Stroke incidence, mortality, subtypes in rural and urban populations in five geographic areas of India (2018-2019): results from the National Stroke Registry Programme

Background

Increasing stroke burden in India demands a long-term stroke surveillance framework. Earlier studies in India were urban-based, short term and provided limited data on stroke incidence and its outcomes. This gap is addressed by the establishment of five population-based stroke registries (PBSRs) of the National Stroke Registry Programme, India. This paper describes stroke incidence, mortality and age, sex, and subtypes distribution in the five PBSRs with urban and rural populations.

Methods

First-ever incident stroke patients in age group ≥18 years, resident for at least one year in the defined geographic area, identified from health facilities were registered. Death records with stroke as the cause of death from the Civil Registration System (CRS) were included. Transient ischemic attack (TIA) was excluded. Three PBSRs (Cuttack, Tirunelveli, Cachar) included urban and rural populations. PBSRs in Kota and Varanasi were urban areas. The crude and age-standardized incidence rate (ASR) by age, sex, and residence (urban and rural), rate ratios of ASR, case fatality proportions and rates at day 28 after onset of stroke were calculated for years 2018-2019.

Findings

A total of 13,820 registered first-ever stroke cases that included 985 death certificate-only cases (DCOs) were analysed. The pooled crude incidence rate was 138.1 per 100,000 population with an age-standardized incidence rate (ASR) of 103.4 (both sexes), 125.7 (males) and 80.8 (females). The risk of stroke among rural residents was one in seven (Cuttack), one in nine (Tirunelveli), and one in 15 (Cachar). Ischemic stroke was the most common type in all PBSRs. Age-standardized case fatality rates (ASCFR) per 100,000 population for pooled PBSRs was 30.0 (males) and 18.8 (females), and the rate ratio (M/F) ranged from 1.2 (Cuttack) to 2.0 (Cachar).

Interpretation

Population-based registries have provided a comprehensive stroke surveillance platform to measure stroke burden and outcomes by age, sex, residence and subtype across India. The rural-urban pattern of stroke incidence and mortality shall guide health policy and programme planning to strengthen stroke prevention and treatment measures in India.

Funding

The National Stroke Registry Programme is funded through the intramural funding of the Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, India.

Effect of Vaccination on Markers of Severity among Elderly Covid-19 Patients-A Retrospective Comparative Analysis

Since December 2019, an emerging coronavirus called Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV-2) has been spreading worldwide. Older people and those with comorbidities are more likely to develop severe illness. Vaccines against coronavirus have been developed recently. In India, the two vaccine currently authorized to use are namely ChAdOx1 nCov, Covishield and Covaxin; both of which require 2 shots few weeks apart for adequate protection. Although COVID antibody test has not been done following vaccination in my subjects, it was observed that those who were vaccinated with one or two doses had less clinical severity compared to non vaccinated patients. In this study, we did a comparative analysis of the laboratory markers of severity in elderly COVID patients who were fully vaccinated, partially vaccinated and non vaccinatednon-vaccinated.

MATERIAL

This study is conducted with COVID-19 patients in age group more than 65 years for duration of 6 months. Participants were divided in three group Fully Vaccinated group who received 2 doses, Partially Vaccinated group with only 1 dose and non-vaccinated group. Assessment of inflammatory markers like CRP, LDH and Ferritin, Procalcitonin, RDW and NLR were done in the three groups.

OBSERVATION

A total of 52 fully vaccinated, 120 partially vaccinated and 458 non vaccinated patients were included in this study. The mean LDH, ferritin, procalcitonin, RDW, NLR in the fully vaccinated group were 381.61±167.53 U/l, 286.77±226.73 ng/ml, 0.40±0.32 ng/ml, 14.23±1.80 % and 8.85±10.36 respectively; that in the partially vaccinated group were 413.89±209.75 U/l, 387.44±317.55 ng/ml, 1.08±2.98 ng/ml, 14.45±1.42 % and 10.20±12.30 respectively; and in the non vaccinated group were 583.97±638.90 U/l, 479.03±332.85 ng/ml, 5.30±15.91 ng/ ml, 14.93±1.96 % and 11.97±12.57 respectively. Significant differences were found in terms of LDH, Ferritin, RDW and CRP among the groups with p values of <0.01, <0.0001, <0.01 and <0.05 respectively. However, no significant difference (p>0.05) was observed in terms of procalcitonin and NLR among the groups although the average values were found to increase from fully vaccinated to partially vaccinated to non-vaccinated groups.

