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With over three decades of participation in the Paralympic Games, twelve medalists and eighty-three Paralympians who have represented India, today the country’s improving success at each Paralympic event cannot be ignored. With a new disability rights law passed in 2016, athletes with disabilities are just beginning to be recognized in India as citizens who can raise the country’s profile in the sporting world. From India, there is nil research in Paralympic sport, and journalistic discourse is often focused on inspirational story reporting. Research on sport governance within this ecosystem will bring to discussion what is the governance framework that exists within the Paralympic world of newly developing countries like India. The purpose of this article is to provide an overview of sport governance in India’s Paralympic movement, the country’s legislation concerning the sporting rights of persons with disabilities (PwD), and to further highlight potential gaps that plague India’s Paralympic system from further developments. Collaborative efforts between the International Paralympic Committee and the Indian Government, increased efforts to train technical officials in India and emphasis on structuring state level governance standards are some of the recommendations from this research to sustain the Paralympic movement in India.

Armed Forces doctors are often required to treat children affected in war, combat, and disasters. Tender care & comprehensive tact is needed for children. Acquisition of these qualities comes with knowledge, its application, and practicing skills. Throughout history, children have been victims of armed conflict. War-related injuries are more severe as compared to the civilian sector injuries. Penetrating injuries are associated with significant damage to local structures, whereas blast injuries are associated with less local injury and more multisystem trauma. Children are not small adults. The differences have important practice implications. Identifying and correcting physiological compromise improves outcomes. The examination and vital sign data can be interpreted only if the caregiver has a thorough understanding of normal values. Identification & treatment of what is killing the patient is done in primary survey. Secondary survey, extremity trauma, fracture biomechanics, & burns peculiarities need attention. Care of the injured patient is a dynamic process. Frequent monitoring required for proper response. Small infants have a narrow margin for error. Combat trauma provides multiple opportunities for improvement. Continuation of research will ensure ongoing progress and further improvement in the outcomes of both military and civilian casualties.

Context: Adolescent health information within new global health initiatives is advocated. Global School-based Student Health Survey (GSHS) is among young people 13 to17 years. Early prevention and promotion is beneficial. Aim: To find health behaviors and protective factors at different adolescence physiological stages. Settings and Design: School-based survey in an Army Public School. Methods and Materials: The study parameters were dietary behaviors, hygienic practices, mental health, physical activity, and protective factors. A total of 1232 adolescents were surveyed. Early adolescence (10–13 years) participants were 760 and middle adolescence (14–17 years) were 472. Male: female ratio was 1.819:1. Statistical Analysis: Calculation of percentage ± Standard error using standard methods. Results: The study reveals interesting trends. There is a disparity between body mass index (BMI) findings and effort direction for weight. There is a sharp rise in girls making efforts to lose weight from early to middle adolescence (27.8% and 40.7%, respectively). Hygienic practices are marginally short of 100%. Worry causing the inability to sleep at night most of the time or always reported by 9.2–18.7%. There is a sharp rise in the number of girls feeling this from early to middle adolescence (9.8%–18.7%). Adolescents spending three or more hours per day doing sitting activities are 25.6–38.6%. This is rising from early to middle adolescence, and sharply in girls. Protective factors are trending towards the positive side. Conclusions: First, for advancements of adolescents' health, top priorities are (i) Popularizing importance of ideal BMI, (ii) Betterment of mental health for a smooth transition across stages and being proactive for preventing worsening, (iii) Promoting physical activity early and sustaining efforts, especially amongst girls. Second, the 'GSHS Questionnaire' needs to be modified for fruits and vegetable consumption to how many servings/what part of plate and include questions for details of physical activity likings of girls.

