Indian Journal of Critical Care Medicine

Register      Login

Table of Content

2017 | September | Volume 21 | Issue 9

Total Views


Salvatore Aiello, Rohit Loomba, Connor Kriz, Matthew Buelow, Saurabh Aggarwal, Rohit Arora

The need for extracorporeal membrane oxygenation in adults undergoing congenital heart surgery: Impact and trends of utilization

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:5] [Pages No:547 - 551]

Keywords: Adult congenital heart disease, extracorporeal membrane oxygenation, mechanical support

   DOI: 10.4103/ijccm.IJCCM_169_17  |  Open Access |  How to cite  | 


Introduction: Adults with congenital heart disease (ACHD) represent a population with unique health-care needs. Many patients require cardiac surgery, with some requiring postoperative extracorporeal membrane oxygenation (ECMO). This study aimed to identify the risk factors for the need of postoperative ECMO and characterize the impact of ECMO on admission characteristics. Methods: Data from the 2005–2012 iterations of the Nationwide Inpatient Sample were used. ACHD admissions over 18 years with a documented cardiac surgery were included. Univariate analysis was conducted to compare the characteristics between those requiring ECMO and those who did not. Regression analysis was done to identify the independent risk factors associated with ECMO and to determine the impact of ECMO on length, cost, and mortality of the admission. Results: A total of 186,829 admissions were included. Of these, 446 (0.2%) admissions required ECMO. Those with acute kidney injury, double-outlet right ventricle, or total anomalous pulmonary venous connection were more likely to require ECMO. ECMO was also significantly more utilized in patients undergoing septal defect repair, complete repair of tetralogy of Fallot, atrial switch, and heart transplant. The use of ECMO significantly increased length, cost, and mortality of stay. Overall mortality was 62.6% in the ECMO group. Conclusion: ECMO is only needed in a small proportion of postoperative ACHD patients. The use of ECMO significantly increases cost, length of stay and mortality in these patients. Improved identification of postoperative ACHD patients who are more likely to survive ECMO may facilitate improved survival and decreased resource utilization.



Subhash Varma, Neelam Varma, Aditya Jandial, Susheel Kumar

Elevated red cell distribution width as a prognostic marker in severe sepsis: A prospective observational study

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:11] [Pages No:552 - 562]

Keywords: 30-day mortality, Acute Physiology and Chronic Health Evaluation II score, red cell distribution width, severe sepsis

   DOI: 10.4103/ijccm.IJCCM_208_17  |  Open Access |  How to cite  | 


Introduction: Sepsis is a dysregulated host response to infection resulting in potentially life-threatening organ dysfunction. Elevation in red cell distribution width (RDW), a simple routinely done investigation, could be a prognostic marker in these patients. Methods: Between January 2014 and June 2015, 200 patients with severe sepsis at admission were prospectively evaluated for association between RDW at admission and 30-day mortality. Besides the groups of raised and normal RDW, study population was further analyzed after categorizing into three RDW groups as follows: ≤14.5%, 14.6–17.3%, and >17.3% as well. To find out factors associated independently with 30-day mortality, we applied multivariate logistic regression analysis. Results: Among 200 patients, 115 (57.5%) were males. Mean age of the study subjects was 51.32 ± 16.98 years. Mean RDW at admission was 17.40 ± 3.21%, ranging from 12.6% to 33.3%. Mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score of study population at admission was 22.49 ± 5.72. One hundred and fourteen (57%) patients had 30-day mortality. Even though RDW showed a hierarchical association with 30-day mortality among three RDW groups, it was not found to be an independent predictor of 30-day mortality. APACHE II score, serum albumin, partial pressure of arterial oxygen/fraction of inspired oxygen ratio, and serum fibrinogen level at admission were observed to be independent predictors of 30-day mortality. Conclusions: In severe sepsis patients, RDW though showed a graded relationship with 30-day mortality was not found to be an independent predictor of 30-day mortality.