CONCLUSION

Vaccination was associated with less severity when analysed in terms of laborotary parameters in COVID-19 elderly patients.

Families of Children Newly Diagnosed With Cancer Incur Significant Out-of-Pocket Expenditure for Treatment: Report of a Multi-Site Prospective Longitudinal Study From India (INPOG-ACC-16-01)

Background: Diagnosis of cancer in a child places considerable economic burden on families. The health expenditures are more catastrophic in resource limited countries like India where GDP spend on health is just over 1% and financing of treatment is usually out-of-pocket (OOP). Consequently parents may abandon their child's cancer treatment to ensure financial sustainability of the family. Research in this area is mostly from resource rich countries and OOP expenditure burden remains unknown in India. Aim: The objective of this study is to describe the OOP expenditure incurred by families of children (< 18 years age) with cancer being treated in India prior to and during cancer directed treatment. Methods: A prospective cost of illness study from a family household perspective was conducted in 14 centers (5 public, 5 private and 4 charitable trust sector) in 4 cities in India from 2016-2018. Baseline family demographic and socioeconomic data were collected followed by OOP expenditure incurred prior to start of treatment. For the duration of the child's treatment, a social worker contacted parents at regular intervals to record their expenditure on cancer directed treatment. Data collection was stopped when one of these happened - completion of treatment or death or progression/relapse or abandonment or transfer. Data were described descriptively and a univariate/multivariate analysis using logistic regression was done to detect factors associated with OOP expenditure. Results: 394 children (63% male, median age 5 years) with cancer (64% leukemia/lymphoma, 33% solid tumors, 3% CNS tumors) were enrolled from public (45%), charitable trust (28%) and private (27%) sector hospitals. They were symptomatic for a median duration of 6 weeks (range 0 to 104 weeks). 88% had no insurance and 73% were from families with monthly income of ≤ 10,000 rupees (≤ 159 US$). Mean OOP expenditure was Rs 209,500 (3325 US$) which is 195% of per capita income (1706 US$) of India. OOP expenditure from onset of symptoms to start of treatment was Rs 53,104 (843 US$) of which 77% was medical (15% laboratory tests, 11% medicines, 9% hospital bed costs) and 23% nonmedical (12% travel, 6% food, 3% lodging). OOP expenditure on cancer directed treatment was Rs 156,396 (2482 US$) of which 64% was medical (9% hospital bed costs, 9% supportive care drugs, 8% laboratory tests) and 36% nonmedical (19% food, 9% travel, 6% lodging). On univariate analysis age, gender, city, type of treatment facility, insurance, type of cancer, driving time and distance were significantly associated with OOP expenditure but only insurance and type of treatment facility were found significant on multivariate analysis. Conclusion: Families of children with cancer incur significant OOP expenditure prior to and during cancer directed treatment, which includes a significant portion on nonmedical expenses. Expenditure varied significantly by insurance and type of treatment facility.

Reaching Consensus by Allowing Moments of Indecision

Group decision-making processes often turn into a drawn out and costly battle between two opposing subgroups. Using analytical arguments based on a master equation description of the opinion dynamics occurring in a three-state model of cooperatively interacting units, we show how the capability of a social group to reach consensus can be enhanced when there is an intermediate state for indecisive individuals to pass through. The time spent in the intermediate state must be relatively short compared to that of the two polar states in order to create the beneficial effect. Furthermore, the cooperation between individuals must not be too low, as the benefit to consensus is possible only when the cooperation level exceeds a specific threshold. We also discuss how zealots, agents that remain in one state forever, can affect the consensus among the rest of the population by counteracting the benefit of the intermediate state or making it virtually impossible for an opposition to form.