Purpose Advanced methodical learning and optimised learning leads to better-trained doctors. Such teaching typically comprises the illustration of features and access to facilities. This article explores the role of “Special clinics” in medical education. The role of sophisticated “Special clinics” is to provide vigour and vibrancy in treating and teaching as well as advancing the art and science of medicine. All this contributes towards the current evidence indicating benefits of reducing hospitalization. Methods This article comprises an analysis of the guidance produced by leading medical education institutions. Findings are presented in the perspective of a relevant theoretical framework around “Special clinics”, in light of the available evidence and personal experience. Results The implementation and potential impacts of “Special clinics” are presented within the context of the “4SAs”, a favoured teaching mnemonic: 1) Scientific Approach: medical education rules and regulations reflecting scientific reasoning in support of “Special clinics”, 2) Setting Advantages: the mechanisms by which “Special clinics” are conducive to and contribute towards increasing the capacity to comprehensively treat complex disorders in the outpatient setting, avoiding hospitalization and its associated risks, as well as expenditure, 3) Sophistication Advantages: tools and techniques to ensure advanced clinical skills teaching including novel outpatient technologies, understanding the need for focussed study and practice, and exploiting the advantages of internationalization of medical education, and 4) Successes and Advancements: opportunities to observe experts providing specialist care of the highest standard. The use of a focussed approach aims to explore and advance frontiers of medical education. Conclusion “Special clinics” will soon form a major component of the hospital workload and play a crucial role in medical education. They provide the advantage of condition-specific patient-centered care, the motivation for excellence. Clinical skills learnt by medical students in “Special clinics” will undoubtedly contribute to long-term improvements in the medical care., Video Abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/ZM-TLlS02rQ

Purpose Current recommendations for ‘Febrile seizures’ management include emergency first aid and treatment along with intermittent prophylaxis. Evidence of practices, efficacy, side-effects, and complications should lead to refined and rational management strategies. Patients and Methods Study of cases referred and treated at a tertiary level hospital, providing referral services to a large state in India. Evidence sought for the research questions identified, these were (i) immediate treatment: First aid components and practices; response to drug treatment (ii) intermittent prophylaxis: effectiveness, compliance, and side-effects (iii) complications arising due to treatment side-effects: quantifying the number of cases of CNS infections missed as a result of alterations in consciousness levels due to benzodiazepines. Results A total of 85 febrile seizure cases were studied. Full correct “First Aid” was provided by only 13 parents. Total 35 cases (41.18%) had seizures lasting more than 05 minutes. Emergency treatment for these included rectal diazepam in 14 cases with 57.14% success in terminating seizure, and intranasal midazolam in 21 cases with 71.43% success. The cases with persisting seizures were managed as status epilepticus treatment algorithm. Intermittent prophylaxis prevented recurrence of seizures in 90%, however side-effects were reported in 36.36%. There was no case of CNS infection missed. Conclusion Safe and effective management strategy should include “Health education” for correct first aid and ‘Protocols’ for timely and correct emergency treatment by parents/pre-hospital teams/emergency duty doctors. Intermittent prophylaxis is effective but refinements needed to minimize side-effects. Vigilant clinical monitoring obviates the fear that treatment may mask CNS infection., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/psIZo8G-_N8

Malnutrition and bone disease are common in adults with chronic pancreatitis (CP). We studied the nutritional status and bone mineral density (BMD) of children with CP and the factors predicting them.CP children were prospectively evaluated with a detailed questionnaire, anthropometry, 25-hydroxy vitamin D, fecal elastase and BMD [total body less head (TBLH), spine and hip] by dual energy x-ray absorptiometry. Body mass index (BMI) Z score of -1 to -1.9, -2 to -2.9 and-3 was taken as mild, moderate and severe malnutrition respectively. Low BMD and osteoporosis were defined as per International Society for Clinical Densitometry.83 children (46 boys, 14[4.3-21]years) with CP were enrolled. Majority had Cambridge IV (51,62.2%) or III (15,18.3%) changes. 34(41%) had undernutrition (mild-37.3%, moderate-2.4%, severe-1.2%). Overweight and obesity were present in 3.6% and 1.2% cases. BMI had a significant correlation with haemoglobin, serum albumin, percentage body fat and BMD. A majority had low fecal elastase (69 [84.1%],100 μg/g) and vitamin D deficiency (70[84.3%],20 ng/ml). 9 cases had a history of fractures. 14/75(18.6%) cases had low TBLH-BMD and this group had a lower BMI (-1.3[-1.9 to 0.34] vs 0.8 [-2.1 to 5.50; p = 0.03) than patients with normal BMD. There was no difference in age, disease duration, vitamin D, fecal elastase and Cambridge grade between normal and low BMD.41% CP children have undernutrition with a majority having mild undernutrition. Nearly 20% have low BMD, with osteoporosis in none. Subjects with low BMI have lower BMD and percentage body fat.