Mohammad Heidari, Aram Ghaniyoun, Khosro Shakeri

The association of psychological empowerment and job burnout in operational staff of Tehran emergency center

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:5] [Pages No:563 - 567]

Keywords: Emergency staff, job burnout, psychological empowerment

   DOI: 10.4103/ijccm.IJCCM_56_17  |  Open Access |  How to cite  | 


Background: Workers in social service professions are the first candidates for job burnout. The researchers believe this is due to daily exposure to stressful situations and lack of positive conditions in the workplace. It seems that psychological empowerment of staff can affect their job burnout. This study aimed to investigate the relationship between psychological empowerment and job burnout in operational staff of emergency center. Methods: This was a descriptive correlational study. A total of 1100 operational staff of emergency center were evaluated, and of which, 285 persons were selected by simple random sampling method. Data were collected using Spritzer's psychological empowerment and Maslach Burnout Inventory questionnaires. SPSS software, version 18, was used for data analysis along with descriptive analytical tests. Results: The findings of this study revealed that the majority of units (46%) were in intermediate level in terms of empowerment. Similarly, the majority of cases had intermediate level (77.5%), and a minor percentage (8.4%) had low levels of job burnout. Based on Pearson's correlation test, there was a significant invert correlation between psychological empowerment and job burnout. This inverse and significant relationship was also observed between the four components of psychological empowerment (competence, self-determination, impact, and meaning) and job burnout. Conclusions: According to the results of the study, policy makers and health planners can take some measures in enhancing psychological empowerment to prevent problems associated with job burnout, by identifying stressors and strategies to deal with them.



Yashpal Singh, Monish Nakra, Vishesh Verma, K. Shankar, Amit Nachankar, K.V.S. Kumar

Liraglutide as an alternative to insulin for glycemic control in intensive care unit: A randomized, open-label, clinical study

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:5] [Pages No:568 - 572]

Keywords: Critical care, hyperglycemia, insulin, Intensive Care Unit, liraglutide

   DOI: 10.4103/ijccm.IJCCM_105_17  |  Open Access |  How to cite  | 


Background: Intravenous insulin is the cornerstone in the management of hyperglycemia in the Intensive Care Unit (ICU). We studied the efficacy of liraglutide compared with insulin in the ICU. Materials and Methods: In this prospective, open-labeled, randomized study, we included 120 patients (15–65 years, either sex) admitted to ICU with capillary blood glucose (CBG) between 181 and 300 mg/dl. We excluded patients with secondary diabetes and APACHE score >24. The patients were divided into two groups (n = 60) based on the CBG: Group 1 (181–240) and Group 2 (241–300). They were randomized further into four subgroups (n = 30) to receive insulin (Groups 1A and 2A), liraglutide (Group 1B), and insulin with liraglutide (Group 2B). The primary outcome was the ability to achieve CBG below 180 mg/dL at the end of 24 h. The secondary outcomes include mortality at 1 month and hospital stay. Data and results were analyzed using Mann-Whitney U-test, paired t- test, and Chi-square tests. Results: The mean age of the patients (93M and 27F) was 57.1 ± 13.9 years, hospital stay (16.9 ± 7.5 days), and CBG was 240.5 ± 36.2 mg/dl. The primary outcome was reached in 26, 27, 25, and 28 patients of Groups 1A, 2A, 1B, and 2B, respectively. The 30-day mortality and hospital stay were similar across all the four groups. Hypoglycemia was common with insulin and gastrointestinal side effects were more common with liraglutide (P < 0.001). Conclusion: Liraglutide is a viable alternative to insulin for glycemic control in the ICU. Further studies with a larger number of patients are required to confirm our findings.



