ICMR BULLETIN VOL. 28-No.-8-JULY-1998
Item
- Title
- ICMR BULLETIN VOL. 28-No.-8-JULY-1998
- extracted text
-
ISSN 0377-4910
ICMR
BULLETIN
Vol. 28, No. 7
July, 1998
NUCLEAR MEDICINE PRACTICE AND RADIATION DOSES TO PATIENTS
IN INDIA : I. STATUS OF NUCLEAR MEDICINE IN THE COUNTRY
In modem clinical practice and medical research,
exposures to ionizing radiation are inescapable as they
help to provide new insights into the functions of body
fabric both in health and disease. Radiation exposures in
medicine are predominantly to the individual undergoing
diagnosis, screening or therapy. Except in radiotherapy,
it is not the aim to deliver a dose of radiation to the patient,
but rather to use ionizing radiation to provide diagnostic
information. Nevertheless, the radiation dose is given
deliberately and it cannot he reduced indefinitely without
prejudicising the intended outcome. The detrimental
effects of such radiation are well documented1-4. Although
the exposures in diagnostic radiology are far greater due
to rapid growth in recent times, the practice of nuclear
medicine also contributes significant doses to the patient
population5’6. Information on many aspects of nuclear
medicine practice for a large number of countries (mainly
countries of higher health care-category I) is available.
For India, despite the fact that nearly all types of in vitro
and in vivo programmes including basic research and
patient service are being carried out in major
metropolises, and excellent nuclear medicine facilities
exist that are at par with the rest of the world, yet authentic
data on the type and frequency of nuclear medicine
investigations and on the resultant radiation dose, are very
sparse. Further, the frequency and total medical
irradiation is expected to increase over the next decades
due to the growth of population and urbanization
particularly in countries like India. Such a deficiency or
lack of data was also pointed out in the earlier report of
the United Nations Scientific Committee on the Effects
of Atomic Radiation (UNSCEAR 1988)5. To supplement
the available data on medical radiation exposure statistics,
UNSCEAR* undertook a survey in 1990-91 of medical
radiation usage and exposures world-wide. Due to the
efforts initiated by the Division of Radiological
Protection, Department of Atomic Energy, Government
of India, some useful and much needed information was
provided for the Indian scenario (UNSCEAR 1993)6;
however, it was far from adequate7. Keeping in view the
deficiency of the data and its necessity in health planning
in the co.untry, the Indian Council of Medical Research
sponsored a project on Nuclear Medicine Practice and
Radiation Doses to Patients in India with the objectives
to (i) compile data on various aspects of nuclear medicine
practice in the country with the help of a broad based
questionnaire; (ii) estimate effective dose (that reasonably
reflects the health risk associated with radiation
exposures) due to some selected and widely used nuclear
medicine investigations carried out in the country; and
(iii) transform these estimated radiation effective doses
(that are true for an ICRP reference man that is; a
Division of Publication & Information, ICMR, New Delhi -110029
Caucasian and a Western European or North American
in habitat and customs) to an average Indian.
Table I : The cities where four or more nuclear medicine centres/
clinics are.located (data upto 1996).
The findings of this study will be presented in a series
of articles. This write-up provides information collected
with reference to the first pbjecting of the study.
City
Nuclear inedicine is that field of medical practice in
which unsealed radioactive substances are used for
diagnosis, therapy and clinical research. Diagnosis that is
l. major part of this discipline involves two approaches
viz (i) in vivo studies in which radioactive substances are
administered to the patient either to evaluate the
functioning of an organ or to provide an image of it and
employs, as a rule, radionuclides with short half lives.
Information on the amount of radioactivity employed in
various diagnostic nuclear medicine procedures carried out
at different centres in the country, and the resultant
radiation doses to patients was collected; (ii) in vitro
methods, in which body fluids or tissues are analysed by
radioimmunoassay or allied techniques. In these methods,
radioactive substances are not administered to the patient
and therefore do not contribute to his/her radiation dose.
However, being important constituent of nuclear medicine
procedures, information on this aspect of nuclear medicine
was also collected.
Data Collection
Basic information on the nuclear medicine centres of
the country was collected using a broad based, closed ended
and exhaustive questionnaire. It was designed to elicit
information on the nature and structure of the nuclear
medicine centres, their staffing pattern, types of available
instrumentation and investigations carried out, nature and
amount of radioactive material used in each investigation,
the existing radiation protection, human resource
development as well as waste disposal system. Information
was also solicited regarding the gender and age distribution
of the patients. The questionnaire was sent repeatedly to
the heads of various nuclear medicine centres, and was
also published twice in the Indian Journal of Nuclear
Medicine8,9.
