Indian Journal of Critical Care Medicine May 2014 Vol 18 Issue 5

only ICUs available for the majority of the population) are very different and merit discussion here.

challenging, stressful situations. However, I can’t imagine getting myself burnt out - given the fact that my work earns for me such divine satisfaction that money can never buy.

Number of patients deserving intensive care exceeds the capacity of ICUs at all times of the year. Managing patients here pose a huge challenge of triage, resource allocation, and financial constraints. In these units, which are practically managed by resident doctors are often poorly staffed with limited availability of ventilators, monitors, and trained nurses.

Himmatrao Saluba Bawaskar

Department of Medicine, Bawaskar Hospital and Clinical Research Center, Mahad, Raigad, Maharashtra, India

Correspondence: Dr. Himmatrao Saluba Bawaskar, Bawaskar Hospital and Clinical Research Center, Mahad, Raigad - 402 301, Maharashtra, India. E-mail: [email protected]

References

Pressure from politicians insisting on ICU admission for some patients adds to the tremendous work stress already faced by doctors here. This many times lead to situations where ICU bed remains occupied by moribund patients, while admission is denied for completely treatable young victims of serious tropical infections such as malaria, dengue, and leptospirosis. This creates a sense of guilt and frustration that potentially affects the working capacity of the resident doctors.

1. 2.

Guntupalli KK, Wachtel S, Mallampalli A, Surani S. Burnout in the intensive care unit professionals. Indian J Crit Care Med 2014;18:139-43. Divatia JV. Burnout in the ICU: Playing with fire? Indian J Crit Care Med 2014;18:127-8.

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Private hospitals can enjoy the freedom of keeping affording patients and referring terminally ill and complicated cases to the government ICUs. Resulting high mortality rate can be very demoralizing for a young physician who is about to start his career as internist.

DOI: 10.4103/0972-5229.132514

2009 pandemic influenza A (H1N1) infection in Saurashtra region, India

Apart from physical exhaustion, this emotional exhaustion may also underlie the high incidence of life-threatening medical problems ranging from drug-resistant tuberculosis to premature coronary artery disease in medical professionals. This has already taken a significant toll of young medical workforce in India.

Sir, The previous report on “2009 pandemic influenza A (H1N1) infection in Saurashtra region, India” by Chudasama et al is very interesting.[1] In that report (n = 274), they concluded that “delayed referral from general practitioner/physician, duration of antiviral treatment, and presence of coexisting condition (especially pregnancy) were responsible for intensive care or mortality in patients of severe influenza A (H1N1) illness.[1]” Of interest, Chudasama et al. have just reported another article in J Family Med Prim Care (n = 511) and came to a similar conclusion.[2] Although, the second study might confirm the finding in the first report, it seems that it might be a kind of self-plagiarism. It should also be noted that Chudasama et al. also studied the same group of subjects (n = 274) and published the report in Lung India, but concluded differently that “pregnancy is found as a significant (P < 0.05) risk factor for severe disease.[3]” It should be questioned on what the exact conclusion should be and whether these publications are salami publications.

High incidence of premature coronary artery disease is well-known in physicians, cardiologists, and cardiac surgeons and is often attributed to the work stress. The origin of this may lie in the “work-satisfaction dissociation” that is, increasing day by day due to corporate involvement in the health sector. Doctors working in these set ups have “pressure to perform” not in the best interest of the patient, but for profit of the hospital. This has already replaced the gratifying experience of “healing our patient” by unhealthy competition, serious ethical violations and resulting burn out not only impairing delivery of healthcare, but also harming physicians' own health. Working as a physician in remote areas of Maharashtra since last 37 years of my career, treating life-threatening tropical emergencies without access to modern ICU gadgets, counseling grieving families, researching on the rural health problems – I had often times encountered 83

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Indian Journal of Critical Care Medicine May 2014 Vol 18 Issue 5

And objective of the study was stated to be – “objective of this study was to identify characteristics associated with severity of disease in 511 confirmed cases of pandemic H1N1 influenza, in various hospitals of Rajkot city of Saurashtra region from two waves of pandemic influenza A (H1N1) – the first wave from September 2009 to March 2010, and second wave from June 2010 to January 2011". This clearly mentions that data analysis is from two waves reported in different time frames with n = 511. The study mentions the characteristics observed for both waves. How can it be a plagiarism or salami publication if the study objectives, patient numbers and findings are different?

Beuy Joob, Viroj Wiwanitkit1,2,3

Sanitation1 Medical Academic Center, Bangkok, Thailand, 1Hainan Medical University, China, 2Faculty of Medicine, University of Nis, Serbia, 3 Joseph Ayobabalola University, Nigeria

Correspondence: Dr. Beuy Joob, Sanitation1 Medical Academic Center, Bangkok, Thailand. E-mail: [email protected]

References 1.

2.

3.

Chudasama RK, Verma PB, Amin CD, Gohel B, Savariya D, Ninama R. Correlates of severe disease in patients admitted with 2009 pandemic influenza A (H1N1) infection in Saurashtra region, India. Indian J Crit Care Med 2010;14:113-20. Chudasama RK, Patel UV, Verma PB. Characteristics of hospitalized patients with severe and non-severe pandemic influenza a (H1N1) in Saurashtra Region, India (Two Waves Analysis). J Family Med Prim Care 2013;2:182-7. Chudasama RK, Patel UV, Verma PB, Amin CD, Savaria D, Ninama R, et al. Clinico-epidemiological features of the hospitalized patients with 2009 pandemic influenza A (H1N1) virus infection in Saurashtra region, India (September, 2009 to February, 2010). Lung India 2011;28:11-6.

In reference to third study published in Lung India mentioned in the letter, we would like to clarity that the objective of the study was – “the clinicoepidemiological characteristics of patients who were hospitalized with 2009 influenza A (H1N1) infection in Saurashtra region”. We have not tried any comparison, which we have presented in the first study though the data set was same. It is very clear from the objective that we have analyzed only the clinicoepidemiological characteristics of all patients admitted (n = 274) during the first wave and so how can it be a plagiarism or salami publication?

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DOI: 10.4103/0972-5229.132516

We are thankful to author (s) of the letter submitted for reading our articles with such an interest, but we cannot accept that it is a type of plagiarism or salami publication considering the above explanations. From one article, we show various facets of an issue to better understand the disease condition and in other the severity of the disease. Scientific articles in the journal have a limit to show all details of data set, and it may require another publication to show another detail from the same data set.

Author’s Reply Sir, In reference to first study published in Indian Journal of Critical Care Medicine mentioned in the letter, we would like to state that the objective of the study were very clear – “Factors associated with severe disease were determined by comparing with nonsevere cases”. Considering the objective of the study, we have described the findings as those have severe disease and those who do not having severe disease and we have not made manipulation in the presentation of the data. The whole data were presented for the first wave (n = 274) with its distribution and description as per the objective.

Rajesh K. Chudasama, Pramod B. Verma, Chikitsa D. Amin, Bharat Gohel, Dinkar Savariya, Rakesh Ninama Department of Community Medicine, Government Medical College, Rajkot, Gujarat, India

Correspondence: Dr. Rajesh K. Chudasama, Vandana Embroidary, Mato Shree Complex, Sardar Nagar Main Road, Rajkot - 360 001, Gujarat, India. E-mail: [email protected], [email protected]

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In reference to the second study published in the Journal of Family Medicine and Primary Care mentioned in the letter, we would like to clarify that the title indicated comparison of two waves of the epidemic. – “Characteristics of hospitalized patients with severe and nonsevere pandemic influenza A (H1N1) in Saurashtra region, India (two waves analysis)”. 338

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