Analysis of differences in Oncology practice between the United Kingdom and India
AN. Aswin1, Apurna Jegannathen2, AN. Vaidyswaran3
1Consultant Radiation Oncologist, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu, India
2Consultant Clinical Oncologist & Clinical Lead, Royal Stoke Hospital, University Hospital of North Midlands, Stoke on Trent, United Kingdom
3Senior Consultant Radiation Oncologist & Director of Radiation Oncology, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu, India.
Background
This article is based on my observership of SABR (Stereotactic Ablative Body Radiotherapy)/SRS (Stereotactic Radio Surgery) at few centres (Royal Stoke Hospital, UHNM, Clatterbridge cancer centre, Royal Hallamshire Hospital) in United Kingdom (UK).
In this article, I would like to highlight the differences in the oncology practice prevailing between the two countries.
Cancer detection
Most of the cancers (bowel, cervix, prostate, especially lung, piloted in a few NHS trusts, and breast) are detected by screening programs in the UK whereas, in India, these cancers are usually detected as an incidental finding or usually with symptoms. This may lead to the locally advanced nature of disease presentation in India requiring a multimodality approach (more than one treatment modality).
The Oncologist
In UK, clinical oncologists take care of both radiotherapy/chemotherapy/immunotherapy/biological agents, and medical oncologists work along with clinical oncologists for concurrent chemoradiation, radical radiotherapy, palliative radiotherapy, SABR etc. In India, radiotherapy is done by radiation oncologists and chemotherapy and other systemic therapies are taken care of by medical oncologists. The chemotherapy-related complications are managed by both clinical oncologists and medical oncologists in UK and medical oncologists in India. There is no site specification for radiation oncologist (except educational institutions and few centres) in India whereas clinical oncologists do only site-specific treatment- 1-2 major sites and a minor site. Specific time allocation for clinical trials, research and audit are incorporated in the job plan.
Decision makers in the treatment and palliative care support
In India, the attenders are the decision makers for the treatment, whereas in UK MDT -Multidisciplinary team decides the best treatment and the patient’s choices are given, for them to make the final decision. Family support plays a major role in India, whereas community support groups- community Macmillan nurse team, district nurses, community palliative care team, hospice etc take care of the cancer patients in UK. Advanced Nurse Practitioners called ANP lead chemo clinics, ANP lead Acute Oncology and EAU-emergency admissions unit with 24/7 helpline for patient access. Metastatic Clinical Nurse Specialists are assigned as keyworkers for patients with secondary cancer.
Funding for the treatment
The NHS sponsors the entire treatment for the patients in UK. In addition, Cancer Drug Funding (CDF) is a central pot that funds high-cost drugs including Immunotherapy and biological agents. In India, although the treatment given in government hospitals is free of cost and various national/state government schemes are available for the patients, private insurance and paying out of pocket in private hospitals play a major role.
Treatment protocols
In UK treatment protocols are agreed at the regional level-cancer alliance group after extensive discussion supported by evidence-based practice. There are Quality Assurance (QA) and monitoring, with report systems in place. Radiotherapy related 30-day mortality is collected. National audits from all the NHS Trusts are collected. Targets are used for treatment initiation. Peer review is mandatory for complex/ concurrent chemoradiation patients. MDT discussion is a requirement. ANP led RT reviews are in place. There are fixed protocols for all the sites in UK although there are minor variations in each centre based on evidence. Personalised approach is practised in UK. In India, although centres follow protocol, there is no uniform protocol throughout the country. But the patient specific customization is still practised in India.
Documentation
In UK clinical documentation is paperless throughout the journey. This includes all clinic visits, radiotherapy planning, chemotherapy prescription, and follow-up. Paperless system (EPR-Electronic Patient record, Electronic Medical Record EMR) is followed. This iportal system is visible to all specialities within the trust and to the primary care team. In India, except few centres, the documentation is on paper in some centres and hybrid model (paper + EMR) is followed in some centres.