Nuclear Medicine Centres
A total of 120 centres or clinics situated in 45 cities
were stated to be functioning where in vivo and in vitro
nuclear medicine was practiced, however, only 102 centres
could be contacted. It was observed that although such
centres/clinics were located through out the country, their
spatial distribution was very uneven. Slightly less than half
the centres were located in Mumbai, Calcutta, Delhi and
Chennai. Table I gives the list ofcities where four or more
nuclear medicine centres/clinics are located.
64
Number of nuclear
medicine centres
% of the total
centres
Mumbai
17
16.7
Calcutta
13
12.7
Delhi -
11
ib.o.
Chennai
7
6.9
Cuttack
5
5.0.
Hyderabad
5
5.0
Chandigarh
4
4.0-
Bangalore
4
4.0'
Other cities(32)
36
35.2
Of the 102 centres contacted, 58 situated in 28 cities
responded. These centres were well distributed through
out the country. Of these, 14 were government institutions,
19 were government aided and the rest (25) were in the
private sector. Chronological analysis of this limited data
was suggestive of the trend that in recent times, growth of
private medical institutions with nuclear medicine facili
ties had been faster in comparison to either government
aided or government hospitals, however, the possibility of
a better response selectively from private centres could
not be ruled out. In the event that, this conclusion is con
firmed on further studies and taking cognizance of the fact
that most such medical institutions do not have a full time
radiological safety officer on the staff, the apprehension,
that under excessive patient load and working stress, ra
diation safety may be compromised, should be considered
seriously. This apprehension was confirmed by a recent
incident which occurred in one of the fairly large hospi
tals situated in the capital.
The available data showed that at 23 medical institu
tions (mostly in metropolises), independent nuclear medi
cine departments were carrying out the work. The patient
is seen directly or is referred by other departments and
hospitals foLspecial investigations. In all such places, the
department was headed by a professor or a consultant and
on an average there were 7 persons (5-11) in the depart
ment. The average investigations carried out at these places
were 1100 (500-1600) per month. At 20 other places, the
departments were part of the radiotherapy and oncology,
radiology, pathology or medicine departments. The depart
ments headed by an associate professor or a consultant
had on an average 4(3-6) persons and each gave service to
about 450 patients per month. The remaining 15 centres
(or clinics) were manned either by a single trained person
or by one whole time trained clinician and one or two part
time workers and each clinic, it was claimed, provided
service to about 200 patients per month.
In vivo investigation for thyroid disorders were carried
out at all the centers - small or large. More than 50% of
thyroid investigations were carried out using reactor
produced radioactive iodine (Iodine - 131). In 26 centres
(mostly in metropolises) the use of Iodine-131 has
progressively decreased and due to many attractive
features, most of such and other investigations are carried
out using Technetium-99m and Technetium-99m based
radiopharmaceuticals. In the centers for which the
information was available, 87% of nuclear medicine in
vivo investigations were carried out using Iodine-131 and
Technetium-99m based radiopharmaceuticals. The other
isotopes used at these centers for in vitro and for other
clinical/research activities were Chromium-51, Thallium201, Iodine-125, Phosphorus-32 Gallium-67 and Selenium75. Thallium-201 and some Technetium-99m based
radiopharmaceuticals for renal and cardiac studies were
imported and the rest of the radioactive substances and
radiopharmaceuticals were procured from local sources.
None of the centres provided information on the use of
Indium-111 although application of the radionuclide has
been mentioned in a few publications. Organ imaging
which accounted for more than 85% of administration of
radioactive material to patients was a routinely performed
investigation in the country. The most frequent
radioimaging procedures that are being carried out in the
country are for the thyroid (59%), kidneys (13%), heart
(9%), bones (6%), brain (4%), liver and blood vessels (3%
each) and lungs, GIT tumours/abscesses (1% each). Data
obtained on in vitro studies were not adequate except to
demonstrate that radioimmunoassay tests pertaining to
thyroid disorders were far greater in number in comparison
to other investigations.