Sharmila Chatterjee, Mahuya Bhattacharya

Epidemiology of adult-population sepsis in India: A single center 5 year experience

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:5] [Pages No:573 - 577]

Keywords: Epidemiology, intensive care patients, mortality, prevalence, severe sepsis

   DOI: 10.4103/ijccm.IJCCM_240_17  |  Open Access |  How to cite  | 


Background and Aims: Sepsis is a major worldwide cause of morbidity and mortality. Most sepsis epidemiologic data are from the Western literature. Sparse data from India describe the epidemiology of infection rather than sepsis which is a host response to infection. This study describes the epidemiology of sepsis in the Intensive Care Unit (ICU) of an Indian tertiary care hospital. Subjects and Methods: A prospective study conducted between June 2006 and May 2011. All consecutively admitted patients during the 5 year study >=18 years of age were included and data obtained from hospital in-patient records. Variables measured were the incidence of severe sepsis, ICU, hospital, and 28-day mortality, the median length of ICU stay, median Acute Physiology and Chronic Health Evaluation II (APACHE II) score, infection site, and microbial profile. Results: There were 4711 admissions during the study with 282 (6.2%, 95% confidence interval 2.3, 13.1) admissions with severe sepsis. ICU mortality, hospital mortality, and 28-day mortality were 56%, 63.6%, and 62.8%, respectively. Predominant infection site was respiratory tract. The most common organisms were Gram-negative microbes. The most common microbe was Acinetobacter baumanni. Median APACHE II score on admission was 22 (interquartile range 16–28) and median length of ICU stay was 8 days. Severe sepsis attributable mortality was 85%. Conclusion: Severe sepsis is common in Indian ICUs and is mainly due to Gram-negative organisms. ICU mortality is high in this group and care is resource intensive due to increased length of stay.



Arezoo Ahmadi, Elchin Barzegar, Masoumeh Nouri, Sarah Mousavi, Mojtaba Mojtahedzadeh

Vasopressin in septic shock; assessment of sepsis biomarkers: A randomized, controlled trial

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:7] [Pages No:578 - 584]

Keywords: Sepsis biomarkers, septic shock, vasopressin

   DOI: 10.4103/ijccm.IJCCM_258_17  |  Open Access |  How to cite  | 


Background and Aims: Vasopressin (VP) in sepsis apart from vasoconstrictive effect may have some immunomodulatory effects. The aim of this study was to evaluate the effect of VP on different aspect of sepsis by measuring of sepsis biomarkers. Materials and Methods: In this trial, a total number of 42 septic shock patients were included. The first group received norepinephrine (NE) infusion to reach the target mean arterial pressure (MAP) of ≥ 65 mm Hg and the second group received arginine vasopressin (AVP) infusion in addition to NE. Serum lactate, C-reactive protein (CRP), interleukin-6 (IL-6), IL-10, pentraxin 3 (PTX3), angiopoietin 1 and 2 (Ang 1 and 2) levels were assessed. Results: Level of IL-6 and IL-10 decreased, but there was no significant difference between the two groups after 48 h. CRP and PTX3 levels were not also significantly different between groups. Although Angs were not statistically different, there was a trend toward higher Ang-1 in and lower Ang 2 in AVP group after 24 and 48 h. In addition, lactate level did not differ between NE and AVP groups. There was no interaction between VP and hydrocortisone use on IL-6, IL-10, and PTX3, but a significant statistical interaction on Ang 1 and Ang 2 were observed. Conclusions: Although analysis of sepsis biomarkers showed no significant difference between two groups, no immunomodulatory effect for VP alone, subgroup analysis of hydrocortisone used in this study showed that the combination of glucocorticoids and AVP had a significant effect on Angs level which eventually causes less endothelial permeability and higher MAP in this group of patients.



Ali Jendoubi, Ahmed Abbes, Salma Ghedira, Mohamed Houissa

Pain measurement in mechanically ventilated patients with traumatic brain injury: Behavioral pain tools versus analgesia nociception index

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:4] [Pages No:585 - 588]

Keywords: Behavioral pain scale, Intensive Care Unit, pain assessment, traumatic brain injury