The Clinic (Outpatient consultation)
The number of patients seen and followed up are exponentially more in India when compared to UK. The quality of time spent with the patients/attenders is better in UK for the same reason, one hour for new patient, twenty minutes for FU. The timing of work is between 9 to 5pm for 5 days and hence a waiting list is common. Paid for PA (programmed activity, 1PA = 4 hours) is followed. Telephonic consultation is widely practiced in UK. For getting consultant appointments, it might take minimum 2 to 3 months in the UK. There is a huge waiting list which is getting better as there is cross cover in each site-based team. In India it is within 1-2 days.
Waiting time for imaging investigations
The approximate waiting period for investigations like Computerized Tomography (CT) and Positron Emission Tomography (PET CT) is usually within a week in India; It is mostly 3-6 weeks in UK but urgent scans are done within 1-2 weeks if specifically requested and same day for emergency scans
Biopsy
Some of the patients with lung nodules which are PET Positive and shown to increase in size are treated with SABR even without the biopsy in UK, if biopsy is not feasible and the radiological features are suggestive of malignancy after Tumour Board discussion. In India this is rarely done because there are high chances of associated diseases like tuberculosis.
Consent
There is a proper site- specific consent in UK whereas it is more a generalised consent in India.
Immobilization and CT simulation in Radiotherapy
The immobilisation device like Omni board (Fig. 1) with arm support, knee support and ankle support is designed in such a way that it is so much convenient to the patients in UK. The abdominal binders can be attached to the Omni board for intra-abdominal tumours. Aquaplast is used only for patients with head & neck cancers and brain tumours. In India, aquaplast is used for almost all sites which may be a little inconvenient for the patients. The CT simulation process is almost essentially the same in both the countries. The breath- hold technique followed using Visual Display Unit in UK is more convenient for the patients when compared to the techniques followed in India.
![onco-5-1](https://www.kauveryhospital.com/images/journals/v5i7/onco-5-1.jpg)
Fig. 1.
Omni Board used for immobilization
.
Image acquisition and voluming of normal structures
Image acquisition and voluming of normal structures are done using Artificial Intelligence (AI) on the next day of CT simulation in UK as per the workflow algorithm by the dosimetrists. In contrast, image acquisition is done on the same day by physicists and voluming of normal structures is done by radiation oncologists. Moreover, PET CT, Magnetic Resonance Imaging (MRI) and the planning CT scans are fused before voluming in India. In UK, very rarely the PET CT images are fused for planning.
Voluming
The voluming of the target alone is done by clinical oncologist whereas the voluming of the target as well as normal structures are done by radiation oncologist. The peer review is mandatory and is getting documented in UK, whereas the peer review is not documented and not mandatory in India.
Treatment planning
The treatment planning is done by dosimetrists and sent for physicists’ approval. The physicists will make modifications if needed and finalise the plan. The physicists will do Quality Assurance (QA) and are responsible for radiation safety in UK. As there are no separate dosimetrists in India, physicists will do the job of dosimetrists in addition to their job.
The plan approval
The plan approval is done by clinical oncologists in UK and radiation oncologists in India.
Treatment execution
The treatment execution is done by radiographers themselves as per the schedule given to them. The entire treatment process is communicated between the oncologists, dosimetrists, physicists and radiographers through official mail id in UK. In contrast, at least during the first day of execution, the treating oncologist as well as physicists come to the console during the treatment execution in India. There is one to one communication and paper documentation in India. For bladder protocol patients, bladder filling is measured using a portable ultrasound machine (Fig. 2) by the radiographers before the patients are made to lay down in the couch in UK whereas in India, the bladder filling is assessed only using CBCT which causes increased amount of radiation exposure to the patient.
![onco-5-2](https://www.kauveryhospital.com/images/journals/v5i7/onco-5-2.jpg)
Fig. 2.
Portable Ultrasound machine.