Knowing current trends for timely comprehensive action for health promotion practices is an important prerequisite for medical practitioners and policy makers.A survey of mothers at a Tertiary Care Hospital in central India.On the knowledge front83.75% of the mothers studied showed good knowledge about breastfeeding and complementary feeding. Similar, but not as encouraging, were the results about attitude, with 76.25% of mothers having a positive attitude. The results of the practices part were varied. The WHO indicators assessed were 'early initiation of breastfeeding' (68.75%), 'exclusive breastfeeding under 6 months' (85%) (however exclusive breast feeding for first 6 months was carried out by only 36.25%), 'introduction of solid, semi-solid or soft foods' (48.75%), 'continued breastfeeding at 1 year' (63.75%) and 'continued breastfeeding at 2 years' (6.25%).There is a discrepancy between knowledge and practices. The exclusive breast feeding rates are far from the ideal and there is a decline of continued breast feeding beyond 15 months. This calls for sustained efforts with the aim - 'cover all and cover completely'. The ideal WHO indicator for exclusive breast feeding should be 'exclusive breastfeeding for first 6 months' which will provide information about the completeness of this ideal practice.

Background: The current happenings in the country for the good should be of importance in the crucial places and the criticalphases of life, i.e., hospitals and during hospitalization, even for normal life processes. The current “Clean India Campaign” isa catalyst for hospitals for improvements in hygiene. Objective: The objective of this study is to define and describe the impactof multifaceted infection control and hygienic practices by all on hospital-acquired infections (HAIs) in the pediatric age group.Materials and Methods: Implementation of multifaceted infection control policies was ensured along with the health educationfor hygienic practices by all, including attendants of patients and patients when possible. These were rigorously enforced withthe renewed enthusiasm since the launch of “Clean India Campaign” from January 2015. The setting was “Paediatric Wing” of atertiary care hospital catering to a large army cantonment, and also, referred cases. The outcome measures were the incidence ofHAIs. Results: The incidence rate of HAIs was 2.91% (July 2013-December 2014) and declined to 1.59% (January 2015-June2016) (relative risk: 0.547, 95% confidence interval: 0.409-0.733; p=0.0001). The most significant decline in HAI in our studyhas been in that of gastrointestinal infections (RR: 0.428%, 95% CI: 0.241-0.761; p=0.0034). Overall, the results of preventiveactions were rewarding (RR: 0.547, 95% CI: 0.409-0.733; p=0.0001). Conclusion: The mission “Clean India Campaign” and theWHO’s vision “clean care is safer care” lead to prevention and reduction of HAIs. Implementation of multifaceted infection controlinterventions is impactful. Hygienic practices teaching should be for both caregivers and caretakers.

Background: A new health system for the 21st century should be based on the best scientific knowledge, according to the Institute of Medicine, US. Objective: We have evaluated the effectiveness of asthma clinic providing comprehensive care based on the best available scientific evidence. Materials and Methods: This intervention study was conducted in a tertiary care hospital having a devoted asthma clinic for the comprehensive management. All children diagnosed as having asthma were included, and data of cases managed from July 2014 to June 2016 were analyzed. Intervention - comprehensive management of asthma including assessment, monitoring, health education, avoidance of triggers, management of comorbid conditions, appropriate medications, written asthma action plan, and counseling for follow-up. Outcome measures were treatment direction, asthma control, emergency visits, and hospitalizations. Results: 260 children were treated over a 2-year period. The effects of focused approach with progressive expertise lead to statistically significant benefits over the two successive years from July 2014 to June 2015 and July 2015 to June 2016. These were in: (i) Treatment direction: Cases requiring stepping up of treatment decreased from 36.49% to 17.24% (relative risk [RR]: 0.473 [95% confidence interval {CI}: 0.249-0.895]); p=0.01229, (ii) asthma control: Cases with not well-controlled asthma decreased from 16.44% to 7.02% (RR 0.427: [95% CI: 0.199-0.914]); p=0.045, (iii) emergency department visits decreased from 35.62% to 21.05% (RR 0.591: [95% CI: 0.39-0.897]), p=0.00766, (iv) hospitalizations decreased from 16.44% to 5.26% (RR 0.32: [95% CI: 0.135-0.757]), p=0.00462. Conclusion: Establishing an asthma clinic and progressive expertise leads to significant beneficial results.