   DOI: 10.4103/ijccm.IJCCM_419_16  |  Open Access |  How to cite  | 


Introduction: Pain is highly prevalent in critically ill trauma patients, especially those with a traumatic brain injury (TBI). Behavioral pain tools such as the behavioral pain scale (BPS) and critical-care pain observation tool are recommended for sedated noncommunicative patients. Analysis of heart rate variability (HRV) is a noninvasive method to evaluate autonomic nervous system activity. The analgesia nociception index (ANI) device (Physiodoloris®, MDoloris Medical Systems, Loos, France) allows noninvasive HRV analysis. The ANI assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The primary aim of our study was to evaluate the effectiveness of ANI in detecting pain in TBI patients. The secondary aim was to evaluate the impact of norepinephrine use on ANI effectiveness and to determine the correlation between ANI and BPS. Methods: We performed a prospective observational study in 21 deeply sedated TBI patients. Exclusion criteria were nonsinus cardiac rhythm; presence of pacemaker; atropine or isoprenaline treatment; neuromuscular blocking agents; and major cognitive impairment. Heart rate, blood pressure, and ANI were continuously recorded using the Physiodoloris® device at rest (T1), during (T2), and after the end (T3) of the painful stimulus (tracheal suctioning). Results: In total, 100 observations were scored. ANI was significantly lower at T2 (Median [min – max] 54.5 [22–100]) compared with T1 (90.5 [50–100], P < 0.0001) and T3 (82 [36–100], P < 0.0001). Similar results were found in the subgroups of patients with (65 measurements) or without (35) norepinephrine. During procedure, a negative linear relationship was observed between ANI and BPS (r2 = −0.469, P < 0.001). At the threshold of 50, the sensitivity and specificity of ANI to detect patients with BPS ≥ 5 were 73% and 62%, respectively, with a negative predictive value of 86%. Discussion: Our results suggest that ANI is effective in detecting pain in ventilated sedated TBI patients, including those patients treated with norepinephrine.



Tamer Helmy, Ehab El-reweny, Farahat Ghazy

Prognostic value of venous to arterial carbon dioxide difference during early resuscitation in critically ill patients with septic shock

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:5] [Pages No:589 - 593]

Keywords: Acute Physiology and Chronic Health Evaluation II score, lactate, partial pressure carbon dioxide gap

   DOI: 10.4103/ijccm.IJCCM_64_16  |  Open Access |  How to cite  | 


Context: The partial pressure of venous to arterial carbon dioxide gradient (PCO2gap) is considered as an alternative marker of tissue hypoperfusion and has been used to guide treatment for shock. Aims: The aim of this study was to investigate the prognostic value of venous-to-arterial carbon dioxide difference during early resuscitation of patients with septic shock and compared it with that of lactate clearance and Acute Physiology and Chronic Health Evaluation II (APACHE-II) score. Settings and Design: Forty patients admitted to one Intensive Care Unit were enrolled. Subjects and Methods: APACHE-II score was calculated on admission. An arterial blood gas, central venous, and lactate samples were obtained on admission and after 6 h, and lactate clearance was calculated. Patients were classified retrospectively into Group I (survivors) and Group II (nonsurvivors). Pv-aCO2difference in the two groups was evaluated. Statistical Analysis Used: Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. Results: At T0, Group II showed high PCO2gap (8.37 ± 1.36 mmHg) than Group I (7.55 ± 0.95 mmHg) with statistically significant difference (P = 0.030). While at T6, Group II showed higher PCO2gap (9.48 ± 1.47 mmHg) with statistically significant difference (P < 0.001) and higher mean lactate values (62.71 ± 23.66 mg/dl) with statistically significant difference (P < 0.001) than Group I where PCO2gap and mean lactate values became much lower, 5.91 ± 1.12 mmHg and 33.61 ± 5.80 mg mg/dl, respectively. Group I showed higher lactate clearance (25.42 ± 6.79%) with statistically significant difference (P < 0.001) than Group II (−69.40–15.46%). Conclusions: High PCO2gap >7.8 mmHg after 6 h from resuscitation of septic shock patients is associated with high mortality.



