Development and Validation of a Clinical Symptom-based Scoring System for Diagnostic Evaluation of COVID-19 Patients Presenting to Outpatient Department in a Pandemic Situation

Background Preventive strategies in the form of early identification and isolation of patients are the cornerstones in the control of COVID-19 pandemic. We have conducted this study to develop a clinical symptom-based scoring system (CSBSS) for the diagnostic evaluation of COVID-19.  Methods In this study, 378 patients presenting to screening outpatient clinic with clinical suspicion of COVID-19 were evaluated for various clinical symptoms. Statistical associations between presenting symptoms and reverse transcription-polymerase chain reaction (RT-PCR) results were analysed to select statistically significant clinical symptoms to design a scoring formula. CSBSS was developed by evaluating clinical symptoms in 70% of the total patients. The cut-off score of the CSBSS was determined from ROC (receiver operating characteristics) curve analysis to obtain a cut-off for optimum sensitivity and specificity. Subsequently, developed CSBSS was validated in the external validation dataset comprising 30% of patients. Results Clinical symptoms like fever >100⁰F, myalgia, headache, cough and loss of smell had significant association with RT-PCR result. The adjusted odds ratios (95% confidence interval [CI]) for loss of smell, fever >100°F, headache, cough and myalgia were 5.00 (1.78-13.99), 2.05 (1.36-3.07), 1.31 (0.67-2.59), 1.26 (0.70-2.26) and 1.18 (0.50-2.78), respectively. The ROC curve and area under the curve of development and validation datasets were similar. Conclusion The presence of fever >100°F and loss of smell among suspected patients are important clinical predictors for the diagnosis of COVID-19. This newly developed CSBSS is a valid screening tool that can be useful in the diagnostic evaluation of patients with suspected COVID-19. This can be used for the risk stratification of the suspected patients before their RT-PCR results are generated.

Cognitive Performance and Neuro-Metabolites in HIV Using 3T Magnetic Resonance Spectroscopy: A Cross-Sectional Study from India

BACKGROUND

Cognitive impairment in patients with human immunodeficiency virus (HIV) is associated with higher morbidity. The prevalence of the metabolite changes in the brain associated with cognitive impairment in anti-retroviral therapy naïve patients with HIV is unknown.

OBJECTIVE

To estimate the prevalence of the neurometabolites associated with cognitive impairment in antiretroviral therapy (ART) naïve patients with HIV.

METHODS

We conducted a cross-sectional study among ART naïve patients with HIV aged 18-50 years in a tertiary care center in India. Cognition was tested using the Post Graduate Institute battery of brain dysfunction across five domains; memory, attention-information processing, abstraction executive, complex perceptual, and simple motor skills. We assessed the total N-acetyl aspartyl (tNAA), creatine (tCr) and glutamate + glutamine (Glx) using 3T magnetic resonance spectroscopy. Cognitive impairment was defined as an impairment in ≥2 domains.

RESULTS

Among 43 patients eligible for this study, the median age was 32 years (IQR 29, 40) and 30% were women. Median CD4 count and viral load were 317 cells/μL (IQR 157, 456) and 9.3 copies/ μL (IQR 1.4, 38), respectively. Impairment in at least one cognitive domain was present in 32 patients (74.4%). Impairment in simple motor skills and memory was present in 46.5% and 44% of patients, respectively. Cognitive impairment, defined by impairment in ≥2 domains, was found in 22 (51.2%) patients. There was a trend towards higher concentration of tNAA (7.3 vs. 7.0 mmol/kg), tGlx (9.1 vs. 8.2 mmol/kg), and tCr (5.5 vs. 5.2 mmol/kg) in the frontal lobe of patients with cognitive impairment vs. without cognitive impairment but it did not reach statistical significance (p>0.05 for all). There was no difference in the concentration of these metabolites in the two groups in the basal ganglia.

CONCLUSION

There is a high prevalence of cognitive impairment in ART naïve patients with HIV. There is no difference in metabolites in patients with or without cognitive impairment. Further studies, with longitudinal follow-up are required to understand the underlying pathophysiological mechanisms.

Efficacy of low glycemic index diet therapy (LGIT) in children aged 2-8 years with drug-resistant epilepsy: A randomized controlled trial

BACKGROUND

A classic ketogenic diet, even though effective in children with drug-resistant epilepsy is not tolerated well by them and cumbersome to prepare. Low glycemic index therapy (LGIT), the least restrictive with minimal adverse effects among ketogenic dietary therapies has been proven effective in uncontrolled trials, but a placebo-controlled trial in this regard is still lacking.

METHODS

In this open-label randomized controlled study, we randomized children above age two years with drug-resistant epilepsy into two groups (LGIT and control groups). Patients in the LGIT group received an add-on low glycemic index diet for 3 months along with the ongoing antiepileptic drugs and the patients in the control group did not receive any dietary intervention. Seizure frequency was assessed from the seizure diary maintained by the parents. Diet compliance was assessed using the diet diary that was maintained by the parents for three days just before the scheduled monthly visits of the patients.

RESULTS

Forty children with drug-refractory epilepsy (20 in each group) were enrolled. While 6/20 children in the LGIT arm have >50 % reduction in seizure frequency, none achieved this in the control arm (p = 0.02). The overall compliance with the low glycemic diet in the intervention group was 88.5 %. Out of six responders to LGIT, one child achieved seizure freedom and one achieved >90 % seizure reduction. Five continued LGIT further for a median duration of 8 months (range-4-12 months) successfully. The number needed to treat for more than 50 % seizure reduction was 3 and for more than 90 % seizure reduction was 10. The mean frequency of seizures for the intervention and control groups at three months of follow-up was not significantly different (p = 0.16), but the change in seizure frequency as compared to baseline was better in the intervention arm (p = 0.01). Three patients in the LGIT arm had non-serious adverse events (lethargy in two, vomiting in one).

CONCLUSION

In children aged 2-8 years with drug-refractory epilepsy, the administration of LGIT along with ongoing anti-seizure medications (ASM) is more efficacious in reducing seizure frequency as compared to ASM alone.

Efficacy and safety of EBUS-TBNA and EUS-B-FNA in children: A systematic review and meta-analysis

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and transesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA) are established modalities for evaluation of mediastinal/hilar lymphadenopathy in adults. Limited literature is available on the utility of these modalities in the pediatric population. Herein, we perform a systematic review and meta-analysis on the yield and safety of EBUS-TBNA and EUS-B-FNA in children.

METHODS

We performed a systematic search of the PubMed and EMBASE databases to extract the studies reporting the utilization of EBUS-TBNA/EUS-B-FNA in children (<18 years of age). The pooled diagnostic yield and sampling adequacy (proportions with 95% confidence intervals [CIs]) were calculated using meta-analysis of proportions using the random effects model. Details of any procedure-related complications were noted.

RESULTS

The search yielded 12 relevant studies (5 case series and 7 case reports on EBUS-TBNA/EUS-B-FNA, 173 patients). Data from five case series (164 patients) were summarized for the calculation of the sampling adequacy and diagnostic yield. Safety outcomes were extracted from all publications. The pooled sampling adequacy and combined diagnostic yield of EBUS TBNA/EUS-B-FNA were 98% (95% CI, 92%-100%) and 61% (95% CI, 43%-77%), respectively. A procedure-related major complication was reported in one patient (1/173, a major complication rate of 0.6%), and minor complications occurred in six patients (6/173, a minor complication rate of 3.5%).

CONCLUSIONS

EBUS-TBNA and EUS-B-FNA are safe modalities for evaluation of mediastinal lymphadenopathy in the pediatric population. EBUS-TBNA/EUS-B-FNA may be considered as the first-line diagnostic modalities for this indication, as they have a good diagnostic yield and can avoid the need for invasive diagnostic procedures.

Development and Validation of a Comprehensive Neuropsychological and Language Rehabilitation for Stroke Survivors: A Home-Based Caregiver-Delivered Intervention Program

Context:

Aphasia is a major disabling condition after a stroke that profoundly affects the quality of life of stroke survivors (SS) and their caregivers. Comprehensive neuropsychological rehabilitation has emerged as a complementary intervention that helps in improving the associated cognitive and psychological deficits and quality of life following a brain injury. A standardized, simple, and easy to administer intervention that can be delivered as a home-based intervention can assist in faster recovery.

Aims:

To describe the development, validation, and feasibility of a home-based, caregiver-delivered comprehensive neuropsychological and language rehabilitation for SS.

Methods and Material:

A culture-specific picture and task-based 8-week training workbook and manual were developed based on extensive review and focused group discussions. This intervention targeted areas of language (comprehension, fluency, and naming) and cognition (working memory, attention and concentration, executive functioning, and response inhibition). It was standardized on 40 healthy controls (HC) and 15 SS. Before recruitment, written informed consent was obtained from each patient, their primary caregiver, and the HCs.

Results:

All tasks were found to be effective in discriminating the performance of SS from the HC. The performance of the HC with respect to the errors and the time taken for each task was used for the hierarchical arrangement of the tasks. The developed intervention was later validated on 15 SS where they significantly improved in the pre-post assessment of language functioning (P < 0.001), quality of life (P < 0.001), and depression (P < 0.001).

Conclusions:

This intervention can be feasible to administer as a home-based intervention and may help to alleviate language and neuropsychological complaints after stroke in low-literate or mixed-cultural populations. Further, large sample size studies are recommended.

Clinicoepidemiologic Profile of Pediatric Traumatic Brain Injury: Experience of a Tertiary Care Hospital From Northern India

Traumatic brain injury is an important cause of acquired brain injury. The current study brings to light the clinicoepidemiologic profile of pediatric traumatic brain injury in India. Retrospective record analysis of children (aged ≤ 16 years) with traumatic brain injury presenting to an apex-trauma-center in North India over 4 years was done. Of more than 15 000 patients with a suspected head injury, 4833 were children ≤16 years old. Of these, 1074 were admitted to the inpatient department; 65% were boys with a mean age at presentation being 6.6 years. Most patients (85%) had a Glasgow Coma Scale score of 13 to 15 at presentation while Glasgow Coma Scale scores of ≤8 was seen in 10% of patients. Neuroimaging (computed tomography [CT]) abnormalities were seen in 12% of patients, with the commonest abnormality being skull fracture, followed by contusions, and extradural hemorrhage. Around 2% of patients required decompressive craniotomy whereas 3% of patients succumbed to their illness.Among the inpatients with pediatric traumatic brain injury, two-thirds were boys with a mean age at presentation of 7.6 years. Severity of traumatic brain injury varied as mild (64%), moderate (11%), and severe (25%). The most common mode of injury was accidental falls (59%) followed by road traffic and rail accidents (34%). Neuroimaging abnormalities were seen in half of inpatients with pediatric traumatic brain injury, with the commonest abnormality being skull fracture. Pediatric head injuries are an important public health problem and constitute a third of all head injuries. They are more common in boys, and the most common modes of injury are accidental falls, followed by road traffic accidents.

