mask these signals and wrongdoings. “It is health that is real wealth and not pieces of gold and silver.” Our Institution strongly advocates the implementation of Gandhian values in all its constituent Units of Health Sciences (Medical, Nursing, Physiotherapy, Biomedical Sciences, Prosthetics, and Orthotics) The parent trust established in 1982, works with the motto, “Wipe every tear from every eye.” Objectives To create an awareness regarding Gandhian philosophy amongst all stakeholders To nurture a healthy work ambiance, in the light of Gandhian values To foster a true sense of comradarie and team-building To advocate green initiatives and a clean environment Practice The Institute has implemented several strategies to create awareness about Gandhian values amongst its stakeholders: Formulation of Vision and Mission statements in accordance with Gandhian philosophy Display of boards in the campus, indicating Gandhian thoughts Paying tribute to the Father of the Nation on Republic and Independence Days, before the start of educational events like conferences, workshops Recitations of Vaishnav Janato Award of idol of Mahatma Gandhi as a token of appreciation to all guest speakers Khadi centre Exhibition on the Life of the Mahatma, on 2nd October Movie depicting Gandhian values Use of Gandhian thoughts during formal training activities including didactic lectures Inclusion of Human Values and Ethics into the undergraduate and postgraduate curricula of all Health Science courses Tree plantation program Participation in Swacch Bharat Abhiyan Yoga sessions for a healthy mind and body Charity for needy patients Diagnostic health camps in remote villages Provision of financial and medical help in case of national calamities Observations Keeping the Gandhian values in view, various initiatives and practices have been institutionalized by the organization. The outcome of such initiatives has been analyzed: Clean campus: Participation in Swacch Bharat Abhiyan Awards by Government of India in recognition of the same Participation of students, duly recognized by the Government Environmental protection Green initiatives: Tree plantation programs E-Governance strategies Inclusion of Gandhian values into teaching-learning process: Increased awareness regarding Gandhian philosophy amongst faculty and students Initiative taken by Faculty to include Gandhian thoughts during their lectures and mentoring sessions Implementation of Communication Skills module including plays depicting values of empathy and patient rights Initiatives taken by students to construct scripts for movies and plays depicting Gandhian values Overwhelming response of students for an essay writing competition organized by Indian Council of Medical Research on “Gandhi and Health” E-poster competition on Life of Mahatma, organized by Institution Bioethics Unit of UNESCO Chair in Bioethics Value-added course on Gandhian values Fostering freedom of thought, inquiry, creative thinking amongst students ReThink India awards for students who were appreciated as “scintillating students in the framework of Gandhian values” Social commitment: Charity for needy patients Display of Gandhian thoughts at strategic places in the hospital Over 1000 diagnostic health camps in remote villages Adoption of 10 remote villages under Unnat Bharat Abhiyan Stoppage of open field defecation practices in villages Decreased mortality and morbidity from water-borne diseases as a result of Information, Education and Communication (IEC) activities in villages Cleanliness drives in Ashram schools and slum areas Grade A1 accredited Mahatma Jyotiba Phule Jan Arogya Yojana scheme of Government of Maharashtra Provision of financial and medical help for flood victims of State of Kerala, duly recognized by Government of Kerala Overall Development: Nurturing human values in the formal education process Improved teacher – student and doctor – patient bonding Team building spirit Feeling of inclusiveness amongst stakeholders Strong inculcation of the values of social commitment, honesty, and sincerity into the minds of budding health professionals Self-realization, self-respect Patriotism Respect for all religions Discussion The Institution has been striving towards quality benchmarks in higher education. In doing so, the visionary founders have always felt the need for inclusion of Gandhian Values in Health Science education. (Fig. 1). Spiritual values in health care are gaining immense importance. Spirituality is a universal concept in all societies and cultures and has a correlation with Quality of Life scores. Patients with the advanced disease would have a strong feeling of fulfillment of life goals. Spiritual effects are seen in a positive manner in alleviating pain1. Cultural Competence in health care is crucial. The American College of Physicians and the Association of American Medical Colleges have reiterated the value of attributes of altruism, compassion, and empathy, in dealing with patients2,3. Spiritual values provide comfort, hope, and faith in