Md Alam, Mainul Haque, Mozibul Haque

An appraisal of mortality in Intensive Care Unit of a Level III military hospital of Bangladesh

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:5] [Pages No:594 - 598]

Keywords: Bangladesh, Intensive Care Unit, Level III military hospital, mortality rate

   DOI: 10.4103/ijccm.IJCCM_250_17  |  Open Access |  How to cite  | 


Background: Mortalities in Intensive Care Units (ICUs) are high and widely variable. The unpredictability of death rates is attributable to age, sex, nature and severity of illness, comorbidity, well-timed medical attention, quality of the attending staffs, iatrogenic events, total management facilities, and overall grade of the ICU in general. Materials and Methods: A total of seventy patients who died in the ICU of a Level III Combined Military Hospital within a period of 2 years were studied in retrospect to review the mortality pattern. Results: Overall mortality rate was 3.58%, among which 81.43% were male and 18.57% were female. The mortality rate in geriatric patients was 12.26% and 2.84% in the age group of 12–60 years and 2.56% in below 12 years. The major causes of death were ischemic heart disease (20%), cerebrovascular disease (14.28%), and chronic obstructive pulmonary disease (10%). Highest incidence of death occurred during 1–3 days of ICU stay (34.28%) and the lowest was at 4 days to 1 week (4.28%). Conclusion: Ischemic heart disease (IHD) is remaining as the most important cause of mortality in our community although many countries have succeeded in reducing the IHD mortality by a combination of lifestyle modification and improving the health-care delivery systems.



Nagaraj Pandharikar, Shekhar Venkatraman

Hospital-acquired hyponatremia in pediatric intensive care unit

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:5] [Pages No:599 - 603]

Keywords: Antidiuretic hormone, dysnatremia, hyponatremia intravenous fluid, pediatric intensive care, sodium

   DOI: 10.4103/ijccm.IJCCM_131_17  |  Open Access |  How to cite  | 


Objective: The objective of the study was to evaluate the etiology of hospital-acquired hyponatremia (HAH) and its effects on morbidity and mortality in the Pediatric Intensive Care Unit (PICU) patients. Design: This study design was a prospective observational case–control study. Setting: this study was conducted at tertiary care PICU. Materials and Methods: All consecutive cases admitted with at least one measured serum sodium (PNa) value were evaluated. Those with normal admission PNa were followed till they develop hyponatremia (PNa < 35 mEq/L) 7 days or PICU discharge whichever was earlier. Results: During the study period, 123 (19.6%) cases developed HAH and 126 patients remained isonatremic (control group). The admission PNa 138.8 ± 3.03 mEq/L decreased to 132 ± 2.58 mEq/L (drop of 6.68 ± 3.39 mEq/L, P < 0.001) in HAH cases. The use of antidiuretic hormone (ADH)-stimulating drugs (odds ratio [OR]: 2.83, P = 0.01), postsurgical status (OR: 2.95, P = 0.006), and fluid intake ml/kg (OR: 1.0, P = 0.001) were found to be significant risk factors in HAH group on multivariate analysis. HAH cases had prolonged PICU stay (P = 0.000) and mechanical ventilation (P = 0.01), but no difference in the mortality when compared to controls. Conclusions: HAH is associated with increased fluid intake, presence of ADH-stimulating drugs or conditions, and postsurgical status and has an adverse effect on the outcome of PICU patients.



Umesh Bhadani

Dual oxygen therapy in patient on bilevel positive airway pressure prevented invasive mechanical ventilation

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:3] [Pages No:604 - 606]

Keywords: Bi-level positive airway pressure, dual oxygen therapy, high-flow nasal cannula

   DOI: 10.4103/ijccm.IJCCM_199_17  |  Open Access |  How to cite  | 


During noninvasive bilevel positive airway pressure (BiPAP) ventilation it is found that several times patients are unable to maintain oxygen saturation and develop breathing difficulty despite its high setting and high oxygen flow, further management requires invasive positive pressure mechanical ventilation. Increasing oxygen concentration inside the BiPAP mask using nasal cannula with addition of another flow meter not only increase oxygen saturation but also make the patient more comfortable and prevent intubation and its complications. This dual oxygen therapy is particularly useful in patients where non invasive ventilation is required and avoiding the need invasive mechanical ventilation. High-flow nasal cannula oxygen therapy has many advantages over traditional oxygen delivery systems. Here, we are going to report two cases of patients on BiPAP in which invasive positive pressure ventilation was prevented using dual oxygen therapy using nasal cannula with flow meter and BiPAP mask with addition another flow meter in a single sitting.