Instrumentation
As per information, 75 gamma cameras and gamma
cameras with single photon electrical computer
tomography (SPECT) facilities were operating in the
country, however, detailed information could be obtained
for 45 gamma cameras and gamma cameras with SPECT
facilities that were located in 21 centers. Besides thyroid
disorder investigations, renal function tests, cardiac
function studies, bone scanning and hepatobiliary and
pulmonary investigations were also performed. Here the
consumption of unsealed radioactive substances at each
centre exceeded 500 mCi per month. The dose to a patient
was so calculated that the dose per kg body weight
remained more or less constant. At 17 places only thyroid
disorders studies and renal function tests were carried out
using rectilinear scanner and thyroid uptake system. Here
the consumption of radioactive material was between 100500 mCi per month at each centre. At the remaining 18
centres, the patient investigations were confined to thyroid
disorders and the activity of radionuclide varied from 2-6
mCi per month at each center. At all the centres in vitro
tests were carried out using the standard radioimmunokits supplied either by Board of Radiation and Isotope
Technology (BRIT) or by other companies.
Despite the fact that the Electronic Corporation of India
Ltd (ECIL) has been functioning for the last three decades
and has the mandate to develop and market nuclear
medicine instruments in the country, yet its market
presence for such instrumentation is very small. Most of
the instruments used in private hospitals for clinical
investigations, were imported. In all the places such
instruments were placed in air conditioned areas. Quite a
few government hospitals and government aided hospitals
had imported as well as indigenous equipment. Regarding
the equipment, the general complaint had been that (i) the
supply schedule was hardly maintained and the instrument
never became functional in time, and (ii) service facilities
(except in a very few selected cities) were generally not
good.
On account of the stringent stipulations of the Direc
torate of Radiation Protection, Bhabha Atomic Research
Center, Mumbai, at all the places for which data were avail
able at present, a good radiation protection system was
operational. Each centre that responded had at least one
person trained in radiation protection procedures and was
covered under Thermo-luminiscence Dosimetry (TLD)/
Film Badge type personnel monitoring. In addition, the
centres had survey meters, contamination monitor, ad
equate waste disposal system and facilities required to meet
radiation emergencies. However, the in-house training
programmes were not very popular. The lack of such
programmes affects radiation hazard awareness of the
workers and perhaps might be one of the causative factors
for the radiation incident that occurred in one such centre
in the capital.
In all, based on 6 radionuclides, 20 radiopharma
ceuticals were being used in the country (Table II). At 13
places radiopharmaceuticals were prepared at the centre
sites and some preparations were imported for medical
and clinical research. Thallium-201 and some Technetium-99m based radiopharmaceuticals for renal, cardiac
and cerebral studies were invariably imported. At the
other places, radioactive diagnostic agents were procured
’65
from the Regional Radiopharmaceutical Centers of the
BRIT, Department of Atomic Energy or directly from
BRIT.
131 I-Sodium Iodide
99mTc-large colloid (sulphur colloid)
which the information was available, had good radiation
safety facilities for patients as well as for staff. Most of
the centres used imported instruments and indigenous
radiopharmaceutical preparations. None of the centres
provided any worthwhile data on the distribution of patients
as a function of age, sex and socio-economic status.
References
99m Tc pertechnetate
99mTc DMSA
1.
99m Tc DTPA
99mTc IDA
99m Tc glucohaptonate
51CrEDTA
National Academy of Sciences. Health Effects ofExposure to Low
Levels ofIonizing Radiation. BEIRV. Report National Academy
Press, Washington, DC 1990.
99m Tc HAS
99mTcHMPAO*
2.
99m Tc phosphonate
67 Ga citrate*
Report ofthe National Institutes ofHealth Ad Hoc Working Group
to Develop Radioepidemiological Tables. NIH Publication No.
85-2748. US Department of Health and Human Services, Wash
ington DC 1985.
3.
Upton, A.C. Risk estimates for carcinogenetic effects of irradia
tion . Ann ICRP 22: 1,1991.
4.
Smith, H. The detrimental health effects of ionizing radiation. Nucl
Med Commun 13(4): 10, 1992.
5.
UN SC EAR. Sources, Eeffects and Risks of Ionizing Radiation.
Report to the General Assembly with Annexes. United Nations,
New York, 1988.
6.
UN SC EAR. Sources and Effects ofIonizing Radiation. Report to
the General Assembly with Annexes. United Nations, New York,
1993.
7.
Gupta, M.M., Nagaratnam, A., Jain, S.C. and Reddy, AR. Nuclear
medicine practice and radiation exposure therefrom : A synoptic
view of world-wide scenario (summary of UNSCEAR1993 data)
Indian J Nucl Med 10: 145, 1995.
8.
Gupta, M.M. Questionnaire to gather information about NM
facilities in India. Indian J. Nucl Med 8: 118, 1993.
9.