The impact of obstructive sleep apnoea severity on cardiac structure and injury

BACKGROUND

Obstructive sleep apnoea (OSA) is an important factor in the development and progression of heart failure (HF). The prevalence of OSA is higher in patients with HF than in the general population. We sought to test the hypothesis that OSA severity was predictive of ventricular function and cardiac injury [as assessed by high-sensitivity cardiac troponin I(hs-cTnI)].

METHODS

A total of 60 patients were recruited after evaluation for sleep disturbances using the Jenkins Sleep Questionnaire (JSQ) and Epworth Sleepiness Scale (ESS). Subsequently, they underwent polysomnography thus confirming the diagnosis of OSA and were equally divided into three groups according to OSA severity grade. Following polysomnography, the next morning patients underwent venous blood sampling and echocardiography.

RESULTS

We observed a statistically significant association (P = 0.009) between diastolic dysfunction grades and severity grades of OSA. All the three diastolic dysfunction variables E/A ratio, deceleration time and E/e' ratio had a significant association(P < 0.05) with severity grades of OSA. There was a marginally significant positive correlation (ρ = 0.3244, p = 0.04) between AHI events per hour and mitral E/e' ratio. There was a statistically significant association(P < 0.001) between hs-cTnI value among different severity grades of OSA.

CONCLUSIONS

Here in our study, we found OSA a potential risk factor for development of myocardial injury and diastolic dysfunction. Severe grades of OSA are associated with higher grades of diastolic dysfunction and circulating levels of hs-cTnI. These data are consistent with the notion of a vicious cycle of frequent apnoea's or hypoxemia and recurrent myocardial injury, which could increase the risk of heart failure especially diastolic dysfunction in OSA.

Is excess weight a risk factor for the development of COVID 19 infection? A preliminary report from India

BACKGROUND AND AIM

This study explored the association between BMI and COVID-19 positive status in a tertiary care hospital from New Delhi.

METHODS

Three hundred and seventy nine adult patients who presented to COVID-19 screening outpatient department of the hospital were interviewed over the phone regarding their body weight and height. The COVID-19 RT-PCR report of the patients was extracted from the hospital information system.

RESULTS

The mean BMI and the prevalence of obesity was observed to be higher in individuals who were detected to be COVID-19 RT-PCR positive as compared to those who were negative. With every one-unit increment in BMI above 23 kg/m², the odds of being COVID-19 positive increased by 1.8 times among these patients.

CONCLUSION

The findings suggest a dose-response association between BMI and the odds of COVID-19 infection in individuals with excess weight.

Measurement of Serum EGFR mRNA Expression is a Reliable Predictor of Treatment Response and Survival Outcomes in Non- Small Cell Lung Cancer

Background:

EGFR over-expression plays a key role in the development and progression of lung cancer. However, its status as a prognostic biomarker for survival outcomes is unclear.

Objectives:

To evaluate the prognostic utility of serum EGFR mRNA expression in Non-Small cell lung cancer (NSCLC) for treatment response and survival.

Methods:

EGFR mRNA levels were determined in serum using quantitative reverse transcriptase polymerase chain reaction (qRT-PCR). Based on ROC curve, a cut off value of 16.0-fold increase was selected to categorize patients into low EGFR (≤ 16.0) and high EGFR (> 16.0) groups.

Results:

A total of 350 subjects were included (78.3% males), with mean (± SD) age of 57.1 (± 11.2) years, and including 247 (70.6%) adenocarcinoma (ADC). Majority (73.1%) had metastatic (stage IV) disease. Patients had higher pre-treatment serum EGFR mRNA levels than controls [median fold-increase (min, max), 16.2 (1.9, 66.7). Serum EGFR mRNA levels significantly reduced in those who achieved objective response and disease control. Significantly longer OS and PFS was observed in subjects having baseline EGFR mRNA expression ≤ 16.0 fold- increase compared to those with > 16.0 fold- increase [median (95% CI) OS: 25.0 (14.9, NR) versus 7.7 (6.3, 8.9) months; HR (95% CI) 2.9 (2.3, 4.0), p< 0.001; and PFS: 9.9 (7.1, 11.5) versus 6.0 (4.1, 7.5) months; HR (95% CI) 1.8 (1.3, 2.4), p< 0.001].

Conclusion:

Serum EGFR mRNA expression is a useful parameter for predicting treatment response and survival outcomes in NSCLC.

Diabetes mellitus in pheochromocytoma and paraganglioma: Prevalence, dynamics of insulin secretion / sensitivity and predictors of remission

BACKGROUND AND AIMS

Pheochromocytoma and paraganglioma (PPGL) are associated with dysglycemia and diabetes mellitus (DM) much of which improves post operatively. In this study, we set out to ascertain pre and post-operative prevalence of DM in patients with PPGL based on oral glucose tolerance test (OGTT) and HbA1c and to evaluate effect of insulin secretion and sensitivity indices on DM pre-operatively.

METHODS

Clinical and anthropometric data collection, HbA1c, 75 g OGTT with serum insulin estimation were done pre-operatively (n = 34) and at follow-up after successful surgery (n = 24) in patients with PPGL.

RESULTS

Pre and post-operative prevalence of DM were 48%(18/37) and 17% (4/24) respectively. Comparison of patients with highest (Q4) and lowest (Q1) quartiles of insulinogenic index (IGI),a parameter of insulin secretion, revealed trends towards higher prevalence of DM in patients with lower IGI (Q4 to Q1: 29% versus 71%,n = 28, p = 0.24)but no association was observed with HOMA-IR (Q4 to Q1:50% versus 57%, n = 28, p = 1.00), an insulin sensitivity index. DM remitted in 77% patients post-operatively, predicted by duration of DM of<3 years.

CONCLUSION

There is high prevalence of DM in PPGL, with marked remission post-operatively, especially predicted by shorter duration of DM. Impaired insulin secretion is more strongly associated with pre-operative DM than increased insulin resistance.

Telephone-based follow-up of children with epilepsy: Comparison of accuracy between a specialty nurse and a pediatric neurology fellow

•

Childhood epilepsy forms a significant burden on the health-care delivery system.

•

Telemedicine is a proposed effective alternative in overcoming this burden.

•

Even simple mobile phones can be used by paramedical professionals.

•

Tele-consultation in childhood epilepsy by pediatric neurology fellow has excellent sensitivity and specificity.

•

A specialty nurse has also acceptable sensitivity and specificity in comparison with face-to-face consultation.

Background

Childhood epilepsy forms a significant burden on the health-care delivery system. Only a few pediatric neurologists available in most of the developing countries and caregivers face a lot of financial and logistic hardships, apart from a long waiting period for initial and follow up visits. Telemedicine is a proposed effective alternative in overcoming this burden.

Methods

Telephonic consultation by a pediatric neurology fellow was compared with that of a specialty nurse; both against face-to-face consultation (gold standard). Care-givers of children 4 months-18 years with epilepsy were telephonically consulted 24−48 hours before their scheduled hospital appointment by one specialty nurse and one pediatric neurology fellow at least 24 h apart in a random sequence. During the hospital visit, another pediatric neurology fellow blinded to the telephonic consultation, documented the same after Face-to-Face interview.

Results

In 141 children with epilepsy, 504 critical clinical events were identified. Telephonic consultation by pediatric neurology fellow had a sensitivity of 99 %, 97 %, and 100 % and specificity of 100 % each in detecting whether the child had any breakthrough seizure, any adverse event and whether the drug compliance was adequate or poor respectively, as compared to face-to-face consultation. Telephonic consultation by specialty nurse had a sensitivity of 91 %, 84 %, and 98 % and specificity of 97 %, 99 %, and 81 % in detecting whether the child had any breakthrough seizure, adverse event and whether the drug compliance was adequate or poor respectively. But the specialty nurses fared poorly in identifying atypical seizure semiologies like atonic and myoclonic seizures and documenting an exact number of breakthrough seizures, as well as few subjective adverse effects like behavioral abnormality and scholastic worsening, which was performed excellently by the pediatric neurology fellow.

Conclusions

Telephonic consultation in childhood epilepsy by pediatric neurology fellow has excellent sensitivity and specificity. A specialty nurse has also acceptable sensitivity and specificity in comparison with a face-to-face consultation.

Prevalence of smooth muscle dysfunction among children with Duchenne muscular dystrophy

Smooth muscle dysfunction in Duchenne muscular dystrophy (DMD) has been rarely studied. A cross-sectional study was conducted to estimate the prevalence of smooth muscle dysfunction (vascular, upper gastrointestinal, and bladder smooth muscle) in children with DMD using questionnaires (Pediatric Bleeding Questionnaire, Pediatric Gastroesophageal Symptom Questionnaire, and Dysfunctional Voiding Symptom Score). Investigations included bleeding time estimation, nuclear scintigraphy for gastroesophageal reflux, and uroflowmetry for urodynamic abnormalities. Ninety-nine subjects were included in the study. The prevalence of vascular, upper gastrointestinal, and bladder smooth muscle dysfunction was 27.2%. Mean bleeding time was prolonged by 117.5 seconds. The prevalence of gastroesophageal reflux was 21%. Voided volume/estimated bladder capacity over 15% and abnormal flow curves on uroflowmetry were seen in 18.2% and 9.7% of the subjects, respectively. Our study highlights the need for addressing issues related to smooth muscle dysfunction in the routine clinical care of patients with DMD.

Efficacy of Ketogenic Diet, Modified Atkins Diet, and Low Glycemic Index Therapy Diet Among Children With Drug-Resistant Epilepsy: A Randomized Clinical Trial

IMPORTANCE

The ketogenic diet (KD) has been used successfully to treat children with drug-resistant epilepsy. Data assessing the efficacy of the modified Atkins diet (MAD) and low glycemic index therapy (LGIT) diet compared with the KD are scarce.

OBJECTIVE

To determine whether the MAD and LGIT diet are noninferior to the KD among children with drug-resistant epilepsy.