Background & Aims Data on minimal hepatic encephalopathy (MHE) in children is scarce. We aimed to study MHE in children with chronic liver disease (CLD) and to validate non-invasive objective tests which can assist in its diagnosis. Methods We evaluated 67 children with CLD (38 boys; age 13 [7–18] years) and 37 healthy children to determine the prevalence of MHE. We also assessed the correlation of MHE with changes in brain metabolites by magnetic resonance spectroscopy ( 1 HMRS), diffusion tensor imaging (DTI) derived metrics, blood ammonia and inflammatory cytokines (interleukin-6 [IL6], tumor necrosis factor alpha [TNF-α]). In addition, the accuracy of MR-based investigations for diagnosis of MHE in comparison to neuropsychological tests was analysed. Results Thirty-four (50.7%) children with CLD had MHE on neuropsychological tests. MHE patients had higher BA (30.5 [6–74] vs. 14 [6–66]μmol/L; p =0.02), IL-6 (8.3 [4.7–28.7] vs. 7.6 [4.7–20.7]pg/ml; p =0.4) and TNF-α (17.8 [7.8–65.5] vs. 12.8 [7.5–35]pg/ml; p =0.06) than No-MHE. 1 HMRS showed higher glutamine (2.6 [2.1–3.3] vs. 2.4 [2.0–3.1]; p =0.02), and lower choline (0.20 [0.14–0.25] vs. 0.22 [0.17–0.28]; p =0.1) and myo-inositol (0.25 [0.14–0.41] vs. 0.29 [0.21–0.66]; p =0.2) in MHE patients than those without MHE. Mean diffusivity (MD) on DTI was significantly higher in 6/11 brain areas in patients with MHE vs. no MHE. Brain glutamine had a significant positive correlation with blood ammonia, IL-6, TNF-α and MD of various brain regions. Neuropsychological tests showed a negative correlation with blood ammonia, IL6, TNF-α, glutamine and MD. Frontal white matter MD had a sensitivity and specificity of 73.5% and 100% for diagnosing MHE. Conclusions In children with CLD, 50% have MHE. There is a significant positive correlation between markers of hyperammonemia, inflammation and brain edema and these correlate negatively with neuropsychological tests. MD on DTI is a reliable tool for diagnosing MHE. Lay summary Fifty percent of children with chronic liver disease develop minimal hepatic encephalopathy (MHE) and perform poorly on neuropsychological testing. These children have raised blood ammonia, inflammatory cytokines and mild cerebral edema on diffusion tensor imaging as compared to children without MHE. The higher the ammonia, inflammatory cytokines and cerebral edema levels the poorer the performance on neuropsychological assessment. The estimation of mean diffusivity on diffusion tensor imaging is an objective and reliable method for diagnosing MHE.

Pulmonary embolism (PE) may be potentially fatal if not diagnosed and treated in time. Although specific electrocardiogram (ECG) findings often suggest the diagnosis of PE, occasionally, the ECG may mimic that of an acute coronary syndrome (ACS). We report an interesting case of a 45-year-old female presenting with sudden onset chest pain and shortness of breath with widespread ST depression in anterior precordial leads. Although initially treated and referred as a case of ACS, careful analysis of the ECG and subsequent echocardiography and computed tomography imaging confirmed the diagnosis of PE. Intensivists and cardiologists need to be aware that diagnostic dilemma between PE and ACS is not uncommon due to such "ischemic-looking" ECG as well as elevated troponin levels in both conditions. The use of multimodality imaging techniques is helpful in arriving at the correct diagnosis.