Response to Modified Antitubercular Drug Regime and Antiretroviral Therapy in a Case of HIV Infection with Disseminated Tuberculosis with Isoniazid Induced Toxic Epidermal Necrolysis

Toxic epidermal necrolysis (TEN) is a potentially life-threatening disorder characterized by widespread erythema, necrosis, and bullous detachment of the epidermis and mucous membranes. Without proper management,TEN can cause sepsis leading to death of the patient. Though TEN is commonly drug induced, Isoniazid (INH) has been uncommonly associated with TEN. As INH is one of the first line drugs in treatment of tuberculosis, TEN induced INH needs modification of antitubercular therapy (ATT) with withdrawal of INH from the treatment regime along with other supportive treatments. Patients with HIV infection and disseminated tuberculosis need to be urgently initiated on an effective ATT on diagnosis of tuberculosis. However, if the patient develops potential life-threatening toxicity to first line antitubercular drugs like INH, an alternative effective ATT combination needs to be started as soon as the condition of the patient stabilizes as most of these patients present in advanced stage of HIV infection and this is to be followed by antiretroviral therapy (ART) as per guidelines. The present case reports the effectiveness of an ATT regime comprising Rifampicin, Pyrazinamide, Ethambutol, and Levofloxacin along with ART in situations where INH cannot be given in disseminated tuberculosis in HIV patients.

Comparison of central venous and external jugular venous pressures during repair of proximal femoral fracture

BACKGROUND

External jugular venous pressure (EJVP) is a close estimate of central venous pressure (CVP) in patients undergoing mechanical ventilation in the supine position, but the effects of spontaneous respiration and posture on this relationship are not known. In this study, we compared CVP with EJVP measurements in 36 patients undergoing repair of proximal femoral fracture breathing spontaneously in the supine or lateral positions.

METHODS

A standard general anaesthetic was administered with patients breathing spontaneously via a laryngeal mask airway and i.v. fluids administered according to an algorithm guided by CVP measurements. CVP and EJVP catheters were placed on the right side of the neck where possible.

RESULTS

In the supine position, 185 paired measurements of CVP and EJVP and 79 in the lateral position were recorded by a blinded observer during surgery. In the supine position, the mean difference between CVP and EJVP was -0.3 mm Hg (limits of agreement -2.6 to +1.9 mm Hg, 95% confidence intervals for both upper and lower limits of agreement, respectively, were -2.9 to -2.2 and +1.6 to +2.2 mm Hg). In the lateral position, the mean difference was -1.2 mm Hg (limits of agreement -5.8 to +3.8 mm Hg, 95% confidence intervals -6.8 to -4.5 and +2.7 to +4.9 mm Hg).

CONCLUSIONS

These data suggest that EJVP is an acceptable estimate of CVP in the supine position. Agreement was poor in the lateral position but was stronger for estimates of trend rather than absolute values. This could be explained by the direct effects of posture.

Is intraperitoneal levobupivacaine with epinephrine useful for analgesia following laparoscopic cholecystectomy? A randomized controlled trial

BACKGROUND AND OBJECTIVE

A randomized controlled trial of patients undergoing laparoscopic cholecystectomy. To evaluate whether the instillation of levobupivacaine, with epinephrine, intraperitoneally, reduces morphine consumption; further, to consider the degree of abdominal and shoulder pain in the presence of local anaesthetic at the site of surgical incision.

METHODS

Patients received a standardized procedure and were allocated randomly to receive either (a) 2.5 mg mL(-1) levobupivacaine 30 mL, with epinephrine 5 microg mL(-1), or (b) normal saline 30 mL, with epinephrine 5 microg mL(-1), to the bed of the gall bladder and above the liver, immediately before wound closure.

RESULTS

Median (interquartile range) total abdominal pain during inspiration in the levobupivacaine group was significantly (P = 0.041) lower (71 (21-129) mm) than that in the placebo group (123 (71-179) mm). However, there was no significant difference between the two groups with respect to total abdominal pain at rest, right shoulder pain or the consumption of rescue morphine and rescue dihydrocodeine. There were no differences between the two groups with respect to the administration of cyclizine, total nausea and total sedation scores. In addition, the number of episodes of vomiting was not significantly different.

CONCLUSIONS

Intraperitoneal administration of levobupivacaine with epinephrine is associated with modest analgesia following laparoscopic cholecystectomy.

Randomized controlled trial investigating the effect of transcervical papaverine and bupivacaine on postoperative analgesia following laparoscopic sterilization

BACKGROUND AND OBJECTIVE

A critical factor that delays patient discharge following day-surgery is severe postoperative pain and the requirement for strong analgesics. Laparoscopic sterilization is a day case procedure and is associated with additional postoperative pain compared with diagnostic laparoscopy. This pain, associated with application of Filshie clips, may be ischaemic or spasmodic in aetiology. Papaverine relaxes smooth muscle, and the aim of the study was to investigate if papaverine would be effective in improving postoperative pain if administered directly to the Fallopian tubes. Bupivacaine is used commonly in day-surgery and so we compared the effect of this local anaesthetic with saline placebo.