Waiting period for starting radiation
The waiting period after investigations is usually 3 -4 weeks in UK except palliative patients as compared to 3-7 days in India although it varies from centre to centre. Cancer Centres in UK follow hypofractionated schedules for radical radiotherapy (2-4weeks treatment) or ultrahypofractionated treatment (1 week) treatment for breast cancer (Fast Forward Protocol).
Replanning
In case the patient needs replanning, it takes nearly a week in UK, whereas in India it is usually done within few days.
Follow up
The follow-up is done by the oncologists in both the countries but it is more meticulous especially in educational institutions in India.
Tumors of the brain
The Royal Hallamshire Hospital, Sheffield treats both benign as well as malignant tumours using Gamma knife (Stereotactic Radiosurgery) in a very precise and effective way. The plan of action meeting occurs in the morning where doctors, physicists, nurses and all the staffs involved in the treatment participate, discuss the treatment plan and executed subsequently.
Research activities
The clinical oncologists and medical Oncologists allocate their time for research in doing trials, analysing data and publishing papers in UK. In India the research activities are more confined to educational institutions.
Conclusion
Each country’s healthcare system has its own merits and demerits. It is worthier to incorporate the merits of one system into the other for better patient care. The things which can be incorporated in India include increasing cancer awareness among the public, National Cancer Screening Protocol for early detection of cancers, improving the community support for cancer patients, establishment of more palliative centres, uniform treatment protocol for cancer nationwide, proper documentation system, establishment of EMR, uniform consent system, providing more sophisticated equipment (like Omni board, abdominal binders, portable ultrasound machine), following proper breath holding techniques, bladder/rectum protocols, more precise execution of treatment and allocating more time for research and clinical trials/audit.
![oncodoc-5-1](https://www.kauveryhospital.com/images/journals/v5i7/oncodoc-5-1.jpg)
Dr. AN. Aswin
Consultant Radiation Oncologist
![oncodoc-5-2](https://www.kauveryhospital.com/images/journals/v5i7/oncodoc-5-2.jpg)
Dr. AN. Vaidyswaran
Director and Senior Consultant, Radiation Oncologist
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- CRT CSP Cases
- Journal scan
- Learning from Experience – Intra Operative, Chapters 25 and 26
- The Consultation Room
- Recommended Readings
- Editorial
- Editorial Board
- Multiple Sclerosis: An overview
- A flower born to blush unseen
- Guest Editorial
- Radio-frequency ablation as an effective treatment strategy in a case of VT storm post STEMI
- Lymphatic malformation of tongue
- Bilateral anterior shoulder dislocation in epilepsy: A case report and review of literature
- An unusual cause of Stridor
- Monoclonal Antibodies (mAbs) – the magic bullets: A review of therapeutic applications and its future perspectives
- Write the Talk
- Press release and Comments
- Probability Distribution of Bernoulli Trials
- Journal Scan
- Recommended Readings
- poem-v4i4
- Editorial
- Editorial Board
- Research
- Research
- Lambda-cyhalothrin and pyrethrin poisoning: A case report
- Good Enough
- The Monoclonal antibodies (mAbs): the beginning
- Comprehensive trauma course 2022: Trauma Management & Kauvery
- Comprehensive trauma course 2022: Introduction to Comprehensive trauma course
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 27 and 28
- The Consultation Room
- Recommended Readings
- Poem
- Editorial
- The Brave New World of Anaesthesia
- Anesthetic considerations in Wilson’s disease for fess: A case report
- The painful story behind modern anaesthesia
- Anesthesia considerations for Ankyslosing Spondylitis
- Total intravenous anaesthesia: An overview
- Risk stratification for cardiac patients coming for non-cardiac surgeries
- The Anaesthesiologist’s role in fluoroscopic guided epidural steroid injections for low back pain
- Awake Craniotomy
- Malpositioned central venous catheter: Step wise approach to avoid, identify and manage
- Benefits outweighing risk: Neuraxial anaesthesia in a patient with Spina Bifida with operated Meningomyelocele
- Pain free CABG: newer horizon of minimally invasive cardiothoracic surgery a walk through anaesthesiologist perspective
- Stellate Ganglion Block: A bridge to cervical sympathectomy in refractory Long QT Syndrome
- Venous Malformation in Upper Airway – Anesthetic Challenges and Management: A Case Report
- Editorial
- USG guided peripheral nerve block in surgery for hernia
- Anaesthesia and morbid obesity: A systematic review
- Patient-Controlled Analgesia
- Parapharyngeal abscess of face and neck: Anesthetic management
- 3D TEE, a boon for the diagnosis of Left Atrial Appendage thrombus!