Gupta, M.M. Questionnaire to gather information about NM
facilities in India. Indian JNucl Med 10:227, 1995.
Table II: Radiopharmaceuticals used in the country (data upto
1996)
131-I-hippuran
99m Tc MAG3*
201 T1 chloride
99m Tc M1BI*
99m Tc MAA
75 Sc methionine*
99m Tc RBC
99m Tc denatured RBC
♦ Use of these radiopharmaceuticals was restricted to only a few cen
tres due to their limited availability and prohibitive cost
Conclusions
About 35,000 nuclear medicine in vivo investigations
were being carried out per month at 58 centres located in
28 cities in the country, with slightly less than 50% of
them being located in the four metropolises. Examination
pertaining to thyroid disorders were carried out by all
centres, however, in the metropolises, excellent facilities
existed or were being build up to cahrry out the full
spectrum of in vivo and in vitro nuclear medicine
investigations. There appeared to be a rapid expansion of
the facilities in the private sector. All the centres about
(To be contd.)
©
ABSTRACTS
Some Research Projects Completed Recently
Effects of apolipoprotein E polymorphism on the
lipid and lipoprotein levels related to risk for car
diovascular disease.
The study was carried out on unrelated individu
als ofKshatriya (182) and Mala (3 8) communities from
Andhra Pradesh to identify the apolipoprotein (apo) E
genotypes and allele frequencies in these population.
Among the Kshatriya, five apo E genotypes (3/3, 3/4,
3/2, 4/2 and 4/4) were observed in males and (3/3, 3/4
66
and 3/2) in females. But in Mala population only three
genotypes (3/3, 3/4 and 3/2) were observed in both the
sexes. There was no significant gender differences in the
frequencies of apo E genotypes in both the populations
as well as between two population groups. The 4/2 and
4/4 genotypes were found to be less frequent and observed
only among 2 individuals each (missing in female
Kshatriya and both sexes in Mala). The gene frequencies
of the three alleles designated apo £ 2, E 3 and S 4 for
the Kshatriya (male and female pooled together) were
0.0522,0.8516 and 0.0962 and for Maias 0.0395,0.9210
and 0.0395 respectively. Gene frequencies.for three alle
les for the pooled population of Kshatriya and Maias were
0.0500, 0.8636 and 0.0864 respectively.
In the apo E genotypes, the apo E4 homo or
heterozygotes showed higher levels of cholesterol
compared to other genotypes. The influence of each of
the three common apo E alleles (E2, E3, E4) on
cholesterol and HDL cholesterol levels was evaluated
by the test o f average allelic effects. The E 2 and E 4
alleles showed lowering and elevating effects respectively
on cholesterol levels. But there was no evidence for a
consistent relationship between apo E genotypes and
HDL cholesterol. The study also supports the
assumption that lower E 4 frequency may be associated
with lowered risk of cardiovascular disease in rural
population.
P. Venkatramana
P. Chengal Reddy
Deptt. of Anthropology
S.V. University
Tirupati.
Study of the natural history and seizure outcome
in patients with solitary cysticercus granuloma and
seizure.
A prospective study was carried out in 183 patients
with seizures to determine the natural history of soli
tary cerebral cysticercus granuloma (SCG) and seizure
outcome after the resolution of the granuloma and si
multaneous or early withdrawal (2 to 3 months after
resolution) of antiepileptic drugs. Only those patients
who fulfilled all the diagnostic criteria (clinical and
computerised tomographic for SCG) were included in
the study.
One hundred and twenty nine (70.5%) patients
presented with partial seizures with or without
secondary generalization, 53 (29%) with generalized
seizure and 1 (0.5%) with partial complex seizure. Of
these, 78.1% patients had 5 or less seizures, 16.9%
had 6-10 and 4.9% >10 seizures at initial presentation.
Most of the patients had their initial CT scan within
one month of their first ictus. Majority (93%) of
patients.could be managed with a single antiepileptic
drug (monotherapy). Breakthrough seizures occurred
in 30 (16.4%) patients who needed increased dose of
the drug or an additional drug.
ELISA for cysticercus antibodies in serum was of
limited value as it was found to be negative in a
majority of patients. The CT lesions were typically
between 5-15 mm in maximal dimension and were
usually associated with mild to moderate oedema. The
parietal lobe was the most favoured site of lodgement
of the granuloma.
SCG was found to have a varied natural history
and the granulomas resolved spontaneously though at
different rates in individual patients. Kaplan Meier
analysis of lesion resolution in the present study
showed that at 3 months after first CT scan, 96.7%
patients had persistent granulomas (though smaller in
size in nearly 40% patients), at 6 months 75.5%
patients and even after 12 months 46.5% patients had
persistent granulomas.