crisis4. The nursing profession is spiritual, with a deep presence, providing compassion, love, and healing5,6. This calls for the development of curricula on spirituality in medicine in health science Universities. Health care professionals need to have values of integrity, trust, and a feeling of caring for others. Ethical dilemmas can pose several challenges. We need to involve patients and their families in decision-making. The individuality of every person needs to be given due respect7. The intellectual values define leadership potential in a health care professional to a great extent. The intellectual domain comprises of human, structural, and customer capitals8. The values of reflection, critical thinking, reasoning and judgement, open mindedness, and creativity, need to be nurtured. The doctor-patient relationship is now moving towards a patient-provider relationship. Moral values reflect the code by which we practice9. Health care professionals strive towards ethical practices. In fact, ethics includes the moral values that influence one’s behavior10. Moral distress in the health care profession has been described extensively with the nursing professionals, who spend a lot of time in resolving ethical dilemmas11. The Institution Model of Integrated Curriculum aims at the holistic development of the budding health professional. This model has removed the inter-departmental barriers, thereby doing away with the fragmented approach to teaching-learning (Fig. 2). Every effort is made by the Institution to nurture the Gandhian values in a vibrant academic environment. The ethos thus created, encourages students to actively participate in various events such as the celebration of Gandhi Jayanti on 2nd October. The film made by these students and the eye-catching exhibition on the life of the Mahatma, has been truly inspiring. In fact, such events stand testimony to the fulfillment of the Vision and Mission of the Institution. The precious teachings of the Father of the Nation are taught through several literary events like essay writing, poetry, mono acts, debates. These thematic activities are organized by the students themselves, are indeed a treat to watch. Gandhian thoughts are well depicted in all the student documents such as handbooks, log-books, and student charter. Every guest arriving into the Institution campus first takes the blessings of the Mahatma. The statue of the Father of the Nation on the lush green campus lawns catches the eye of every visitor. The Institution has nurtured a rich tradition of felicitating the guests with our in-house woven Khadi shawl and an idol of Mahatma. Gandhiji advocated social service and cleanliness. Tree plantation drives, adoption of villages under Unnat Bharat Abhiyan, Swachh Bharat campaign, reflect the true sense of social commitment among faculty and students. It is indeed encouraging to note the participation of alumni in many of these activities. The Swachh Bharat campaign conducted by the Institution has won accolades from the Government of India. Energy conservation measures adopted by the Institution in all its constituent Units, add to the green initiatives. Cleanliness drives are conducted periodically in the campus as well as adjacent villages. The Institution feels proud to note the whole-hearted voluntary participation of faculty and students in these activities. Gandhiji knew that the future of the country was in the villages. Our Institution also believes “Village health is a sound investment”. The conduct of diagnostic health camps in remote villages provides a social platform for the students to understand the importance of communication skills and important principles of bioethics including patient privacy and autonomy. The students have been proactive in conducting health awareness drives in villages, especially in relation to the stoppage of open defecation and safe sanitation practices. The dietary practices are explained to the villagers. The IEC strategies adopted by the Institution have brought about the desired changes in the community. The Institution has been at the forefront in offering required services for natural calamities and mass casualty events. The Gandhian principle of learning by doing, is well reflected in the teaching-learning model of the Institution. The creativity of the students is brought to light by various student-centred activities like Case-Based Learning, role plays, short projects, essay writing, and wall magazines. The Mahatma advocated the importance of understanding ones responsibility. The students, in the process of participation in all events as a team, also value this principle. It is then that they find the path for social awareness and social mindedness. The encouragement provided by the Institution for undergraduate research activities, ignites an element of critical thinking into young minds. Recitation of Vaishnava Janato during important events of the Institution creates a serene atmosphere for teaching-learning. It is a simple endeavor to instill into the minds of all