- Anaesthetic management of difficult airway due to retropharyngeal abscess and cervical spondylosis
- Expect the unexpected – Breach in continuous nerve block catheter
- Lignocaine nasal spray: An easy remedy for Post Dural Puncture Headache
- Potassium permanganate poisoning and airway oedema
- Angioedema following anti-snake venom administration
- Editorial
- Editorial Board
- Ra Fx ablation of Atrioventricular nodal reciprocating tachycardia
- Pace and Ablate Strategy: Conduction system pacing with AV junction ablation for drug refractory atrial arrhythmia – A novel approach
- Why Cardiac Resynchronization Therapy (CRT) For complete heart block? A case discussion
- Pacemakers and Bradyarrhythmias in Diabetic Mellitus
- Outcomes of Total Knee Arthroplasty in patients aged 70 years and above
- An approach to CBC for practitioners
- Acute cerebral sinus venous thrombosis with different presentations and different outcomes: A case series
- Diet and nutritional care for DDLT: A case study
- Vaccine for Dengue (Dengvaxia CYD-TDV)
- Diagnostic Image
- Learning from Experience – Intra Operative, Chapters 31 and 32
- Recommended Readings
- காவிரித்தாய்
- ATLAS OF HAEMATOLOGY AND HEMATOONCOLOGY
- Editorial
- Editorial Board
- Case reports and Case series:
- Usefulness of NEWS 2 score in monitoring patients with cytokine storm of COVID-19 pneumonia
- Treatment approach for extensively Drug-Resistant Tuberculosis (XDR-TB)
- Modified Lichtenstein mesh repair, for a patient of Coronary Artery Disease, Heart Failure and with Implanted Cardioverter- Defibrillator
- Fever-induced Brugada Syndrome
- Pulmonary Thrombo Embolism: When to Thrombolyse?
- Ultra-Short Case Report
- Learning from the failure of Nebacumab
- Journal scan
- Learning From Experience Intra Operative Chapters 29 and 30
- Recommended Readings
- Poem
- Editorial
- Editorial Board
- Heart transplantation: Life beyond the end of life
- Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal
- Medial retropharyngeal nodal region sparing radiotherapy versus standard radiotherapy
- Proximie: Patient safety in surgery – the urgent need for reform
- Analysis of femoral neck fracture in octogenarians and its management
- Adult Immunisation in Clinical Practice: A Neglected Life Saver
- “Icing” The Eyes
- Doppler vascular mapping in Arterio Venous Fistula (AVF)
- Cosmesis and cure: Radiotherapy in basal cell carcinoma of the dorsum of nose – A case report
- Pulmonary Hypertension and Portal Hypertension
- Comprehensive review of Drug-Induced Cardiotoxicity
- Statistics – Data Collection – Case Study Method
- Atlas of Haematology and Hematooncology
- PRE-OPERATIVE Chapters 1 and 2 – Learning from Experience
- Chapter 2. Uncertainties in medicine in spite of advances
- No Splendid Child
- Editorial
- Editorial Board
- A Young Girl Lost in the Storm
- ECMO as a bridge to Transplant: A case report
- Renal anemia – from bench to bedside
- Mission Possible
- New kids on the block – Update on diabetic nephropathy therapy
- Infections – Trade off in Transplants
- To Give Or Not to Give – Primer on Bicarbonate Therapy
- Sialendoscopy: Shifting paradigms in treatment of salivary gland disease
- Gait imbalance in a senior due to Chronic Immune Sensory Polyneuropathy (CISP)
- Statistics – Mcnemar Test
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE Chapters 3 and 4 – Learning from Experience