DESIGN, SETTING, AND PARTICIPANTS

One hundred seventy children aged between 1 and 15 years who had 4 or more seizures per month, had not responded to 2 or more antiseizure drugs, and had not been treated previously with the KD, MAD, or LGIT diet were enrolled between April 1, 2016, and August 20, 2017, at a tertiary care referral center in India.

EXPOSURES

Children were randomly assigned to receive the KD, MAD, or LGIT diet as additions to ongoing therapy with antiseizure drugs.

MAIN OUTCOMES AND MEASURES

Primary outcome was percentage change in seizure frequency after 24 weeks of dietary therapy in the MAD cohort compared with the KD cohort and in the LGIT diet cohort compared with the KD cohort. The trial was powered to assess noninferiority of the MAD and LGIT diet compared with the KD with a predefined, noninferiority margin of -15 percentage points. Intention-to-treat analysis was used.

RESULTS

One hundred fifty-eight children completed the trial: KD (n = 52), MAD (n = 52), and LGIT diet (n = 54). Intention-to-treat analysis showed that, after 24 weeks of intervention, the median (interquartile range [IQR]) change in seizure frequency (KD: -66%; IQR, -85% to -38%; MAD: -45%; IQR, -91% to -7%; and LGIT diet: -54%; IQR, -92% to -19%) was similar among the 3 arms (P = .39). The median difference, per intention-to-treat analysis, in seizure reduction between the KD and MAD arms was -21 percentage points (95% CI, -29 to -3 percentage points) and between the KD and LGIT arms was -12 percentage points (95% CI, -21 to 7 percentage points), with both breaching the noninferiority margin of -15 percentage points. Treatment-related adverse events were similar between the KD (31 of 55 [56.4%]) and MAD (33 of 58 [56.9%]) arms but were significantly less in the LGIT diet arm (19 of 57 [33.3%]).

CONCLUSIONS AND RELEVANCE

Neither the MAD nor the LGIT diet met the noninferiority criteria. However, the results of this study for the LGIT diet showed a balance between seizure reduction and relatively fewer adverse events compared with the KD and MAD. These potential benefits suggest that the risk-benefit decision with regard to the 3 diet interventions needs to be individualized.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02708030.

Ketamine mouthwash versus placebo in the treatment of severe oral mucositis pain in children with cancer: A randomized double-blind placebo-controlled trial

BACKGROUND AND AIMS

Oral mucositis (OM) is a common and distressing toxicity in children on chemotherapy. There are a limited number of safe and effective therapeutic options available for OM. Ketamine oral rinse has shown promising results in a few studies in adults. This randomized, double-blind placebo-controlled trial aimed to test the efficacy of ketamine mouthwash in reducing chemotherapy-induced severe OM pain in children.

METHODS

Children aged 8-18 years with severe OM were randomized to a single dose of ketamine mouthwash (4 mg/mL solution; dose 1 mg/kg) or a placebo. A sample size of 44 patients was determined. Pain score (6-point faces scale) was noted at baseline and 15, 30, 45, 60, 120, 180, and 240 min. The outcome variables were a reduction in pain score, need for rescue medications, and adverse events.

RESULTS

The baseline characteristics were comparable in the two groups. The mean OM pain at 60 min decreased by 1.64 points (CI 1.13-2.14) in the ketamine group and 1.32 points (CI 0.76-1.87) in the placebo group (P = 0.425), with a group difference of 0.32 points. Rescue pain medication (at 60 min) was required in 13.6% in the ketamine group and 18.2% in the placebo group (P = 1.000). No significant adverse events were observed.

CONCLUSIONS

Among children on cancer chemotherapy with severe OM, ketamine mouthwash at a dose of 1 mg/kg did not significantly reduce OM pain. It did not decrease the need for rescue pain medications. Further research is warranted to test higher doses of ketamine for a clinically significant effect.

Can costochondral grafts fulfil ramus-condyle unit reconstruction goals in children with temporomandibular joint ankylosis?

The purpose of this study was to analyse whether costochondral grafts (CCG) fulfil temporomandibular joint (TMJ) reconstructive goals in children with TMJ ankylosis. A total of 23 patients (12 male, 11 female, aged 3-16 years) with unilateral or bilateral TMJ ankylosis operated on between January 2014 to April 2018 were included in the study. Maximal incisal opening (MIO), frequency of reankylosis, and growth of CCG, were evaluated at one month and six months for one year, and after that once yearly. Mouth opening changes with time were assessed by the Friedman test and growth was compared at follow up and analysed using the paired t test. Mean (range) follow up was 18 (12-48) months. Study results revealed follow up MIO at 12 months was highly significant (p=0.001). Out of 27 CCG studied, only one graft had undergone re-ankylosis. Based on the predetermined criteria using condylion to gnathion (Co-Gn) measurement in the posteroanterior cephalogram, CCG were categorised into optimum, sub-optimum, and overgrowth. However, long-standing TMJ ankylosis cases still displayed mandibular asymmetry at the end of the study, even with "optimal growth" radiographically. Overall comparison between the immediate postoperative and last follow up Co-Gn measurements in either unilateral or bilateral cases was not significant. CCG with functional matrix maintained the growth of the mandible and MIO in TMJ ankylosis. It can be concluded that CCG partially fulfils reconstructive goals; however, patients need to be followed up till the end of puberty for a substantive conclusion.

A randomized trial of the immediate effect of Bee-Humming Breathing exercise on blood pressure and heart rate variability in patients with essential hypertension

OBJECTIVES

Bee-Humming Breathing (BHB) exercise is a simple yogic practice recommended for its favorable effect on cardiac physiology, including blood pressure (BP) and autonomic nervous system. However, strong evidence supporting its effectiveness is lacking. The present study was designed to evaluate the immediate effect of BHB exercise on blood pressure parameters and heart rate variability (HRV) in patients with essential hypertension.

STUDY METHODS

We conducted a randomized control trial including 70 patients with essential hypertension, randomly allocated to perform either BHB exercise (n=35) or placebo slow breathing exercise (n = 35) for 5-minutes duration. Blood pressure and HRV were measured before, during, and after the practice.

RESULTS

There was no significant decrease in systolic [effect size (95% CI): 2.22 (-13.20, 17.64); p 0.77], diastolic [4.54 (-17.40, 26.48); p 0.68] and mean blood pressures [1.37 (-8.78, 11.52); p 0.78] after BHB exercise in comparison to the control group in our study. The HRV analysis showed a significant increase in the HF power [6.8 (1.47, 12.12); p 0.01], and decrease in the LF power [-26.47 (-34.25, -18.68); p < 0.01] during the recovery phase of the 5-minute BHB exercise in comparison to the control group.

CONCLUSIONS

This is the first randomized controlled trial to show that though a single short session of BHB exercise in hypertensive patients does not significantly reduce BP, it significantly augments the parasympathetic tone as indicated by a significant improvement in HRV parameters.

CLINICAL TRIAL REGISTRATION NUMBER

CTRI/2018/08/015215.

Comparison of statistical methods for recurrent event analysis using pediatrics asthma data

When the same type of event is experienced by a subject more than once it is called recurrent event, which possess two important characteristics, namely "within-subject correlation" and "time-varying covariate." As a result, the traditional statistical methods do not work well on recurrent event data. Over the past few decades, many alternatives methods have been proposed for the analysis of recurrent event data. In this article, the six most prominent methods for recurrent event analysis have been compared on pediatric asthma data. Three variance corrected models (viz "Anderson and Gill [AG] model," "Prentice, William, and Peterson-Counting Process [PWP-CP] model," and "Prentice, William, and Peterson-Gap Time [PWP-GT] model") and three corresponding frailty variants (AG-frailty, PWP-CP-frailty, and PWP-GT-frailty) were compared using three mathematical criterion (AIC, BIC, and log-likelihood) and one graphical criteria (Cox-Snell goodness of fit, visual test). All model comparison indices showed the PWP-GT model as the most appropriate model on asthma data over other models. By using PWP-GT model, seven predictors of asthma exacerbation (viz "abdominal pain at previous visit," "Z5 (%) at previous visit," "diagnosis of asthma at previous visit," "calendar month of exacerbation," "history of maternal asthma," "monthly per capita income," and "emotional stress") were identified. The PWP-GT model was identified as the most appropriate model over other models on pediatrics asthma data.

Histotyping of Indian thymomas: A clinicopathologic study from north India

Background & objectives:

Thymomas are rare, but most common anterior mediastinal lesions. The histomorphologic spectrum of thymic epithelial tumours (TETs) in Indian population has not been explored in depth. This study was aimed to assess the histomorphology of TETs in the Indian patients and correlate clinical parameters with pathological features.

Methods:

It was a retrospective study conducted in a tertiary referral hospital in north India. All morphologically confirmed cases of TETs since 2009 were included. Clinical details and histology slides were reviewed using the Modified Masaoka-Koga staging system and WHO 2015 classification. Clinicopathological correlation and survival analysis were done. A comparative review from other published Indian studies was performed.

Results:

A total of 219 cases of TETs (138 resections and 81 biopsies) were identified. The most common histomorphologic type was B2, and the most frequent stage was I. Types A/AB were common in older age (P<0.01). Clinically, higher stage tumours were found mostly in men (P<0.01), and these were Type B thymomas (P<0.01). Myasthenia gravis was more common in women (P<0.02) and in lower stages (P<0.05). Survival analysis revealed significant association between recurrence and tumour stage. Although thymic carcinoma was diagnosed on biopsy, no resectable case was identified.

Interpretation & conclusions:

Our findings showed that the thymomas in Indian patients were most commonly Stage I tumours of B2 and AB histotypes. Resected thymic carcinomas were conspicuously absent in our study. More studies need to be done to establish the frequency and biology of TETs from India.

Hindi Version of Addenbrooke's Cognitive Examination III: Distinguishing Cognitive Impairment Among Older Indians at the Lower Cut-Offs

Background

Screening and diagnostic tests provide an objective measure of cognitive performance and also aid in distinguishing mild cognitive impairment (MCI) from major neurocognitive disorder (MNCD). Further, when such tests are culturally and educationally unbiased, it strengthens their diagnostic utility. This study aimed to validate the Hindi version of Addenbrooke’s Cognitive Examination III (ACE-III) in Indian older adults and compare its validity with the Hindi Mini-Mental State Examination (HMSE).