stakeholders, the definition of a Vaishnav. It is emphasized to the students that it is essential to understand the agony of their patients that they should refrain from speaking lies, have true respect for others, and have the best of knowledge without an element of ego. This gesture adds flavor to the rich cultural framework of the Institution. The Father of the Nation always maintained that students should refrain from politics. Students should never exploit the autonomy that is imparted to them by the education system. They need to be well informed regarding the evils of society which can ruin their professional ambitions. The Institution has adopted a student-centric nomination system for appointment of student representatives on various bodies. In fact, utmost care is taken to maintain adequate gender representation as well. The standard operating procedures of the Institution ensure adequate student autonomy in decision-making. The well-drafted Student Charter outlines the roles and responsibilities of the Student and the Institution towards each other. The Institution has taken an initiative to start the Bioethics Unit in collaboration with the UNESCO Chair in Bioethics. The Unit exhibits active participation in accordance with the World Bioethics Day theme and undertakes short research projects. The Boards of Studies (Pre-Clinical, Para-Clinical, Medicine and Allied, Surgery and Allied, Super-Specialty, Nursing, Physiotherapy, and Biomedical Sciences, have identified various sub-topics related to Bioethics in their respective specialties for Undergraduate and Postgraduate programs. Bioethics forms an integral part of the induction programs for the undergraduate and postgraduate students. Professionalism, Communication skills, doctor-patient relationship, research ethics, environmental ethics, are some of the key features of the training program. The Unit has pioneered the tradition of administering a pledge to all members of the Bioethics Student Wing. The Bioethics Unit conducts structured training sessions for Human Values and Ethics, for all health science students. It is noteworthy to note the positive response of students for these sessions. Moreover, the faculties are self-motivated to conduct these sessions. In fact, periodic training programs on Bioethics are also conducted for faculty. The Doctor-Patient relationship and Professionalism are depicted in these training sessions with the use of videos and role-plays. This makes the teaching-learning process more enjoyable and increases the receptiveness of students to these values. The success of these activities lies in a remarkable change in the attitude and behavior of several stakeholders. Moreover, the students who benefit from these sessions act as mentors for their junior colleagues, thereby facilitating Peer-Assisted Learning. The learning resource centre is a temple in any Higher Education Institution. We have strived to build up a unique collection of Gandhian literature for the benefit of our students and faculty. These documents provide a deep insight into the philosophy rooted behind the Gandhian values. This has triggered off a unique initiative of formulating value-added courses related to Gandhian Values. The Khadi Centre of the Institution has lots to offer in the present education system Students are made aware of the importance of Khadi, which is much more than just a cloth. The message behind the hand spun and hand-woven cotton fabric needs to be driven strongly into the young minds. Khadi reflects national integrity, self-sufficiency, and morality. In fact, the University Grants Commission (UGC) in India has already advocated the use of Khadi in all convocation ceremonies and other special occasions of Higher Education Institutions in the country. It is indeed a matter of pride for our Institution to have adopted this strategy way back since inception. Gandhiji has advocated the importance of exercise for the healthy mind. Unhealthy lifestyles have been the root cause of disharmony. The Institution has always stressed upon the importance of Yoga for its stakeholders. The foundation of Yoga therapy has been related to Ahimsa12. We strictly prohibit the use of liquor in campus and advocate a clean healthy vegetarian diet for all. The Institution endeavors to help students to practice self-restraint with regards to harmful addictions. It needs to be instilled into the minds of students, that the rich Indian traditions and culture are now being adopted globally. The Institution has always strived to bring out the importance of the holistic approach to teaching-learning. Integrated teaching is the solution for better outcome of graduate attributes in health sciences. An integrated curriculum as “education that is organized in such a way that it cuts across subject matter lines, bringing together various aspects of the curriculum into meaningful association to focus upon broad areas of study.”13 Institutions are shifting from traditional discipline-based curricula to the SPICES Model: student-centered