- Changing trends a challenge to the already trained
- Journal scan
- Recommended Readings
- EDITORIAL
- EDITORIAL BOARD
- PREGNANCY POST-RENAL TRANSPLANT
- BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION
- REVERSE SHOULDER ARTHROPLASTY FOR ROTATOR CUFF ARTHROPATHY
- THE AMBUSH A TEAM APPROACH
- ENDOSCOPIC TRANS-SPHENOID APPROACH FOR PITUITARY ADENOMA EXCISION
- A STUDY ON PRESENTATION AND OUTCOME OF BULL GORE INJURIES IN A GROUP OF TERTIARY CARE HOSPITALS
- A CASE OF INTERNUCLEAR OPHTHALMOPARESIS AS THE FIRST MANIFESTATION OF MULTIPLE SCLEROSIS
- GRANULOMATOSIS WITH POLYANGITIS AND LUNG INVOLVMENT (WEGENER’S DISEASE)
- RITUXIMAB (RITUXAN, MABTHERA) IN THE TREATMENT OF B-CELL NON-HODGKIN’S LYMPHOMA
- STATISTICAL SIGNIFICANCE
- Atlas Of Haematology And Hematooncology
- PRE-OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- Chapter 4: Diagnostic process often reversed
- Journal scan: A review of 25 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- ஆரோக்கியம் நம் கையில்
- வெற்றியின் பாதை
- Editorial
- Editorial Board
- Prevalence of vitamin D deficiency in a multi-speciality hospital orthopaedic outpatient clinic
- Esomeprazole induced Hypoglycemia
- Dynamic external fixator for unstable intra articular fractures of Proximal Interphalangeal Joint (PIP): “Suzuki” frame
- How to Practice Academic Medicine and Publish from Developing Countries? A Practical Guide, Springer Nature, 2022
- WINTNCON 2022 – Scientific Program
- Pulmonary Thrombo Embolism: A state of the art review
- Role of Artificial Intelligence in improving EHR/EMR and Medical Coding and billing
- Monoclonal Antibodies: Edrecolomab and Abciximab
- Atlas of haematology and hematooncology
- Journal scan
- Learning from Experience – Intra Operative, Chapters 31 and 32
- What doctors must learn: Doctor, look beyond science
- Recommended Readings
- I Whisper Secrets In My Ear
- EDITORIAL
- Instructions for Authors
- Mismatched Haploidentical Bone Marrow Transplantation in a 10-year-old boy with relapsed refractory acute lymphoblastic leukemia, at Trichy
- ST-Segment Elevation is not always Myocardial Infarction
- Acyanotic Congenital Heart Disease, repaired, evolves into a Cyanotic Congenital Heart Disease and presents with an atrial tachycardia
- Family medicine – caring for you for the whole of your life. A Lost and Found Art
- The Principles and Practice of Family Medicine
- Complete Heart Block
- Sick Sinus Syndrome (SSS)
- The First Ever National Award Comes to Kauvery Hospital Chennai & Heart City for Safety and Workforce Category in IMC RBNQA Milestone Merits Recognition 2022
- Diagnostic Image
- PRE-OPERATIVE CHAPTERS 7 AND 7 – LEARNING FROM EXPERIENCE
- Chapter 5: Super-specialist – boon or bane
- Journal scan: A review of 42 recent papers of immediate clinical significance, harvested from major international journals
- RECOMMENDED READINGS
- நேரம் ஒதுக்கு
- மருத்துவரின் மகத்துவம்
- EDITORIAL
- Instructions for Authors
- Surgical Management of Covid-19 Associated Rhino-Orbito-Cerebral-Mucormycosis (Ca-Rocm) – A Single Centre Experience
- Knee Joint Preservation Surgeries
- Guest Editorial Comments
- Ventricular Septal (VSR) closure with ASD device
- Newer Calcium Debulking Angioplasty technique of Orbital Atherectomy
- An hour-long CPR to restart the heart
- VT or SVT with aberrancy?