The shortest period recorded for the resolution of
lesion was 64 days after the initial CT scan whereas
the longest duration of a persistent lesion seen in the
CT scan was 429 days. Antiepileptic drugs were
withdrawn within 2-3 months, after resolution of
granuloma was seen on the CT scan. Of the 60 patients
who could be followed up after withdrawal of the drugs
(median follow up period 10 months), 57 were
symptom- free, and recurrence of seizures was noted
in 3 patients at 3 to 10 months after withdrawal of
drugs.
It can be concluded that SCG, a common cause of
seizures in Indian patients, is a spontaneously resolving
lesion with a variable rate of involution ranging from
weeks to a year or more. The first follow up CT scan
can be delayed for up to 6 months to decrease the
number of scan examinations. Patients with SCG
generally have a benign seizure prognosis and the
antiepileptic drugs can be withdrawn after resolution
of granuloma. However, a longer follow up is necessary
to arrive at a definite conclusion regarding the long
term seizure outcome in these patients.
V. Rajshekhar
Department of Neurosurgery
. Christian Medical College
Vellore
67
ICMRNEWS
Meetings of the Project Review Committee (PRC)/Task
Force (TF) held at New Delhi:
PRC on Oncology and Pathology
June 30,1998
TF on Control Programme for
Thalassaemia by Antenatal
Screening
July 13, 1998
Participation of ICMR Scientists in Scientific Events:
Dr. A. Roy Chowdhury, Dy. Director, Regional Occu
pational Health Centre, Calcutta, participated in the XXV
National Work Medicine Conference at Strasbourg (June
23-26,1998).
Dr. Srikanth Tripathy, Asstt. Director, National AIDS
Research Institute, Pune, and Dr. M.A. Khan, Sr. Research
Officer, Institute of Cytology and Preventive Oncology,
New Delhi, participated in the XII World AIDS Confer
ence at Geneva (June 28 - July 3, 1998).
Dr. K. Satyanarayana, Director and Dr. B.V. Babu, Sr.
Research Officer, Regional Medical Research Centre,
Bhubaneswar and Dr. K.D. Ramaiah, Sr. Research Officer,
Vector Control Research Centre, Pondicherry, participated
in the data analysis meeting of the UNDP/World Bank/
WHO Special Programme for Research and Training in
Tropical Diseases, on community directed treatment of
filariasis (Phase I studies) at Pune (July 10-18, 1998).
ICMR AIDED SYMPOSIA/SEMINARS/WORKSHOPS/COURSES/CONFERENCES
Symposium/Seminar/Workshop/
. Course/Confe rence
Date & Place
Contact Address
International Symposium on Frontiers of Genetics and
Development
July 7-8, 1998;
(at Bangalore)
Dr. U. Vijayaraghavan, Convenor of the Sympo
sium, Department of Microbiology and Cell
Biology, Indian Institute of Science, Bangalore560012.
Internationa! Symposium on Temporomandibular Joint
Disorders and Chronic Orofacial Pain
October 30-31, 1998;
(at Mangalore)
Prof. P.K. Dayal, Organising Secretary of the Sym
posium, KMC College of Dental Surgery, Mangalore-575001.
Symposium on Current Trends in Autoimmune Diseases
Immunology
October 30-31, 1998;
(at Lucknow)
Prof. S. Naik, Department of Immunology, Sanjay
Gandhi Postgraduate Institute of Medical Sciences,
Lucknow-226014.
COUNCIL’S TRAINING PROGRAMMES FOR 1998-99
Leprosy
Reproductive Biology
At the Central JALMA Institute for Leprosy, Agra:
At the Institutefor Research in Reproduction, Mumbai:
•
Multidrug Therapy Orientation Course in Leprosy for
Medical Officers (August 17-28, October 26November 6; and December 7-18,1998).
Virology
At the National Institute of Virology, Pune:
•
68
Diploma in Medical Virology (July 1998-May 1999).
•
Workshop on Andrology for Clinicians (November 1630,1998)
Endocrinology
At the National Institute of Nutrition, Hyderabad:
•
Annual Certificate Course on Endocrinological Tech
niques and their Applications (August 1-September
15, 1998).
Nutrition
Biomedical Statistics
At the National Institute of Nutrition, Hyderabad:
At the Institutefor Research in Medical Statistics, Chennai:
•
Postgraduate Certificate Course in Nutrition
(December 1,1998-February 28,1999).