Methods

A sample of 412 consenting older adults visiting a memory clinic was recruited into the study. They were categorized into three groups: healthy controls (n=222), MCI (n=70), and MNCD (n=120). The complete clinical protocol was followed. Hindi ACE-III and HMSE were administered and were statistically analyzed.

Results

The optimal cut-off values to detect MCI and MNCD with ACE-III were 71 and 62 (AUC: 0.849 and 0.884), respectively, which were slightly higher than with HMSE (AUC: 0.822, 0.861). Education- and age-stratified cut-offs were also computed.

Conclusion

Hindi ACE-III has good discriminating power at lower cut-offs than the standard scores in differentiating between MCI and MNCD.

The Development and Validation of DSM 5-Based AIIMS-Modified INDT ADHD Tool for Diagnosis of ADHD: A Diagnostic Test Evaluation Study

BACKGROUND

The current study was planned at a tertiary centre in northern India to develop and validate a Diagnostic and Statistical Manual-5 (DSM-5)-based diagnostic tool and design a severity score for attention deficit hyperactivity disorder (ADHD) in children aged 6-18 years. An existing DSM-IV-based tool, INDT (International Clinical Epidemiology Network [INCLEN] diagnostic tool) for ADHD has been modified and named All India Institute of Medical Sciences (AIIMS)-modified INDT ADHD tool.

METHOD

The first phase was development of the tool and the second phase was validation of the same against the gold standard of diagnosis by the DSM-5. A severity score was developed for ADHD in concordance with the Conners rating scale.

RESULTS

The tool was validated in 66 children with a sensitivity and specificity of 100 per cent and 90 per cent, respectively. A cut-off score of 12 was decided for labelling severity of ADHD, which corresponded to 63 in the Conners rating scale.

CONCLUSION

This diagnostic tool for ADHD based on DSM-5 has acceptable psychometric properties. The severity score will be useful for prognostication, monitoring treatment response, and designing intervention trials.

Evaluation of rapid diagnostic tests and assessment of risk factors in drug-resistant pulmonary tuberculosis

Background:

Early diagnosis and treatment of drug-resistant tuberculosis (TB) is crucial to halt the spread of drug resistance in the community.

Aim:

The aim of the study was to compare rapid diagnostic tests (GeneXpert and line probe assay, LPA) with conventional liquid culture for the diagnosis of drug-resistant TB and to assess the risk factors for it.

Method:

This cross-sectional study recruited 229 multidrug-resistant TB suspects who were sputum smear positive. They were evaluated by the rapid diagnostic tests and sensitivity, specificity, positive predictive value and negative predictive value were calculated for drug resistance detection as compared to liquid culture drug susceptibility testing. The risk factors for the development of drug resistance were also assessed and the P value of < 0.05 was considered significant.

Results:

In the final comparison, 193 samples were included. The sensitivity and specificity of GeneXpert for detection of drug resistance (rifampicin) was 100% (95% confidence interval, CI: 88.8–100%) and 99.4% (95% CI: 96.6–99.9%), respectively. Whereas sensitivity and specificity of LPA was 94.3% (95% CI: 80.8–99.3%) and 100% (95% CI: 97.7–100%), respectively. Only three discordant samples were observed. Defaulting to antitubercular therapy, contact with resistant TB, and disseminated disease were found to be significant risk factors for the development of drug-resistant TB with high statistical significance (P value < 0.05).

Conclusion:

Both rapid diagnostic tests have very high sensitivity and specificity for detection of drug resistance in sputum smear positive with the advantage of short turn-around time. Defaulting to antitubercular therapy, contact with resistant TB, and disseminated disease are significant risk factors for drug resistance.

Frequent plateletpheresis donations & its effect on haematological parameters: An observational study

Background & objectives:

The well-being of donors undergoing frequent plateletpheresis has been a matter of concern. The aim of this study was to analyze the effect of frequent plateletpheresis on the haematological parameters (HP) of repeat donors.

Methods:

The study was conducted during February 2016 to March 2017 on all the repeat plateletpheresis donors undergoing the 2^nd plateletpheresis within a month of the first in a tertiary care centre. Donors repeating plateletpheresis 3^rd and 4^th times were also studied. The values of the HP observed on follow up after plateletpheresis done on three different separators were compared.

Results:

HPs of the 98 donors were similar at follow up except mean platelet volume (P<0.05). Of the 98 donors, 35 were followed up within a week and 63 were followed up within 8-30 days. No significant alteration was found in the HPs except a significant difference in the variation of platelet counts of the two groups (P=0.025). In 34 donors who presented 3^rd time for plateletpheresis (mean gap between 1^st and 3^rd plateletpheresis=31 days), no significant differences in the HPs were found except the platelet distribution width (P<0.05). Minimal difference in the HP was found in the baseline and the follow up of 3^rd plateletpheresis i.e., at 4^th plateletpheresis donation. Plateletpheresis through all the three cell separators used had similar effects on the follow up HPs.

Interpretation & conclusions:

Repeated plateletpheresis can be done without any detrimental effects on the cell counts of the plateletpheresis donors. The three cell separators yielded similar post-donation follow up haematological parameters.

A comparison of three strategies for withdrawal of noninvasive ventilation in chronic obstructive pulmonary disease with acute respiratory failure: Randomized trial

Background:

The optimal strategy for the withdrawal of noninvasive ventilation (NIV) remains unknown. This study was planned to compare three different strategies for the withdrawal of NIV among patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnic respiratory failure (HcRF).

Materials and Methods:

Patients with AECOPD with HcRF who improved on NIV were randomized into three groups – immediate withdrawal (Group A), stepwise reduction of pressure support (Group B), and stepwise reduction of duration (Group C) of NIV. The probability of successful withdrawal was compared among the groups.

Results:

This study included 90 patients (males – 86.6%) with a mean (±standard deviation [SD]) age of 59.9 ± 8.3 years. The mean (±SD) pH and PaCO₂ at admission were 7.23 ± 0.04 and 84.4 ± 12.0 mm Hg, respectively. The duration of NIV received before randomization was 31.6 ± 9.2 h with maximum inspiratory positive airway pressure and expiratory positive airway pressure of 17.6 ± 2.7 cm H₂O and 7.4 ± 1.4 cm H₂O, respectively. NIV was successfully withdrawn in 23/30 (76.6%) in Group A, 27/30 (90%) in Group B, and 26/30 (86.6%) in Group C (P = 0.31). The total duration of NIV use and length of hospital stay was lower in Group A and B as compared to Group C (P = 0.001).

Conclusions:

Immediate withdrawal of the NIV after recovery of respiratory failure among patients with exacerbation of COPD is feasible. Immediate withdrawal did not increase the risk of weaning failure from the NIV.

Clinical profile of lung cancer in North India: A 10-year analysis of 1862 patients from a tertiary care center

Introduction:

Over the past few years, the demographic profile of lung cancer has changed. However, most reports are limited by small numbers, short follow-up period, and show an inconsistent pattern. A comprehensive evaluation of changing trends over a long period has not been done.

Materials and Methods:

Consecutive lung cancer patients were studied over a 10-year period from January 2008 to March 2018 at the All India Institute of Medical Sciences, New Delhi, and relevant clinical information, and survival outcomes were analyzed.

Results:

A total of 1862 patients were evaluated, with mean (SD) age of 59 (11.1) years, and comprising 82.9% males. Majority were smokers (76.2%) with median smoking index of 500 (interquartile range [IQR]: 300–800). Adenocarcinoma (ADC) was the most common type (34%), followed by squamous cell carcinoma (SCC – 28.6%) and small cell lung cancer (SCLC) (16.1%). Over the 10-year period, ADC increased from 9.5% to 35.9%, SCC from 25.4% to 30.6%, and non-small cell lung cancer -not otherwise specified (NSCLC-NOS) decreased from 49.2% to 21.4%. The proportion of females with lung cancer increased although smoking rates remained similar. Majority of NSCLC (95%) continued to be diagnosed at an advanced stage (3 or 4). Epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements were present in 25.3% and 11.5% ADC patients, respectively. The median overall survival was 8.8 months (IQR 3.7–19) for all patients and 12.57 (IQR 6.2–28.7) months among the 1013 patients who were initiated on specific treatment (chemotherapy, targeted therapy, radiotherapy, or surgery). Never-smokers were younger, more likely to be female and educated, had a higher prevalence of ADC and EGFR/ALK mutations, and had better survival.

Conclusion:

Among this large cohort, our center seems to follow the global trend with increasing incidence of ADC. EGFR mutation positivity was similar to existing reports, while higher ALK positivity was detected. A characteristic phenotype of never-smokers with lung cancer was elucidated which demonstrated better survival.

Profile of acute poisoning cases and their outcome in a teaching hospital of north India

Objectives:

Aim of this study was to characterize acute poisoning and snakebite cases and their outcome in the Emergency Department (ED).

Methods:

This was a prospective study done in the ED of a tertiary healthcare center. Study included 184 patients of acute poisoning and 16 cases of snakebite. Data regarding demographics, type, time, and mode of poisoning, lag time in reaching the hospital, initiation of treatment, first aid, in-hospital treatment, and comorbid illness were obtained. Data regarding requirement of antidote, duration of hospitalization, and outcome were also obtained.

Results:

Out of 200 cases, 181 (90.5%) were adults and 19 (9.5%) were of pediatric age group. Poisoning was common among males (57%) than females (43%). Majority (40%) were from the age group of 21–30 years. Out of 200, 115 (57.5%) poisonings were suicidal, 68 (34%) were accidental, and 17 (8.5%) were homicidal. Acute poisonings included corrosive 54 (27%), drug overdose 26 (13%), organophosphorus compounds 20 (10%), rodenticides 20 (10%), and symptomatic snakebite 16 (8%). Seventy-two (36%) were admitted with a median hospital stay of 6 days with 5 (2.5%) deaths. Logistic regression analysis revealed poorer outcome for 15–30 years age [OR 12.6 (1.6–97.5), P = 0.015], males [OR 2.5 (1.4–4.4) P = 0.04], patients coming from >30 km [OR 4.3 (1.5–12.1), P = 0.006].

Conclusion:

Our study demonstrated an increased incidence of corrosive ingestion. With increasing rates of suicidal ingestions, there is a need for holistic approach to manage mental health issues at primary care level.