Ashish Jaiswal, Nidhi Anchan

Iatrogenic bilateral simultaneous pneumothorax: Call for vigilance

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:3] [Pages No:607 - 609]

Keywords: Iatrogenic bilateral pneumothorax, pneumomediastinum, simultaneous iatrogenic bilateral pneumothorax

   DOI: 10.4103/ijccm.IJCCM_108_17  |  Open Access |  How to cite  | 


Iatrogenic pneumothorax refers to the pneumothorax generated after diagnostic or therapeutic procedure. We report the case of a 40-year-old male who had bilateral simultaneous iatrogenic pneumothorax with pneumomediastinum leading to cardiac arrest situation, due to wrong placement of nebulization kit in spontaneously breathing intubated patient. We report this case for its rarity, due to the critical importance of this cause as a etiology of bilateral simultaneous iatrogenic pneumothorax leading to cardiac arrest situation, and need to understand the importance of continuous training and stress of emergency environment.



Sheikh Minhaj Ahmed, Krishnakumar Shah, Uma Ali

Diabetic ketoacidosis with extreme hypernatremia in a 4-year-old girl

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:3] [Pages No:610 - 612]

Keywords: Deep vein thrombosis, diabetic ketoacidosis, extreme hypernatremia, skin blisters

   DOI: 10.4103/ijccm.IJCCM_226_17  |  Open Access |  How to cite  | 


A 4-year-old girl admitted with altered mental status, new-onset diabetes mellitus, and diabetic ketoacidosis (DKA) had a rapid rise in serum sodium from 158 mEq/L (corrected sodium 165 mEq/L) at the admission to 204 mEq/L within 18 hours of admission despite standard fluid and insulin therapy recommended for the treatment of DKA. During her illness, she developed arterial and deep vein thrombosis (DVT), bloodstream infection with Candida species, and extensive skin blistering and denudation. The child needed mechanical ventilation, insulin infusion, careful fluid titration to bring down the sodium gradually, and low-molecular weight heparin for her DVT. She had a prolonged Intensive Care Unit and hospital stay but recovered completely without any neurological sequelae.



Paolo Beccaria, Carmine Votta, Luca Lucchetta, Simona Silvetti, Massimo Agostoni, Alberto Zangrillo

Two different endoscopic procedures made feasible by the Janus mask in a high-risk patient

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:3] [Pages No:613 - 615]

Keywords: Acute respiratory failure, fiber-optic bronchoscopy, intensive care, noninvasive ventilation, upper endoscopy

   DOI: 10.4103/ijccm.IJCCM_188_17  |  Open Access |  How to cite  | 


The Janus mask is a full face mask designed for providing noninvasive ventilation (NIV) during any kind of upper endoscopies (e.g., fiber-optic bronchoscopy, gastrointestinal endoscopy, and transesophageal echocardiography). Due to its unique conformation, its use can be considered for both elective and urgent endoscopic procedures in high-risk patients. In this case report, we present a patient with acute respiratory failure who underwent two consecutive different endoscopic procedures (fiber-optic bronchoscopy and gastrointestinal endoscopy) during continuous positive airway pressure support by means of this novel NIV mask, thus avoiding tracheal intubation and at the same time, improving his respiratory condition.



Sepsis awareness in India from internet search trends: Where do we stand?

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:2] [Pages No:616 - 617]

   DOI: 10.4103/ijccm.IJCCM_479_16  |  Open Access |  How to cite  | 



Alieh Kiasari

Preventing refractory hypoxemia after lung transplantation by prone positioning: A new agenda for research

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:2] [Pages No:617 - 618]

   DOI: 10.4103/ijccm.IJCCM_215_17  |  Open Access |  How to cite  | 



Ankur Khandelwal

Subcutaneous hematoma following subcutaneous emphysema: An occult association

[Year:2017] [Month:] [Volume:21] [Number:9] [Pages:2] [Pages No:618 - 619]

   DOI: 10.4103/ijccm.IJCCM_113_17  |  Open Access |  How to cite  | 


© Jaypee Brothers Medical Publishers (P) LTD.