learning, problem-based learning, integrated teaching, community-based education, elective programs, and a systemic approach14. The Institution convened a landmark meeting of eminent academicians in 2018 to deliberate upon quality benchmarks in higher education. The event emphasized the role of integrated teaching and the hidden curriculum in health science education. The integrated teaching model provides an opportunity for holistic learning. Interdisciplinary interactions pave the way for effective and meaningful research, which can be easily translated into practice for effective patient care. The disciplines of Ayurveda and other alternative systems can no longer be ignored. The Wellness Centre of our Institution caters to a variety of chronic illnesses as well as provides relaxation therapy, a stress buster for health care professionals. Quality of Life issues is gaining importance for every disease. The treatment protocol no longer ends with the patient feeling better or asymptomatic, but cares for the rehabilitation of the patient. The Institution has facilities not only for psychological counseling but also for prosthetic and orthotic requirements. This helps to inculcate a spirit of a holistic approach to health care. The teaching hospitals provide the best of facilities at subsidized costs and even free of charge for needy patients. The Mahatma clearly put forth the seven deadly sins that would destroy the society: Wealth without work; pleasure without conscience; knowledge without character; commerce without morality; science without humanity; worship without sacrifice; politics without principle15. Hatred and violence is now an integral part of the society. The technology of today, may be the error of tomorrow. The hanging sword of Bioterrorism has created panic waves across the globe. What are we heading for? This is the time that the Higher Education Institutions revisit their curricula and firmly imbibe the Gandhian values. The Gandhian model of teaching-learning needs to be discussed at length on a global platform. Recommendations Every Higher Education Institution in the country should adopt the Gandhian values into its Curriculum. The Learning Resource Centre at every HEI should have a dedicated section for Gandhian literature. Gandhian thoughts should form an integral component of every induction program. Institutions should conduct an annual Oration, inviting reputed speakers to elaborate upon any facet of the life of the Mahatma. It is worthwhile to explore the possibility of observing a ‘Khadi Day’ in the Institution. Doctoral Programs in Bioethics are the need of the hour. Appropriate incentives should be provided to faculty pursuing such programs. Every Health Science Institution should include undergraduate students as part of the village adoption program. The best practices of any Institution should clearly reflect the adoption of any of the Gandhian values in the Institution culture. This should be given due importance in the accreditation of the institution. Conclusion Inclusion of Gandhian values into Health Science education has proved to be an excellent initiative of our Institution. We as health professionals, need to be role models for the community, with moral, and ethical values in the true sense. The technological advancements should be coupled with the much need human touch for optimum outcome in healthcare. The health science graduate should be able to implement the blend of moral, spiritual, social, and intellectual values in society for an optimal outcome. Implementation of Gandhian values into the health science curriculum will foster a rich cultural ethos in a rich academic environment, thereby nurturing good citizens. Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of funding: NIL The said manuscript has not been presented in any meeting. Conflict of interest: NIL Englishhttp://ijcrr.com/abstract.php?article_id=2733http://ijcrr.com/article_html.php?did=2733 Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent) 2001;14(1):352-357. Lo B, Quill T, Tulsky T, for the ACP-ASIM End-of-Life Care Consensus Panel Discussing palliative care with patients. Ann Intern Med. 1999;130:744–749. Association of American Medical Colleges. Report I: Learning Objectives for Medical Student Education: Guidelines for Medical Schools. Medical School Objectives Project. Washington, DC: American Association of Medical Colleges; 1998:4. Available at http://www.aamc.org/meded/msop/report1.htm (accessed March 2020). Jackson C. Healing ourselves, healing others. Holistic Nursing Practice 2004;18:127 -141. Goddard NC. A response to Dawson’s critical analysis of ‘spirituality as integrative energy’. Journal of Advanced Nursing 2000;31:968 -979. Carroll B. A phenomenological exploration of the nature of spirituality and spiritual care. Mortality 2001;6:81-98. Benator S, Upshur R. Virtues and values in medicine revisited: individual and global health. Clinical Medicine 2014;14(5):495–499. Alshawabkeh RKE. The impact of intellectual capital development on