A community-based pragmatic, controlled trial for preventing and reducing oral diseases among 1-6-year-old children visiting Anganwadi centers, under the Integrated Child Development Scheme, India

BACKGROUND

Early childhood caries (ECC) has reached epidemic proportions affecting millions of children worldwide. Its prevention becomes imperative owing to the significant morbidity and financial implications involved with its treatment. The Integrated Child Development Scheme (ICDS), launched in India to provide mid-day meals, pre-school education and primary healthcare to children, can be utilised to counsel and deliver oral health education to mothers. The purpose of the study is to compare the effect of an oral health care package (OHCP) with usual care on the change in dental disease status among 1 to 3-year-old children at Anganwadi centres (AWC) in periurban areas of Chandigarh and rural areas of Cuttack, Orissa over a follow-up period of three years.

METHODS

Two geographically distant ICDS blocks would be selected at each of the two study sites and would be randomly allocated to intervention and control group. Closely located AWCs under each of the selected blocks shall constitute the study setting. OHCP would be delivered to the mothers of the 1-6-year-old children enrolled in the AWCs of the experimental group whereas mothers under control group would receive usual care advice available at the AWCs.

DISCUSSION

ECC prevention had conventionally focused upon testing effectiveness of programs targeting behaviour change among the caregivers and children, but surprisingly minimal efforts have been made to seek translation of these efforts into reduction of ECC at the community level. The present study has two components; testing effect of altering maternal and child behavioral aspects on ECC incidence through cohort follow up of 1-3-year-old children for three consecutive years and cross-sectional follow up of all available 1-6-year old children at the selected AWCs at regular intervals to look for change in prevalence of ECC at community level. In other regions of the world surveys of ECC prevalence before and after the intensive educational programs have shown a significant reduction in ECC prevalence. A similar decline can be anticipated through this program.

TRIAL REGISTRATION

This trial has been prospectively registered at Clinical Trials Registry, India (CTRI/2019/02/017556, 08 February 2019).

Effectiveness of education and antibiotic control programme at All India Institute of Medical Sciences, New Delhi

Background

We aimed to assess the impact of antibiotic optimization education along with understanding the antibiogram on antibiotic-prescribing practices, antibiotic consumption, antimicrobial resistance and cost of antibiotics in a tertiary care hospital in New Delhi.

Methods

We divided the study into 3 phases-before and after intervention and a phase of education in between. We collected data on demographics, indication for antibiotic prescription, appropriateness or reasons for inappropriate antibiotic uses, antibiotic consumption (i.e. the rate and duration of antibiotic use), bacterial resistance and antibiotic cost. Interventions included education, introduction of an antibiogram and use of antibiotic prescription forms. Similar data were collected for the post-interventional phase. The study was conducted at the Department of Medicine, All India Institute of Medical Sciences, New Delhi, India.

Results

There was an improvement in the number of patients who underwent de-escalation of antibiotics, 21/100 v. 36/100 (p = 0.019); appropriate antibiotic usage, 25/ 100 v. 46/100 (p = 0.002); switching from intravenous to oral promptly, 16/52 v. 1 9/36 (p = 0.003) and decrease in expenditure, ₹24 207.5 v. ₹16 51 7.5 per patient (p = 0.001 ); in the post-interventional phase. Significant reductions in the incidence of infections due to Acinetobacter (60% v. 31%; p<0.001) and improvement in sensitivity pattern with cephalosporin sulbactam (80% v. 100%; p<0.001) were seen. Multivariate analysis revealed that Acute Physiology and Chronic Health Evaluation (APACHE) score, hospital stay <10 days, ventilator-associated pneumonia and methicillin-resistant Staphylococcus aureus coverage were independent predictors of mortality with odds ratio of 1.14, 0.1, 9.7 and 1.14, respectively.

Conclusion

Education and an antibiotic control programme constituted an effective and cost-saving strategy to optimise antibiotic use at a tertiary care centre.

Comparative Evaluation of Phacoemulsification Alone versus Phacoemulsification with Goniosynechialysis in Primary Angle-Closure Glaucoma: A Randomized Controlled Trial

PURPOSE

Comparative evaluation of phacoemulsification (phaco) alone versus phacoemulsification combined with goniosynechialysis (phacoGSL) in primary angle-closure glaucoma (PACG).

DESIGN

Prospective, randomized, parallel group, active controlled trial.

PARTICIPANTS

Patients with PACG.

METHODS

A total of 120 consecutive patients with PACG were screened, of whom 80 met inclusion criteria, with PACG uncontrolled on maximal hypotensive therapy and were recruited. Patients were randomized into 2 groups and underwent phaco alone in group 1 or phacoGSL in group 2. The patients were examined at baseline and at 1 week and 1, 3, and 6 months. The anterior chamber angle parameters on swept-source anterior segment OCT (SS-ASOCT) were noted at 1 and 6 months.

MAIN OUTCOME MEASURES

The primary outcome measure was intraocular pressure (IOP) reduction. A reduction in IOP of ≥ 20% from baseline IOP with or without medications was considered a success. Secondary outcome measures included change in the anterior chamber angle temporal parameters, angle-opening distance, trabecular-iris space area and scleral spur angle, surgical safety, visual acuity, and reduction in the number of glaucoma medications postoperatively.

RESULTS

The average age of patients was 58.77±8.14 years and 56.50±9.17 years in groups 1 and 2, respectively (P = 0.31). The mean baseline IOP was 29.48±6.76 mmHg and 30.72±3.88 mmHg in groups 1 and 2, respectively (P = 0.13). Success was obtained in 93.33% of patients in group 1 and 91.18% of patients in group 2 at 6 months (P = 0.39). Mean IOP was 13.17±1.66 mmHg and 13.21±1.97 mmHg at 6 months in groups 1 and 2, respectively (P = 0.001). The reduction in IOP was 55.32% and 56.99% at 6 months in groups 1 and 2 (P = 0.48). Significant widening of the angle parameters was noted at 6 months with an increase compared with baseline values in both groups. In multivariate analysis, the significant predictor of decrease in IOP was the higher baseline IOP.

CONCLUSIONS

Both phaco and phacoGSL are associated with a significant reduction in IOP along with a noteworthy widening of the anterior chamber angle parameters. Both procedures succeeded in reducing the necessity of glaucoma medications postoperatively in PACG eyes. There is no additional benefit of phacoGSL over phaco in PACG.

Altered Expression of Complement Regulatory Proteins CD35, CD46, CD55, and CD59 on Leukocyte Subsets in Individuals Suffering From Coronary Artery Disease

Studies conducted in animal models have suggested that membrane complement regulatory proteins play an important role in the pathophysiology of coronary artery disease (CAD). In this study, a total of 100 individuals, with stable CAD and 100 healthy controls, both groups predominantly male, were recruited. We evaluated the plasma levels of complement regulatory proteins (Cregs) CD35, CD46, CD55, and CD59 and their surface expression on granulocytes, lymphocytes, and monocytes by flow cytometry. The mRNA expression of these Cregs in total leukocytes was determined by quantitative PCR. The soluble forms of Cregs, C3c, Mannose binding protein-associated serine protease 2 (MASP-2), Platelet activating factor-acetyl hydrolase (PAF-AH), and inflammatory cytokines were quantified by ELISA. High plasma levels of C3c, indicative of complement activation, in addition to significantly low levels of Cregs, were observed in CAD patients. A significantly lower expression of CD46 and CD55 on the surface of lymphocytes, monocytes, and granulocytes and higher surface expression of CD35 and CD59 on granulocytes (p < 0.0001) was seen in CAD patients as compared to healthy donors. The high expression of CD59 on granulocytes positively correlated with the severity of disease and may serve as a potential marker of disease progression in CAD.

Arthroscopic and 3D CT Scan Evaluation of Femoral Footprint of the Anterior Cruciate Ligament in Chronic ACL Deficient Knees

The outcome of single-bundle anterior cruciate ligament (ACL) reconstruction depends largely on the anatomic placement of bone tunnel. The lateral intercondylar ridge (LIR) and bifurcate ridge (BR) are useful bony landmarks for femoral tunnel placement. The purpose of our study was to compare the bony landmarks of ACL footprint on femur by three-dimensional computed tomography (3D CT) scan and arthroscopy in chronic ACL-deficient knees. Fifty patients above 18 years of age who were diagnosed of having ACL tear were selected for the study. All the cases were more than 6 months old since the injury. Preoperative 3D CT scan of the affected knee was obtained for each of them. They underwent single-bundle anatomic ACL reconstruction. Measurements were done on the preoperative 3D CT and arthroscopy to quantify the position of the LIR and BR. The proximodistal distance of lateral femoral condyle was 21.41+/-2.5 mm on CT scan and 22.02+/-2.02 mm on arthroscopy. On preoperative 3D CT scan, the midpoint of the LIR was found to be located at a mean distance of 11.17±2.11 mm from the proximal margin of the lateral femoral condyle. On arthroscopy, it was at 10.18+/-1.52 mm from the proximal margin the lateral femoral condyle. The "bifurcate ridge"(BR) was not visible in any of the cases during arthroscopy or CT scan. We concluded that LIR is an easily identifiable bony landmark on arthroscopy in all cases. It can also be identified on CT scans. BR is not identified both on arthroscopy and CT scans in chronic ACL tears. The arthroscopic measurements of bony landmarks are quite close to those of CT scan. Midpoint of LIR is at 52.185% of the proximodistal distance on CT scan evaluation and it is at 46.21% on arthroscopic evaluation.

Serum and Bronchoalveolar Lavage Fluid 25(OH)Vitamin D3 Levels in HIV-1 and Tuberculosis: A Cross-Sectional Study from a Tertiary Care Center in North India

BACKGROUND

Vitamin D is an immunomodulator, and its deficiency is associated with Tuberculosis (TB) infection. Bronchoalveolar lavage fluid (BALF) is a rich milieu of macrophages that form the first line of defense against invading TB bacilli. As there is an increased prevalence of vitamin D deficiency in TB and human immunodeficiency virus-1 (HIV-1) subjects, we intend exploring the possibility of a localized deficiency of vitamin D metabolites in BALF of these patients.

OBJECTIVE

The primary objective was to assess the level of 25D3 in serum and BALF of subjects and look for a significant difference among patients and controls. The secondary objective was to find a correlation between serum and BALF 25D3 levels.

METHODS

We performed a cross-sectional study with subjects divided into four groups: Controls (group 1), HIV positive without active TB (group 2), active TB without HIV (group 3), and HIV-TB coinfection (group 4). BALF and serum 25D3 levels were compared between the groups.