•
Basic Course in Statistics for Postgraduate Medical
Students (July 1998).
•
Basic Course in Statistics for Medical Officers
(November 1998).
Occupational Health
At the National Institute of Occupational Health,
Ahmedabad:
•
Training Course on Environmental Hygiene Practice
(November 16-20, 1998).
Medical Entomology
Haematology
At the Institute of Immunohaematology, Mumbai:
•
Training Course in Transfusion Medicine for Blood
Bank Medical Officers (August 11-October 9, 1998).
•
Training Course in Blood Group Serology and Blood
Bank Methodology for Blood Bank Technicians
(August 11-September 10, 1998).
•
Training Course in Advanced Haematology and
Immunohaematology (September 21 -October 9,1998).
At the Vector Control Research Centre, Pondicherry:
•
y
•
Postgraduate Diploma Course in Medical Entomology
(from August 10,1998).
ICMR PUBLICATIONS
Price(Rs.)
Indian
Nutritive Value of Indian Foods (1985) by C. Gopalan, B.V. Rama Sastri and
S.C. Balasubramanian, Revised and Updated (1989) by B.S. Narasinga Rao, Y.G. Deosthale
and K.C. Pant (Reprinted 1996)
23.00
Growth and Physical Development of Indian Infants and Children (1972, Reprinted 1989)
10.00
Studies on Weaning and Supplementary Foods (1974, Reprinted 1996)
15.00
A Manual of Nutrition (Second Edition 1974, Reprinted 1995)
6.00
Low Cost Nutritious Supplements (Second Edition 1975, Reprinted 1994)
4.00
Menus for Low-Cost Balanced Diets and School-Lunch Programmes Suitable for
4.50
North India (Second Edition 1977, Reprinted 1994)
Menus for Low-Cpst Balanced Diets and School-Lunch Programmes (Suitable for South India)
(Fourth Edition 1996)
6.00
Some Common Indian Recipes and their Nutritive Value (Fourth Edition 1977, Reprinted 1995)
by Swaran Pasricha and L.M. Rebello
10.00
Nutrition for Mother and Child (Fourth Edition 1994, Reprinted 1996) by P.S. Venkatachalam
and L.M. Rebello
11.00
Japanese Encephalitis in India (Revised Edition 1980)
5.00
Some Therapeutic Diets (Fifth Edition 1996) by Swaran Pasricha
7.00
Nutrient Requirements and Recommended Dietary Allowances for Indians (1990,Reprinted 1995)
16.00
Fruits (Second Edition 1996) by Indira Gopalan and M. Mohan Ram
20.00
Count What You Eat (1989, Reprinted 1997) by Swaran Pasricha
15.00
69
♦The Anophelines of India (Revised Edition 1984) by T.Ramachandra Rao
150.00
Depressive Disease (1986) by A. Venkoba Rao
58.00
♦Medicinal Plants of India Vol.2 (1987)
136.00
Diet and Diabetes (Second Edition 1993, Reprinted 1997) by T.C. Raghuram,Swaran Pasricha
and R.D. Sharma
18.00
Dietary Tips for the Elderly (1992, Reprinted 1997) by Swaran Pasricha and
B.V.S. Thimmayamma
5.00
Diet and Heart Disease( 1994,Reprinted 1995) by Ghafoorunissa and Kamala Krishnaswamy
26.00
Dietary Guidelines for Indian - A Manual (1998)
23.00
frqwfl (fg^fta
3Tr?n
1974,
1990)
6.00
(1997)
9.00
♦ 25 per cent discount allowed to individuals
These publications are available on prepayment of cost by cheque, bank draft or postal order (bank and postal charges will be extra) in
favour of the Director-General, Indian Council of Medical Research, New Delhi. Money orders are not acceptable. All correspondence
in this regard should be addressed to the Chief, Division of Publication and Information, Indian Council of Medical Research, Post Box
No.4911, Ansari Nagar, New Delhi-110029 (India).
EDITORIAL BOARD
Members
Dr. Padam Singh
Dr. Bela Shah
Dr. Lalit Kant
Dr. R. Ravi
Dr. V. Muthuswamy
Chairman
Dr. N.K. Ganguly
Director-General
Editor
Dr. N. Medappa
Printed and Published by Shri J.N. Mathur for the Indian Council of Medical Research, New Delhi
* at the ICMR Offset Press, New Delhi-110 029
R.N. 21813/71
Position: 2331 (13 views)