provided health services quality. International Journal of Advanced Educational Research 2018;3(2):481-486. Timimi FK. Medicine, morality and health care social media. BMC Medicine 2012;10:83. Evans JM. The changing ethics of health care. Caring for the Ages 2016;17(7):12. Raines ML. Ethical decision making in nurses Relationships among moral reasoning coping style, and ethics stress. JONA’s Healthcare Law Ethics and Regulation 2000;2(1):29–41. Bhargav H. The principles and practice of Yoga in health care. Int J Yoga 2018;11(1):86-87. Shoemaker BJE. Integrative Education: A Curriculum for the Twenty-First Century. OSSC Bulletin 1989;33(2):n2. Harden RM, Sowden S, Dunn WR. Educational strategies in curriculum development: the SPICES model. Med Educ 1984;18(4):284–297. Dundar H, Erdogan E, Hareket E. A role model in light of values: Mahatma Gandhi. Educational Research and Reviews 2016;11(20):1889-1895.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareThe Hidden Victims of Covid-19 Pandemics English0102Mohammad Shakil AhmadEnglish Ajay G. PiseEnglishEnglishhttp://ijcrr.com/abstract.php?article_id=2734http://ijcrr.com/article_html.php?did=2734

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411214EnglishN2020July22HealthcareTransition to Competency-Based Medical Education: A Proposed Rollout Model English117122Tripti K SrivastavaEnglish Lalitbhushan S WaghmareEnglish Alka T RawekarEnglishThe Undergraduate Medical education curriculum in India is revised to competency-based Competency-Based Medical Education (CBME)) as per Graduate Medical Education (amendment 2019) from 2019 – 20 onwards. This manuscript suggest a Competency-Based Medical Education (CBME) Roll out model that can aid Medical Institutes across India to plan and implement this revised curriculum. The Model suggests formulation of various relevant committees, their terms of reference, Phases of roll out (Planning, implementation, Monitoring, Evaluation and Amendment) and GANTT chart. Implementation of reforms in a phasic manner with capacity building at relevant intervals, as suggested in the model, will provide a steady foundation to the revised curriculum and will ease the process of change. EnglishCompetency-Based Medical Education, Indian Medical Graduate, Ethics and Communication.Introduction: The Undergraduate Medical education curriculumin India is revised to competency–based as per Graduate Medical Education (amendment 2019) from 2019 to 20 onwards.1 The emphasis is to enable Indian Medical Graduate (IMG) to recognize "Health for all" as a National goal and fulfill his/her societal obligations.1 The revised curriculum is better aligned with Health professional attributes that are locally relevant and globally adaptive. The goal is that the IMG must be able to function in the roles of Clinician, Leader and Member of health care team, Communicator and Life long learner and Professional appropriately and effectively. Competency based learning includes designing and implementing medical education curriculum that focuses on the desired and observable ability in real life situations. Competency, per se, is defined as the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.2 The regulatory body of Medical education suggests the broad framework of Competency-Based Medical Education (CBME).1,3 This manuscript suggests a comprehensive roll out plan by Jawaharlal Nehru Medical College, a constituent unit DMIMS, a deemed to be University, with flexibility of appropriate incorporations at local level to suit the need and context, keeping the broad framework intact. The various reforms that are contemplated with regards to Competency-Based Medical Education (CBME) are as stated under; Aligned and integrated curriculum Foundation course Early clinical exposure Electives Student - Doctor Method of Clinical Training Certification of essential skills Attitude, Ethics and Communication (AETCOM) skill module Self directed learning Co-curricular activities Reforms in Formative, Internal and Summative Assessments The rollout plan incorporates formulation of specific committees, terms of reference, phases of rollout, and Gantt chart. Composition of various committees : New COMPETENCY-BASED MEDICAL EDUCATION (CBME) curriculum must be phased out through the co-ordination of three significant committees viz.1. Departmental Curriculum Committee (DCC), 2. College Curriculum Committee (CCC) and 3. Expert Group (EG). The Composition of the three committees is proposed as under; a. Departmental Curriculum committee (DCC) : The DCC committee must consist of three members who have undergone training in MCI recognized Basic course workshop and Curriculum Implementation and Support program (CISP). b. College Curriculum Committee(CCC) : The College Curriculum Committee must consist of six members, in accordance with BOGs, MCI guidelines as stated below; c. Expert group (EG): Four expert groups viz 1.Alignment Integration and ECE , 2. Assessment 3. Skills and 4.Electivesmust be formed. Each expert groups can consist of five members, each