RESULTS

Among the 149 (an immunomodulator) successive subjects enrolled, there were 40 subjects in group 1 (HIV-TB-), 48 in group 2 (HIV+TB-), 37 in group 3 (HIV-TB+), and 24 in group 4 (HIV+TB+). Females constituted 31.6% of the study subjects. In groups 3 and 4, there were significantly lower serum 25D3 levels compared to group 1 (p-value group 3: 0.002; group 4: 0.012). In groups 2, 3, and 4, there were significantly lower BALF 25D3 levels compared to group 1 (p-value group 2: 0.000; group 3: 0.000; group 4: 0.001). There was a significant correlation between serum and BALF 25D3 levels (Spearman's rank correlation coefficient 0.318, p-value = 0.0001).

CONCLUSION

Lower levels of serum and BALF 25D3 were observed in HIV, TB, and HIV-TB coinfected patients. Localized deficiency of vitamin D metabolites might be associated with increased vulnerability to TB infection.

Compliance of WHO Guideline on Dengue Management among Indian Patients: An Interventional Quality Improvement Study

INTRODUCTION

Dengue fever management is guided by WHO guideline, the recent one being 2009; however, compliance to the guideline is difficult to assess and in India there is no data on it. The present study, a longitudinal pre-post interventional quality improvement study, was done to determine the compliance to the guideline on dengue patients before and after resident physicians' training during two peak seasons and their impact on survival.

METHODS

This study was conducted in a tertiary health care centre in North India over 18 months. Data of hospitalized patients who admitted with dengue fever diagnosis in a peak season was collected in the form of quality indicators as described by the WHO-2009 guideline on dengue. Resident physicians were then given appropriate training about the guideline during the off season. Data of new dengue patients in next peak season after resident training was collected and compared with the baseline by standard statistical tests.

RESULTS

The post-intervention compliances of all components increased (total mean score by giving one point to each of the quality indicators reached 7.9 from 6.4). The compliance to individual indicator also increased: the admission criteria (baseline, 44% to post-intervention, 52%, p = 0.37), classification criteria (91.7% to 96%, p = 0.33), correct staging/triage (42.9% to 86%, p <0.001), vitals monitoring (85.7% to 92%, p = 0.28), correct usage of bolus fluids (34.3% to 69.5%, p <0.001), crystalloid as choice of fluid (100% in both groups), proper fluid titration (26.2% to 56%, p <0.001), hematocrit monitoring (95.2% to 98%, p = 0.42), platelet transfusion when indicated (65.5% to 58%, p = 0.39), antibiotic use when required (61.5% to 80%, p = 0.03), and discharge criteria (100% in both groups). The mortality decreased from 7.1% (baseline) to zero (post-intervention). The median duration of hospital stay also reduced by 1 day.

CONCLUSION

The study affirms that the compliance to WHO guideline on dengue management in India can be further improved by regular physician training on the guideline. Simultaneously, this educational intervention not only improves patient outcomes but also direct proper resource utilization especially platelet transfusion and antibiotic use. Furthermore, every hospital/institute should have an internal quality improvement program like this to improve the management of dengue patients. Future studies are needed to understand various barriers to 100% implementation of the guideline.

Effect of sleep quality on memory, executive function, and language performance in patients with refractory focal epilepsy and controlled epilepsy versus healthy controls - A prospective study

We aimed to evaluate the effect of sleep quality on memory, executive function, and language performance in patients with refractory focal epilepsy and controlled epilepsy and compare these with healthy individuals. We prospectively enrolled 37 adolescent and adult patients with refractory focal epilepsy (Group 1) and controlled epilepsy (Group 2) in each group. History pertaining to epilepsy and sleep were recorded, and all patients underwent overnight polysomnography. Language, memory, and executive function assessments were done using Western Aphasia Battery, Post Graduate Institute (PGI) memory scale, and battery of four executive function tests (Trail Making Test A & B, Digit symbol test, Stroop Task, and Verbal Fluency Test), respectively. Forty age- and sex-matched controls were also included in the study. Significant differences were noted in both objective and subjective sleep parameters among all the groups. On polysomnography, parameters like total sleep time, sleep efficiency, sleep latency, and rapid eye movement (REM) latency were found to be significantly worse in Group 1 as compared with Group 2. Cognitive and executive parameters were significantly impaired in Group 1. Shorter total sleep time, poorer sleep efficiency, and prolonged sleep latencies were observed to be associated with poor memory and executive function in patients with refractory epilepsy. Our study strongly suggests that sleep disturbances, mainly shorter total sleep time, poor sleep efficiency, and prolonged sleep latencies, are associated with impaired memory and executive function in patients with refractory focal epilepsy and to a lesser extent, among those with medically controlled epilepsy.

Predictors and microbiology of ventilator-associated pneumonia among patients with exacerbation of chronic obstructive pulmonary disease

Background

Understanding the risk factors and microbiology of ventilator-associated pneumonia (VAP) among patients with chronic obstructive pulmonary disease (COPD) is important for the application of preventive and therapeutic interventions. Therefore, this study was planned to assess the clinical predictors and microbiological features of VAP among COPD patients.

Materials and Methods

This prospective study involved patients with exacerbation of COPD who required mechanical ventilation and admitted in respiratory intensive care unit at a tertiary care teaching hospital. Various baseline demographic and clinical features were compared between patients with VAP and without VAP. Univariate and multivariable analyses were done to assess the impact of demographic and clinical features on the development of VAP.

Results

The study included 100 intubated patients with age (mean ± standard deviation [SD]) of 62.45 ± 8.32 years, duration (median) of COPD of 6 years, and Acute Physiology, Age, and Chronic Health Evaluation score (mean ± SD) of 18.60 ± 4.30. In this cohort, 17 patients developed VAP. Multivariable analysis showed that Sequential Organ Failure Assessment (SOFA) score at admission, re-intubation, and history of previous hospitalization were independent predictors of VAP with odds ratio (95% confidence interval) of 2.70 (1.24, 5.63; P = 0.012), 66.96 (4.86, 922.72; P = 0.002), and 35.92 (2.84, 454.63; P = 0.006), respectively. Acinetobacter baumannii was the most frequent organism (n = 8; 47%), followed by Klebsiella pneumoniae (n = 5; 29%), Pseudomonas aeruginosa (n = 1; 6%), and Enterobacter spp. (n = 1; 6%). All organisms were multidrug resistant (MDR).

Conclusions

SOFA score at admission, re-intubation, and history of previous hospitalization were independent predictors of VAP. Antimicrobial therapy for VAP should cover MDR Gram-negative organisms.

Epidermal growth factor receptor (EGFR), KRAS, and BRAF mutations in lung adenocarcinomas: A study from India

Mitogen-Activated Protein (MAP) Kinase pathway involves several oncogenic genes which can serve as potential targets for therapy. Therefore, aim of the present study is to analyze mutations in the MAP Kinase pathway in pulmonary adenocarcinoma (ADCA) of Indian patients along with clinico-pathologic correlation and determination of the survival status in patients receiving therapy. Blocks and slides of 125 pulmonary ADCA of last 5 years were retrieved. Histo-morphology and tumor content were determined. EGFR, KRAS, BRAF and MEK1 genes were analyzed using Sanger sequencing and Real-time polymerase chain reaction (PCR). Clinico-pathologic correlation and survival analysis were performed. Fifty-eight (46.4%) patients harbored genetic mutations of which 49 had single somatic mutations, 5 had multiple exonic and 4 showed coexisting EGFR and KRAS mutations. EGFR mutations were seen in 24.8%, KRAS in 19.2% and BRAF (non-V600E) in 2.4% cases. There was no difference in progression-free survival of wild- type/single mutations when compared with multiple/ coexisting mutations (P = 0.09). However, the P value may indicate borderline correlation. To conclude, EGFR and KRAS mutations may coexist in the same patient in lung ADCA. Multiple exonic mutations of KRAS gene formed substantial percentage of our cohort, requiring further exploration. Lung ADCA harbouring BRAF mutations are commonly non-V600E. Testing of all major genetic driver mutations of lung ADCA irrespective of histology and other demographic characteristics is necessary.

1011. Sepsis and Secondary Hemophagocytic Lymphohistiocytosis

Background

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory condition diagnosed by HLH 2004 criteria. This criterion has common clinical and laboratory features with sepsis and tropical fevers, but there is marked difference in management and outcome of these two entities. The study is conducted to know whether there is any difference in the clinico-laboratory features, management, and outcome of sepsis with or without secondary HLH.

Methods

This is a prospective observational study where patients presenting with sepsis and bicytopenia are included. The patients underwent relevant investigations according to 2004 HLH diagnostic criteria. The patients are divided into sepsis with or without HLH. The underlying etiology, treatment, and outcome of the two groups are analysed.

Results

Fifty sepsis patients are included in the study, out of which 28 fulfilled the HLH diagnostic criteria which comprised of 18 men and 10 women. The etiology were bacterial (three enteric fever, three tuberculosis, two scrub typhus, one Staphylococcal aureus), viral (one dengue fever, two HIV, two encephalitis), fungal (one aspergillosis, one mucormycosis, two others), parasites (three malaria, one leishmania) malignancy (two hodgkin lymphoma, one non-Hodgkins lymphoma), and unknown etiology in six patients, with >1 etiology in three patients (Figure 2). The percentage of each criterion fulfilled in both groups is given in Figure 1, showing an increased occurrence of splenomegaly, low NK cell activity, hypertriglyceridemia in HLH patients. Steroids along with supportive treatment was given to 53% and etoposide was added in 7%. Treatment for underlying etiology alone without immunosuppressive treatment was given in 39%. The mortality in those with HLH vs. without HLH was 42% and 31%, respectively. The median duration of hospital stay was 18 and 36 days in HLH and without HLH group, respectively.

Conclusion

HLH should be suspected in sepsis patients with bicytopenia specially in tropical fevers. There is increased mortality if the sepsis patients fulfil HLH criteria. Early diagnosis and management is of paramount importance.

Disclosures

All authors: No reported disclosures.

Development and validation of Cognitive Training Intervention for Alzheimer's disease (CTI-AD): A picture-based interventional program

Introduction

Alzheimer’s disease is a gradual and progressive disorder which cripples the person’s functionality due to cognitive decline. Many clinicopathological and pharmacological therapy has the potential to slow down the progression of the disease but has limited efficacy. One complimentary approach that has emerged is cognitive training interventions which have shown synergistic effect with the drug therapy. Nevertheless, many cognitive interventions lack on specificities of the intervention due to which its efficacy gets scrutinized.