- Pituitary Neuroendocrine Tumor (PitNET)
- VSD Device Closure
- PDA Device Closure
- Iron Deficiency Anemia, Post MVR
- Torsades de Pointes
- Quality improvement project to Reducing the Malnutrition Rate of ICU patients from 43% to 20%
- Long term use of Amiodarone in Cardiac patients: A Clinical Audit
- Statistical Independent Events and Probability
- PERI-OPERATIVE Chapters 9 and 10 – Learning from Experience
- Journal scan: A review of 40 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- Kauverian Medical Journal
- First da Vinci Robotic Surgery in Carcinoma Prostate: A Case Report
- Black burden or Taylor the saviour: A case report
- Analysis of differences in Oncology practice between the United Kingdom and India
- A Case of Takayasu Arteritis
- Idiopathic Dilated Pulmonary Artery (IDPA)
- ECG Atlas
- Unusual cause of Dysphagia: A case report
- Tu Youyou: The scientist who discovered artemisinin
- Continuing Nursing Education (CNE) on Risk assessment tools, to assess vulnerable patients at Kauvery Hospital, Tennur
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 11 AND 12 – LEARNING FROM EXPERIENCE
- OLD AND NEW – MAKE THE BEST OF THE TWO
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- Recommended Readings
- EDITORIAL
- INSTRUCTION TO AUTHORS
- A pregnant patient with DKA, septic shock and a lactate mystery
- Radical Thymectomy in Myasthenia Gravis through Partial Sternotomy approach: A report on three patients
- In-utero blood transfusion in two etiologically distinct anaemic fetus
- RARE CAUSE OF PULMONARY HYPERTENSION
- Acute Rheumatic fever is still an enigma
- A remarkable journey: Managing LQTS in a 43-year-old female with recurrent syncope and seizure
- An unusual case of Acute Coronary Syndrome
- Reversible cause of severe LV Dysfunction in Left Bundle Branch Block
- A case study on Rhino-Orbital-Cerebro- Mucormycosis
- Snakebite and its management
- Total Elbow arthroplasty in Post Traumatic arthritis
- Wellens Syndrome: An ECG finding not to miss!
- Dr. C.R. Rao Wins Top Statistics Award a look back at his pioneering work
- PRE-OPERATIVE Chapters 13 and 14 – Learning from Experience
- Chapter 7. Doctor-patient relationship
- Journal scan: A review of 30 recent papers of immediate clinical significance, harvested from major international journals
- EDITORIAL
- INSTRUCTION TO AUTHORS
- FROZEN ELEPHANT TRUNK (FET) PROCEDURE IN A 52 YEARS OLD CHRONIC AORTIC DISSECTION PATIENT
- DIAGNOSING AND MANAGING EISENMENGER SYNDROME IN A YOUNG MALE
- STEMI EQUIVALENT BUT STEMI!
- TEMPORARY HEAL CAN POSSIBLY KILL!