of whom have undergone training in MCI recognized Basic/revised basic course in Medical Education, Curriculum Implementation and Support Program and Advance course in ME/MPhil HPE. Each group must have a Co-convener and a member of CCC. The overall in-charge of the expert groups must be MEU co-coordinator. Each expert group will be responsible for operational monitoring and need based capacity building with regards to COMPETENCY-BASED MEDICAL EDUCATION (CBME). The terms of reference of various committees are identified in table no 3. Phases of Roll-out : As mentioned in earlier paragraphs, the various reforms must be rolled out in five phases, as stated below; 1 : Planning phase The first step to sustainable curricular reform is proper planning. The entire rollout plan must be planned with respect to desired tasks at hand, timeline and responsibility. Planning phase begins from the year of launch of first professional year with new curriculum and must continue prospectively for forthcoming professional years viz Professional year II, III and VI. The planning phase comprises of two parallel levels of operation as depicted below; The tables 1-4 gives operational details during planning phase for Ist – IVth professional year, for the new curriculum launched in 2019academic year, under the sections of Blueprinting and Capacity building. 2. Implementation phase: Implementation of Competency-Based Medical Education (CBME) must be done prospectively and routed through Dean of the Institute and departmental curriculum committee headed by Head of Department. Need based capacity building must be taken up by Expert group as and when required. Report: DCC must submit the report of Competency-Based Medical Education (CBME) implementation to CCC on quarterly basis. The compiled quarterly reports must be submitted to Medical Education Unit on annual basis which should be later submitted to Regulatory body for compliance. 3.Monitoring Phase: The monitoring will be done at two levels, as stated below; 1. Mechanical monitoring: DCC 2. Operational monitoring: Expert group It is proposed that DCC must meet fortnightly to discuss implementation of Competency-Based Medical Education (CBME) at the departmental level. The monthly report from DCC must be submitted to CCC. The CCC and expert group meetings should be held monthly to review the reports of DCC to ensure smooth implementation, necessary amendments, and relevant observations. The minutes of this monthly meeting must be itemized in the monthly college council meetings. This will enable formative evaluation of COMPETENCY-BASED MEDICAL EDUCATION (CBME) and allow intermediate corrections during the course. The same will be reviewed in quarterly joint college council meetings. 4. Evaluation Phase: The entire roll out plan must be evaluated (formatively and summatively) by Internal Quality Assurance Cell (IQAC), as per the indicators identified in the planning and implementation phase. 5. Amendment Phase: The observations and suggestions of IQAC must be incorporated and aligned planning should be done before implementation. COMPETENCY-BASED MEDICAL EDUCATION (CBME)Roll-out Time line: The entire roll out plan must have well defined deliverables with dedicated timeline as depicted in the GANNT chart for the COMPETENCY-BASED MEDICAL EDUCATION (CBME) launch in 2019 academic year. Implication :Implementation of reforms in a phasic manner with capacity building at relevant intervals, as suggested in the model, will provide a steady foundation to the revised curriculum and will ease the process of change. Conclusion : Any change should be weighed from multiple perspectives.The magnitude of change also defines the amount of input, resources and time. Bigger the change , more will be the time required for planning and leadership support. 4One key aspect involves involving various stakeholders as change agents and appraising them about the benefits of the Change. Competency Based Medical Education is one such change that requires careful planning, diligent implementation and robust monitoring. The proposed rollout plan, with its five distinct phases, can serve as a useful guide for educational leaders at various Medical schools to bring about this change with capacity building at one hand and administrative support at the other. The Interoperable systems that support information flow in number of directions is a hallmark of the proposed plan. Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Conflict of Interest: Nil Source of Funding: Nil Englishhttp://ijcrr.com/abstract.php?article_id=2791http://ijcrr.com/article_html.php?did=2791 https://www.mciindia.org/CMS/e-gazette (last accessed on 25th April 2020) Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226-235. Curriculum Implementation Support Program of the Competency Based Undergraduate Medical Education Curriculum, Medical Council of India, 2019 Bland CJ, Starnaman S, Wersal L, Moorhead-Rosenberg L, Zonia S, Henry R. Curricular change in medical schools: how to succeed. Acad Med 2000; 75:575-94