Objective

To describe the foundation, content, and development of Cognitive Training Intervention for Alzheimer’s disease (CTI-AD) along with the treatment feasibility based on a pilot study.

Materials and methods

A culture-specific picture-based eight weeks cognitive training manual was developed based on extensive review and focused group discussions. It was standardized on 63 older participants (48 healthy controls (HC); 15 early Alzheimer’s disease cases).

Results

All the tasks were progressive in nature and were found effective in discriminating the cognitive performance of early Alzheimer’s disease and HC throughout the intervention period. Moreover, it also improved early Alzheimer’s disease performance on the memory (HC: 1st week/8th week = 21.6 ± 5.7/57.3 ± 19.0; early Alzheimer’s disease: 1st week/8th week = 48.5 ± 22.9/60.5 ± 21.8); attention (HC: 1st week/8th week = 90.2 ± 18.0/196.9 ± 28.0; early Alzheimer’s disease: 1st week/8th week = 216.6 ± 78.2/286.8 ± 87.0) and language (HC: 1st week/8th week = 29.8 ± 9.4/115.3 ± 31.1; early Alzheimer’s disease: 1st week/8th week = 211.8 ± 68.4/270.4 ± 104.9) domains, respectively, from the baseline level.

Conclusion

The current manual (CTI-AD) is one of the first promising non-pharmacological program developed nationally with a strong theoretical base to cater to the tertiary needs of the older adults with early Alzheimer’s disease.

Outcomes of Implementing the Central Venous Catheter Bundle at a Tertiary Care Hospital in North India, at AIIMS, New Delhi

INTRODUCTION

Central venous catheter (CVC) associated infection are many times higher in India compared to western countries. A group of interventions called as CVC bundle, if implemented effectively prevents CVC related complication.

METHODOLOGY

Our study was a prospective quasi-experimental study. The study evaluated the level of compliance with the central venous catheter bundle in the management of patients in our Medicine wards and Intensive care unit (ICU).

RESULTS

:In the study, the incidence of central line associated bloodstream infection (CLABSI) was zero and the incidence of pneumothorax was 5%. Most of the patients had higher Acute physiology and chronic health evaluation (APACHE II) at baseline and multi organ dysfunction. The compliance with whole CVC bundle improved from 0% at baseline to 10% in post-intervention phase. Compliance of many components increased significantly in the post intervention period. These were Hand washing before insertion (15% to 72.5%, p<0.001), Maintenance (0% to 52.5%, p<0.001), Prompt removal of catheters (40% to 70%, p=0.007), Skin antisepsis with chlorhexidine increased approaching significance (0% to 12.5%, p=0.055). Avoidance of femoral catheters was done in more than 95% of the cases. The predictors of mortality were higher APACHE II (OR 1.23 [CI 1.03-1.47], p=0.020) and duration of hospital stay (OR 0.87 [CI 0.78-0.97], p=0.022).

CONCLUSION

This study done at All India Institute of Medical Sciences showed improved outcome in terms of catheter infection and mechanical complications. CVC bundle compliance increased significantly though adherence to full bundle was less. In future, with rectification of barriers to bundle completion, the compliance with CVC bundle can be further improved.

Prognostic significance of plasma matrix metalloprotease-2 in pancreatic cancer patients

Background & objectives:

Pancreatic cancer has a propensity for wide stromal invasion. Matrix metalloprotease-2 (MMP-2) is a protease that degrades the peri-tumoural tissue and helps in tumour dissemination. Thus, this study was aimed to assess any association of plasma MMP-2 levels with clinicopathological parameters and survival of patients with pancreatic cancer.

Methods:

Plasma samples from 127 pancreatic cancer patients were analyzed for MMP-2 levels by ELISA. Survival and other clinicopathological parameters of patients were analyzed for any correlation with plasma MMP-2 levels.

Results:

The mean MMP-2 levels in pancreatic cancer patients were 560.3±222.0 ng/ml which were significantly elevated compared to chronic pancreatitis patients (P<0.001) and healthy individuals (P<0.05). The plasma levels of MMP-2 significantly correlated with tissue expression of this protease (P=0.004). However, MMP-2 levels did not exhibit any association either with clinicopathological parameters or with survival.

Interpretation & conclusions:

Elevated MMP-2 levels were observed in blood of pancreatic cancer patients which correlated with its tissue expression. However, these levels did not associate with survival or any clinicopathological parameters of patients. Further studies need to be done to confirm the prognostic/clinical significance of MMP-2 in cancer patients before and after surgery.

'Van Herick Plus': a modified grading scheme for the assessment of peripheral anterior chamber depth and angle

AIM

To evaluate the accuracy of a new, modified grading scheme involving a short vertical slit beam, at the inferior angle for peripheral anterior chamber depth (PAC) and angle estimation and its correlation with anterior segment optical coherence tomography (ASOCT).

METHODS

A cross-sectional study of consecutive phakic patients, above 40 years of age, was performed. Using a short, vertical slit beam not reaching the pupil, the inferior angle at the sclerolimbal junction was evaluated, photographed and assessed by a ratio of peripheral anterior chamber depth to peripheral corneal thickness (PAC:PCT) and iridocorneal angle (ICA) on ImageJ software. The inferior angle at the same meridian was also recorded on ASOCT.

RESULTS

Based on the PAC:PCT ratio, the subjects were divided into four groups: I (<1/4), II (1/4-1/2), III (>1/2-1) and IV (>1). The clinically assessed angle by short vertical slit beam correlated well with ASOCT values, trabecular-iris angle (TIA) (r=0.918; p<0.001) and scleral spur angle (r=0.903, p<0.001). The mean difference between ICA and TIA on ASOCT was 0.797⁰; 95% limits of agreement:-5.767⁰ to 7.361⁰ (±1.96 SD). For angles graded narrow on ASOCT (TIA <20⁰), using a cut-off of peripheral PAC:PCT <1/4, the area under the curve was 0.918 with a sensitivity of 85.2% and a specificity of 88.2%. There was good agreement between ImageJ parameters with those assessed subjectively on photograph of the slit beam examination by a glaucoma fellow (weighted kappa=0.74) as compared with a general ophthalmologist, where there was moderate agreement (weighted kappa=0.57).

CONCLUSION

A short, vertical slit lamp beam evaluation at the inferior angle is an easy and relatively accurate method for both peripheral anterior chamber depth and angle assessment. It correlated well with ASOCT and can be used as a more reliable screening tool to identify eyes with possibly occludable angles.

Evaluation of the diagnostic yield of ARQIP: A new restless legs syndrome diagnostic questionnaire and validation of its Hindi translation

Background

Restless legs syndrome (RLS) is misdiagnosed due to a variety of clinical presentations and lack of a diagnostic biomarker. Sociocultural differences in patients' reporting of symptoms further contribute to this under diagnosis. We developed an expanded diagnostic tool for RLS, incorporating all International RLS Study Group (IRLSSG) diagnostic criteria with a number of additional questions mainly focusing on specific sociocultural influences in RLS symptom reporting among Indians. The purpose of this study was to examine the change in the diagnostic yield of RLS, if any, through administration of this expanded questionnaire.

Materials and Methods

The AIIMS RLS questionnaire for Indian patients (ARQIP) was developed in English language, and then translated into Hindi. All consecutive patients attending Neurology and sleep disorders clinic with complaints of leg discomfort were recruited in the study. Two examiners evaluated all patients with complaints of leg discomfort seen by a senior Sleep Medicine expert, one using only IRLSSG diagnostic criteria and the other using the ARQIP. Patients were categorized as RLS or "no-RLS" by the expert, and this was considered as the "standard" for analysis.

Results

A total of 155 participants (78 males, 50.3%) with a mean age of 44.1 ± 14.5 years were enrolled. A total of 105 patients were diagnosed as having RLS (group 1) and the rest as having "non-RLS" (group 2). The ARQIP was found to have a much higher sensitivity (100% vs 73%), specificity (44% vs 32.7%), negative predictive value (100% vs 36.4%), and positive predictive value (79% vs 70%) compared to the standard questionnaire. The diagnostic yield of this tool was 26.7% (Confidence interval = 100-73.3).

Conclusions

The ARQIP for RLS diagnosis, validated in this study, has been observed to have a high sensitivity and a negative predictive value with a high diagnostic accuracy.

Patients Who Benefit from Intracranial Pressure Monitoring without Cerebrospinal Fluid Drainage After Severe Traumatic Brain Injury

BACKGROUND

India has a high traumatic brain injury (TBI) burden and intracranial pressure monitoring (ICP) remains controversial but some patients may benefit.

OBJECTIVE

To examine the association between ICP monitor placement and outcomes, and identify Indian patients with severe TBI who benefit from ICP monitoring

METHODS

We conducted a secondary analysis of a prospective cohort study at a level 1 Indian trauma center. Patients over 18 yr with severe TBI (admission Glasgow coma scale score < 8) who received tracheal intubation for at-least 48 h were examined. Propensity-based analysis using inverse probability weighting approach was used to examine ICP monitor placement within 72 h of admission and outcomes. Outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) score at discharge, 3, 6, and 12 mo. Death, vegetative, or major impairment defined unfavorable outcome.

RESULTS

The 200 patients averaged 36 [18 to 85] yr of age and average injury severity score of 31.4 [2 to 73]. ICP monitors were placed in 126 (63%) patients. Patients with ICP monitor placement experienced lower in-hospital mortality (adjusted relative risk [aRR]; 0.50 [0.29, 0.87]) than patients without ICP monitoring. However, there was no benefit at 3, 6, and 12 mo. With ICP monitor placement, absence of cerebral edema (aRR 0.54, 95% confidence interval 0.35-0.84), and absence of intraventricular hemorrhage (aRR 0.52, 95% confidence interval 0.33-0.82) were associated with reduced unfavorable outcomes.

CONCLUSION

ICP monitor placement without cerebrospinal fluid drainage within 72 h of admission was associated with reduced in-patient mortality. Patients with severe TBI but without cerebral edema and without intraventricular hemorrhage may benefit from ICP monitoring.