Summary Background Late-stage isolated medial knee osteoarthritis can be treated with total knee replacement (TKR) or partial knee replacement (PKR). There is high variation in treatment choice and little robust evidence to guide selection. The Total or Partial Knee Arthroplasty Trial (TOPKAT) therefore aims to assess the clinical effectiveness and cost-effectiveness of TKR versus PKR in patients with medial compartment osteoarthritis of the knee, and this represents an analysis of the main endpoints at 5 years. Methods Our multicentre, pragmatic randomised controlled trial was done at 27 UK sites. We used a combined expertise-based and equipoise-based approach, in which patients with isolated osteoarthritis of the medial compartment of the knee and who satisfied general requirements for a medial PKR were randomly assigned (1:1) to receive PKR or TKR by surgeons who were either expert in and willing to perform both surgeries or by a surgeon with particular expertise in the allocated procedure. The primary endpoint was the Oxford Knee Score (OKS) 5 years after randomisation in all patients assigned to groups. Health-care costs (in UK 2017 prices) and cost-effectiveness were also assessed. This trial is registered with ISRCTN (ISRCTN03013488) and ClinicalTrials.gov ( NCT01352247 ). Findings Between Jan 18, 2010, and Sept 30, 2013, we assessed 962 patients for their eligibility, of whom 431 (45%) patients were excluded (121 [13%] patients did not meet the inclusion criteria and 310 [32%] patients declined to participate) and 528 (55%) patients were randomly assigned to groups. 94% of participants responded to the follow-up survey 5 years after their operation. At the 5-year follow-up, we found no difference in OKS between groups (mean difference 1·04, 95% CI −0·42 to 2·50; p=0·159). In our within-trial cost-effectiveness analysis, we found that PKR was more effective (0·240 additional quality-adjusted life-years, 95% CI 0·046 to 0·434) and less expensive (−£910, 95% CI −1503 to −317) than TKR during the 5 years of follow-up. This finding was a result of slightly better outcomes, lower costs of surgery, and lower follow-up health-care costs with PKR than TKR. Interpretation Both TKR and PKR are effective, offer similar clinical outcomes, and result in a similar incidence of re-operations and complications. Based on our clinical findings, and results regarding the lower costs and better cost-effectiveness with PKR during the 5-year study period, we suggest that PKR should be considered the first choice for patients with late-stage isolated medial compartment osteoarthritis. Funding National Institute for Health Research Health Technology Assessment Programme.

Radiation is important in health and disease. It is imperative to use properly and prevent misuse or overuse. Pertinent trends of increasing radiation in the environment need analysis. We gleaned important information, from published evidence and authoritative resources, for practicing safely and preventing harm. Science & technology progress is for the betterment of mankind, and all efforts should be made to prevent any untoward effects. Children and paediatric patients deserve special attention because of their vulnerability due to multiple reasons. Effective investigations & interventions in medical settings should be done based on best evidence. All those ordering radiological investigations should take into consideration the radiation exposure values & especially decide on clinical impact of the investigation. Prenatal exposure to radiation has risks. Computed Tomography is responsible for 24% of all radiation exposure. Dual-energy X-ray absorptiometry is useful for measuring changes in body tissue composition. Radiologists should tailor imaging individually. Radiotherapy is administered to more than half of all cancer patients. Acute toxicity alleviation and chronic toxicity consideration is important. Radiation emergencies can occur in isolation or as major catastrophe. Emergency life-support is needed. Decontamination along with using the ABCDE reduction approach components are elucidated. With increasing use of mobile phones the electro-magnetic fields produced by mobile phones use needs consideration. UV radiation overexposure prevention is with shade, clothing and hats. Applying sunscreen essential on those parts of the body that remain exposed like the face and hands. All the safety measures need popularization and continuous practice with precision & perfection.