- UNDERSTANDING PUBERTY
- THE IMPORTANCE OF STATISTICS IN HEALTHCARE
- JOURNAL SCAN: A REVIEW OF 44 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- DIAGNOSTIC IMAGE
- PRE-OPERATIVE CHAPTERS 15 AND 16 – LEARNING FROM EXPERIENCE
- CHAPTER 8. DOCTOR-DOCTOR RELATIONSHIP
- EDITORIAL
- GUEST EDITORIAL
- CLINICAL AUDIT: AN INTRODUCTION
- YOUNG ACS AUDIT
- CLINICAL AUDIT: ANAESTHESIA
- CLINICAL OUTCOME IN ICU PATIENTS
- RATE OF MALIGNANCY IN INDETERMINATE OVARIAN CYST – A PROCESS AUDIT
- PATTERNS OF NEEDLE DISPOSAL AMONG INSULIN USING PATIENTS WITH DIABETES MELLITUS: AN AUDIT
- CONTINUOUS PATIENT MONITORING – LIFE SIGNS
- AGE IS JUST A NUMBER!
- SVT WITH LEFT BUNDLE BRANCH BLOCK FOLLOWING GASTRECTOMY
- COMPLEX AORTIC DISSECTION WITH MULTIFACETED CLINICAL PRESENTATIONS
- EDITORIAL
- POST-OPERATIVE SORE THROAT IN GA: A CONCERN
- NEONATAL HLH: OUR EXPERIENCE
- CLINICAL REVIEW MEET 16TH NOV 2023: CHALLENGES IN SETTING UP A NEW HSCT CENTRE IN A TIER-2 CITY IN INDIA
- CARDIAC BIOMARKERS: CLINICAL UTILITY
- HIRAYAMA DISEASE: A CLINICAL-RADIOLOGICAL REVIEW
- ECG AS A WINDOW OF OPPORTUNITY: FOR HYPERKALEMIA
- EFFECTIVENESS OF ROOD’S APPROACH BASED PAEDIATRIC OCCUPATIONAL THERAPY MANAGEMENT: ON CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS
- ELTROMBOPAG, A NOVEL THROMBOPOIETIN (TPO) RECEPTOR AGONIST: AN OVERVIEW
- HENOCH-SCHONLEIN PURPURA
- SUBMANDIBULAR GLAND SIALADENITIS SECONDARY TO SUBMANDIBULAR CALCULUS
- LEAN HOSPITALS
- STATISTICS BLACK-SCHOLES MODEL
- PERI-OPERATIVE CHAPTERS 17 AND 18 – LEARNING FROM EXPERIENCE
- CHAPTER 9. BUILDING BLOCKS OF PATIENT CARE
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
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- ROTATHON-SERIES OF SUCCESSFUL ROTA CASES LAST 2 MONTHS: AN AUDIT
- OUTCOMES OF AKI AUDIT IN KAUVERY
- ETIOLOGY, CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH ACUTE PANCREATITIS IN KAUVERY CANTONMENT HOSPITAL (KCN), TRICHY
- USE OF BLOOD PRODUCTS AND STEROIDS IN THE MANAGEMENT OF DENGUE AT KAUVERY TRICHY HOSPITALS: A CLINICAL AUDIT
- A CLINICAL AUDIT: ON THE MANAGEMENT OF ECTOPIC PREGNANCY
- DIABETIC KETOACIDOSIS WITH HIGH ANION GAP METABOLIC ACIDOSIS
- HYPOKALEMIC PARALYSIS FROM DISTAL RENAL TUBULAR ACIDOSIS (TYPE-1)
- DELAYED PRESENTATION OF INTERMEDIATE SYNDROME IN A PATIENT WITH ORGANOPHOSPHORUS POISONING: A CASE REPORT
- SCAPULA FRACTURES: DO WE NEED TO FIX THEM?