Higher Frequency of HIV-1 Drug Resistance and Increased Nucleoside Reverse Transcriptase Inhibitor Mutations among the HIV-1 Positive Antiretroviral Therapy-Naïve patients Coinfected With Mycobacterium tuberculosis Compared With Only HIV Infection in India

Background:

Emergence of human immunodeficiency virus (HIV) drug resistance mutations prior to highly active antiretroviral therapy is a serious problem in clinical management of HIV/AIDS. Risk factors for appearance of drug resistance mutations are not known. We hypothesize that Mycobacterium tuberculosis infection may contribute to rapid emergence of such mutations in antiretroviral therapy–naïve patients.

Methods:

A total of 115 patients were recruited in this study of which 75 were HIV+TB+ coinfected (group 1) and 40 were HIV+TB− (group 2). Blood samples from all the patients were collected and CD4+ cell counts; HIV-1 plasma viral load and sequencing of protease and two-third region of reverse transcriptase of HIV-1 was performed and analyzed for drug resistance pattern.

Results:

For patients with HIV+TB+, 10.6% (8/75) had mutations to non-nucleoside reverse transcriptase inhibitors (NNRTIs), 4% (3/75) to nucleoside reverse transcriptase inhibitors, and only 2.6% (2/75) patients had mutations to protease inhibitors. Interestingly, for group 2 (HIV+TB−), there were only NNRTI mutations found among these patients, and only 3 patients (7.5%) had these drug-resistant mutations. Clade typing and phylogenetic tree analysis showed HIV-1 subtype C predominance in these patients.

Conclusions:

Our study showed that higher percentage of HIV drug resistance mutations was found among HIV+TB+ individuals compared with tuberculosis-uninfected patients. Tuberculosis coinfection may be a risk factor for emergence of high frequency of drug resistance mutations. Studies with a larger sample size will help to confirm these findings from the Indian population.

Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India

BACKGROUND

Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden.

METHODS AND FINDINGS

We assessed 3,964 children (with almost equal number of boys and girls distributed in 2-<6 and 6-9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6-9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2-<6 year olds ranged from 2.9% (95% CI 1.6-5.5) to 18.7% (95% CI 14.7-23.6), and for any of nine NDDs in the 6-9-year-old children, from 6.5% (95% CI 4.6-9.1) to 18.5% (95% CI 15.3-22.3). Two or more NDDs were present in 0.4% (95% CI 0.1-1.7) to 4.3% (95% CI 2.2-8.2) in the younger age category and 0.7% (95% CI 0.2-2.0) to 5.3% (95% CI 3.3-8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5-11.2) and 13.6% (95% CI 11.3-16.2) in children of 2-<6 and 6-9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6-9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population.

CONCLUSIONS

The study identifies NDDs in children aged 2-9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.

Role of Positive Airway Pressure Therapy for Obstructive Sleep Apnea in Patients With Stroke: A Randomized Controlled Trial

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is an independent risk factor for stroke. The objective of this study was to assess the effect of continuous positive airway pressure (CPAP) treatment on prevention of new vascular events among patients with stroke and OSA.

METHODS

Consecutive conscious patients presenting with first imaging-confirmed arterial stroke were included, 6 weeks or more after ictus. All patients underwent clinical and polysomnography (PSG) testing. Patients with an apnea-hypopnea index (AHI) of > 15 events/h were randomized to posttitration nightly CPAP treatment and non-CPAP (received best medical treatment) groups. On follow-up at 3, 6, and 12 months from randomization, evaluation was carried out for any new vascular events as the primary outcome measure, and for clinical stroke outcomes (using the Barthel Index and modified Rankin scale) and neuropsychological parameters as the secondary outcome measures.

RESULTS

Among the 679 patients with stroke who were screened, 116 reported for PSG, 83 had AHI > 15 events/h, and 70 (34 in CPAP and 36 in non-CPAP) were randomized. Thirteen patients could not be randomized because of a lack of CPAP devices. Four patients crossed over from the CPAP to the non-CPAP group. Age (mean age 53.41 ± 9.85 in CPAP versus 52.69 ± 13.23 years in non-CPAP, P = .81) and sex distribution (24 males in CPAP versus 33 males in non-CPAP, P = .79) were similar in both groups. At 12-month follow-up, there was 1 vascular event (3.33%) in the CPAP group and 6 events (15%) in the non-CPAP group (P = .23). Modified Rankin scale score improvement by ≥ 1 at 12-month follow-up was found in significantly more patients in the CPAP group than in the non-CPAP group (53% versus 27%).

CONCLUSIONS

These findings suggest significantly better stroke outcomes and statistically nonsignificant favorable outcomes in terms of recurrence of vascular events for patients with stroke and OSA who use CPAP treatment.

CLINICAL TRIAL REGISTRATION

Registry: Clinical Trials Registry - India, CTRI Registration No: CTRI/2016/07.007104, Title: Sleep Disordered Breathing in stroke patients: Effect of treatment trial, URL: http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=8682&EncHid=&userName=sleep%20disordered%20breathing.

Narrowing of the Anterior Chamber Angle during Valsalva Maneuver: A Possible Mechanism for Angle Closure

Purpose

To evaluate changes at the anterior chamber angle during Valsalva maneuver in eyes suspected to have a primary adult glaucoma.

Methods

Seventy-six consecutive patients underwent recording of applanation tonometry, measurement of the anterior chamber angle recess, angle opening distance, angle recess area, scleral spur-iris root distance, iris thickness, iridociliary angle, ciliary body thickness, anterior chamber depth, and pupil size on ultrasound biomicroscopy before and during the Valsalva maneuver. The Valsalva maneuver was standardized to a pressure of 40 mmHg for 15 seconds, using a manometer.

Results

The mean baseline intraocular pressure changed from 19.5±4.1 mmHg to 29.5±4.8 mmHg during Valsalva (p<0.0001). The anterior chamber angle recess narrowed from 17.9±9.5 to 7.8±9.2 degrees (p=0.0001). The angle recess area diminished from 0.15±0.14 mm2 to 0.14±0.12 mm2 (p=0.03) and the scleral spur to iris distance decreased from 0.19±0.2 mm to 0.16±0.18 mm (p=0.0001). The iridociliary angle narrowed from 72.6±33.5 degrees to 62.5±32.8 degrees (p=0.04). There was a significant increase in the thickness of the ciliary body, from 0.99±0.19 mm to 1.12±0.16 mm (p=0.001) and in iris thickness from 0.47±0.07 mm to 0.55±0.09 mm (p=0.0001). There was no significant change in the angle opening distance, anterior chamber depth, or pupillary diameter. A significant narrowing of the angle to less than 5 degrees was seen in 37 eyes, with iridocorneal apposition present in 28 eyes. After multivariate regression analysis it was found that the baseline ciliary body thickness and angle recess were significant predictors of narrowing of the angle (R2=96.1%).

Conclusions

Significant elevation of the intraocular pressure, narrowing of the anterior chamber angle recess, thickening of the ciliary body, and increase in the iris thickness is seen during the Valsalva maneuver. The Valsalva maneuver may lead to angle closure in eyes anatomically predisposed to primary angle closure glaucoma.

Prevalence of severe acute malnutrition and associated sociodemographic factors among children aged 6 months-5 years in rural population of Northern India: A population-based survey

Introduction

National Family Health Survey (NFHS)-3 documented that nearly 57 million children are undernourished in India, which is one-third of the world's share. We planned a study to identify the prevalence of severe acute malnutrition (SAM) among children aged <5 years in a rural population of Northern India.

Materials and Methods

A cross-sectional study was conducted at 2 blocks of District Meerut during 2012-2014. A total of 70 villages were identified and all children in the age group 6-60 months were approached through house-to-house visits. Data on sociodemographic profile and anthropometry were collected utilizing standards methods and equipment. The Z-scores for weight-for-age, height-for-age, and weight-for-height (WHZ) were calculated using the World Health Organization (WHO) reference data as standard. SAM (severe wasting) was defined as per the WHO criteria (WHZ score <-3 standard deviation or severe visible wasting or bipedal edema).

Results

A total of 19,449 children were screened and 18,463 children (age, 32.6 ± 15.4 years, and 53.4% males) were enrolled, and 466 were excluded due to erroneous age estimation and physical deformities. The prevalence of SAM was 2.2%, 95% confidence interval (CI) 2.02-2.44%, (409/18,463). Multivariate logistic regression documented age (odds ratio [OR]: 0.97, 95% CI 0.96-0.98), nuclear family (OR: 1.25, 95% CI 1.01-1.54), lower occupation of head of family (OR: 1.29, 95% CI 1.05-1.59), and lower paternal education (OR: 1.49, 95% CI 1.16-1.91) as independent predictor of SAM.

Conclusion

The prevalence of SAM was lower (2.2%) in this Northern district of India as compared to national prevalence (7.9%). Younger age, nuclear family, lower parental education, and poor occupation of the head of the family predispose a child to SAM.

1% versus 2% lignocaine for airway anesthesia in endobronchial ultrasound-guided transbronchial needle aspiration: A pilot, double-blind, randomized controlled trial

Background and Objectives:

No previous study has compared different concentrations of lignocaine for topical anesthesia during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In this pilot study, we compared 1% versus 2% lignocaine for topical airway anesthesia during EBUS-TBNA.

Methods:

In this double-blind, randomized trial, subjects were randomized to receive either 1% or 2% lignocaine for “spray-as-you-go” administration. All received combined moderate intravenous sedation (midazolam and fentanyl). Ten percent pharyngeal lignocaine spray (two sprays) and nebulized lignocaine (2.5 ml of 4% solution) were administered to all subjects. Administration of additional lignocaine was allowed at operator's discretion. The primary endpoints were operator-rated overall procedural satisfaction and cough, each assessed on visual analog scale (VAS), while the secondary outcomes included patient-rated faces pain scale scores, cumulative lignocaine dose, number of subjects receiving lignocaine >8.2 mg/kg, doses of midazolam/fentanyl between groups, and adverse events during procedure.

Results:

The mean (standard deviation [SD]) VAS scores for operator-rated procedure satisfaction were 64.2 (25.6) and 68.7 (23.7) in 1% and 2% group, respectively (P = 0.35). The median (interquartile range) VAS scores for operator-rated cough were 48.4 (23.9–69.9) in 1% group and 38.7 (18.6–69.5) in 2% group (P = 0.24). The mean [SD] cumulative lignocaine received in the 2% lignocaine group (248.6 [29.1] mg) was significantly greater than in 1% lignocaine group (178.5 [14.6] mg) (P < 0.01).

Conclusion:

One percent lignocaine is equally efficacious as 2% lignocaine for topical anesthesia during EBUS-TBNA, at a significantly lower cumulative lignocaine dose.