Background: Characterization of peripheral arterial occlusive disease (PAOD) can be performed with non-invasive angiography using computed tomography (CT). The present study was conducted to evaluate the CT angiographic spectrum of aortoiliac and the lower limb arterial disease in symptomatic patients of peripheral arterial occlusive disease (PAOD) and to classify the lesions according to the Trans-Atlantic Inter-Society Consensus II (TASC II). Methods: The study was carried out in the department of radio-diagnosis in collaboration with departments of cardiothoracic surgery, cardiology and surgery, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi. 50 patients aged above 40 years presenting with symptoms and (or) signs of lower limb peripheral arterial disease were recruited into the study after evaluating the renal function. Patient’s clinical history, ABI index and categories of PAOD according to the classification of Fontaine was noted. CT angiography of aortoiliac and lower limb arteries was performed with Philips Brilliance 40 CT unit. The findings in each CT angiography were analysed in respect to site, number, nature and distribution of the lesions and classified individually according to the TASC II. Results: The patients included in the study were all more than 40 years of age. The age range in the study group was 42 years to 75 years. The majority (86%) were male patients. Smoking and dyslipidemia were found to be the main risk factors in our patients. 24% of patients had documentary evidence of ischemic heart disease. On grading with ABI majority of patients (58%) presented in the end stage of the disease (stage IV). On CT angiography, number of lesions detected was 157. 97.4% of lesions were either stenotic or occlusive and 2.54% are with aneurysm. Maximum number of patients had femoropopliteal lesions followed by aortailiac lesions. 14 Winslow pathways were found in 10 patients. Maximum numbers of femoropopliteal lesions (47.29%) belong to type D, type B lesions account for 50% of total aortoiliac lesions based on TASC II classification. Out of 50, 40 were made follow up. Among them 8 were managed with conservative treatment and remaining 32 managed with treatment based TASC II classification. Conclusions: CT angiography is a reliable noninvasive imaging method for the comprehensive and multi parameter evaluation of patients with PAOD. CT angiographic findings are a highly accurate basis for treatment decisions and planning.

Background Tuberculosis is endemic in India and almost 40 % of the Indian population is infected with tubercle bacilli. Tuberculosis being a great mimicker of infectious as well as non infectious diseases and recent rise of multi drug resistant and extended drug resistant cases have made diagnosis and management more difficult. To the best of our knowledge there have been no reported cases of tuberculosis coexisting with malignant peritoneal mesothelioma leading to multiple site venous thrombosis. Case presentation Forty five year old male, belonging to Indian/Aryan ethnicity presented with cough, breathlessness and fever for 7 months with past history of pulmonary tuberculosis. On examination he was found to have pleural effusion for which he received anti-tuberculosis therapy empirically. Later his condition deteriorated and on further examination he was found to have ascites, multiple site venous thrombosis and pyothorax which was found positive for acid fast bacilli. Despite anti-tuberculosis therapy he did not improve and was suspected to be a multidrug resistant case. Later on computed tomography peritoneal nodule was detected and on biopsy revealed malignant mesothelioma. Conclusion In a diagnosed case of tuberculosis with clinical findings compatible with it but not responding to anti tubercular therapy, underlying secondary co-existing pathology should be explored.

Amoebic liver abscess is a serious but curable hepatic illness predominantly seen in tropical countries. We describe our experience of clinical presentation, laboratory parameters, radiological findings and treatment strategies. This is a retrospective analysis of 114 patients who were admitted from January 2012 to September 2014 at our centre. The mean age of presentation was 41.7 ± 13.9 years, the majority of patients were male (86.8%) with chronic alcoholism (63.2%). Most of the patients had a solitary right lobe liver abscess. Abdominal pain, fever, tachycardia and hepatomegaly were the most common clinical findings while hypoalbuminaemia, anaemia, leucocytosis and electrolyte imbalance were the most common laboratory abnormalities. A significant number of patients could be managed with antibiotics only (45.6%), percutaneous radiological drainage techniques being an important adjunct in selected cases (percutaneous needle aspiration, 20.2%; percutaneous pigtail catheter drainage, 30.7%). Surgical intervention was required in only a few cases (3.5%). Mortality was 3.5%.

Background: Chronic diseases are a leading cause of morbidity and mortality in India. Globally, chronic kidney disease is the 12th cause of death and the 17th cause of disability, respectively. CKD is defined as kidney damage or glomerular filtration rate (GFR)