- SPONTANEOUS CSF RHINORRHEA
- DANCING WITH DIABETES: AN UNUSUAL CASE OF CHOREA HYPERGLYCEMIA BASAL GANGLIA SYNDROME
- CONVALESCENT RASH OF DENGUE
- ECG ATLAS 2
- MI MIMICKER
- PERFORATION PERITONITIS-A CASE REPORT
- APPLICATION OF EVIDENCE BASED PRACTICE CARE FOR INDIVIDUALS WITH SPINAL CORD INJURY WITH FUNCTIONAL DIFFICULTIES: ROLE OF THE OCCUPATIONAL THERAPY PRACTICE GUIDELINES
- METHOTREXATE INDUCED MUCOSITIS AND PANCYTOPENIA: A CONSEQUENCE OF MEDICATION ERROR IN A PSORIASIS PATIENT
- POST OPERATIVE CHAPTERS 1 AND 2 – LEARNING FROM EXPERIENCE
- CHAPTER 10. NURTURING SELF
- விடாமுயற்சி வெற்றி தரும்
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- EDITORIAL
- EDITORIAL BOARD
- LIMB SALVAGE IN EXTREMITY VASCULAR TRAUMA: OUR EXPERIENCE
- MANAGEMENT OF URETHRAL CATHETER RELATED PAIN IN RENAL TRANSPLANT RECIPIENTS: A CLINICAL AUDIT
- NO PAIN VEIN GAIN WITH PRILOX IN PAEDIATRIC POPULATION
- GUIDELINE-DIRECTED MEDICAL TREATMENT (GDMT) OF HEART FAILURE AT KAUVERY HOSPITALS: A CLINICAL AUDIT
- PATIENTS STORY: DIGNITY MATTERS
- PATIENTS STORY: DIGNITY MATTERS
- VIDEO PRESENTATION- CT CORONARY ANGIOGRAPHY
- DRUG INDUCED HYPERKALEMIA
- ADULT NEPHROTIC SYNDROME
- EXPLORING COMPLEX CARDIAC CASES: INSIGHTS FROM DIVERSE PRESENTATIONS IN MID-AGED WOMEN
- EFFECTIVENESS OF ACTIVITY CONFIGURATION APPROACH BASED OCCUPATIONAL THERAPY INTERVENTION FOR CHILDREN WITH CONGENITAL MUSCULAR TORTICOLLIS: A CASE STUDY
- CARDIOMYOPATHY AND ITS ECHO FINDINGS
- THE STRESS TEST ON THE TREADMILL
- POST OPERATIVE CHAPTERS 3 AND 4 – LEARNING FROM EXPERIENCE
- CHAPTER 11. BALANCE IN LIFE BEYOND BANK BALANCES
- JOURNAL SCAN: A REVIEW OF 30 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காணும் பொங்கலும் மனித மன மாற்றமும்
- EDITORIAL
- INSTRUCTIONS TO AUTHORS
- PREVALENCE OF STREPTOCOCCUS PNEUMONIAE SEROTYPES IN AND AROUND TRICHY AND ITS CLINICAL RELEVANCE
- ANAESTHETIC MANAGEMENT OF A PATIENT WITH HUGE GOITER: A CASE REPORT
- EUGLYCEMIC DIABETIC KETOACIDOSIS A RARE CAUSE FOR DELAYED EXTUBATION
- SUCCESSFUL PREGNANCY IN ASD PATIENT – COMPLICATED BY SEVERE PULMONARY ARTERIAL HYPERTENSION
- ENDOCRINE COMPLICATION OF GROWTH HORMONE SECRETING TUMOR: A CASE REPORT
- EFFICACY OF EARLY DIAGNOSIS AND DEVELOPMENT APPROACHES OF PAEDIATRIC OCCUPATIONAL THERAPY ON ACUTE DISSEMINATED ENCEPHALOMYELITIS: A CASE REPORT
- POST OPERATIVE CHAPTERS 5 AND 6 – LEARNING FROM EXPERIENCE
- CHAPTER 12. MILES TO GO – BEFORE TEACHING BECOMES LEARNING
- JOURNAL SCAN: A REVIEW OF 26 RECENT PAPERS OF IMMEDIATE CLINICAL SIGNIFICANCE, HARVESTED FROM MAJOR INTERNATIONAL JOURNALS
- காவேரி – 25
- POEM – மண்ணில் பிறந்தது சாதிப்பதற்குத்தான்