METHODS

Sixty-six ASA I-II females undergoing laparoscopic sterilization were entered into the prospective, randomized, double-blind, placebo-controlled clinical trial. They received intrauterine papaverine (30 mg) or bupivacaine (0.375% 30 mL) or normal saline (30 mL) via the transcervical route before application of Filshie clips.

RESULTS

There were no significant differences in the postoperative period between the three groups in the number of patients needing analgesia in the first 60 min postoperatively, the time to first analgesia, the rescue analgesic or antiemetic consumption, the incidence of postoperative nausea and vomiting, and the sedation and visual analogue pain scores.

CONCLUSIONS

From the data presented, we would not recommend routine transcervical administration of papaverine or bupivacaine for pain following laparoscopic sterilization.

The analgesic effects of intraperitoneal and incisional bupivacaine with epinephrine after total abdominal hysterectomy

The objective of our study was to see if incisional and intraperitoneal bupivacaine with epinephrine produces analgesia after total abdominal hysterectomy. Forty-six ASA physical status I and II patients received a standardized anesthetic, patient-controlled analgesia (PCA) morphine, and rectal paracetamol 1 g every 6 h. Patients were randomized to receive 50 mL of bupivacaine 0.25% with epinephrine 5 microg/mL or 50 mL of normal saline. Thirty milliliters and 20 mL of treatment solution were administered into the peritoneum and incision, respectively, before wound closure. Seventeen and 16 patients in the Placebo and Bupivacaine groups, respectively, completed the study. The reasons for withdrawal were PCA malfunction, PCA discontinued too early, nausea, chest infection, intraabdominal drain insertion, and protocol violation. There were no significant differences between the Bupivacaine and Placebo groups in age, height, weight, or duration of surgery. Pain on movement was significantly more intense in the Placebo group than in the Bupivacaine group on awakening. Morphine consumption (interquartile range) over 24 h was 62 mg (53-85 mg) in the Placebo group compared with 44 mg (33-56 mg) in the Bupivacaine group (P < 0.01). This significant difference was attributable to the larger morphine consumption in the Placebo group in the first 4 postoperative h. We conclude that a combination of intraperitoneal and incisional bupivacaine with epinephrine provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy.

IMPLICATIONS

A combination of intraperitoneal and incisional bupivacaine with epinephrine may be recommended because it provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy.

Flow characteristics of long spinal needles

A 120 mm, 27-gauge needle has recently been introduced for subarachnoid anaesthesia when using a single-space, combined spinal-extradural technique. The flow characteristics of this needle were compared with those of a 120 mm, 26-gauge needle using a pressure monitor infusion pump. Surprisingly, the resistance to fluid flow of the 26-gauge needle was twice that of the 27-gauge needle. The results of this experiment were confirmed by the findings of a clinical study undertaken in 100 obstetric patients who required regional anaesthesia. The time taken from dural puncture to appearance of cerebrospinal fluid at the hub of the needle was on average three times greater with the 26-gauge needle.

Posture and the spread of hyperbaric bupivacaine in parturients using the combined spinal epidural technique

This study was undertaken to analyze the effect of posture on the spread of hyperbaric bupivacaine in pregnant women using a combined spinal extradural technique, and to assess the quality of analgesia provided by 10 mg bupivacaine when using this technique. Fifty parturients undergoing elective Caesarean section under regional anaesthesia were randomly allocated to receive 2.0 ml hyperbaric bupivacaine 0.5% in either the sitting or left lateral position. Spinal injection was performed with a 27 gauge, 120 mm long spinal needle using a single space combined spinal extradural technique. The onset time to analgesia at T4, and grade 3 motor block was on average 7.7 min and 6.9 min respectively in the lateral group, compared with 10.8 min (P < 0.05) and 9.4 min (P < 0.05) in the sitting group. Nine women in the sitting group and one woman (P < 0.05) in the lateral group required epidural supplementation. Hypotension occurred in 48% of the parturients in the lateral group and in 13% (P < 0.05) of the parturients in the sitting group. Nausea was noted in 61% of the parturients in the lateral group and in 22% (P < 0.05) of the parturients in the sitting group. There was no difference between the two groups in neonatal outcome. Overall, the position of the patient during induction of spinal anaesthesia does influence the rate of onset of analgesia and motor blockade. Injection of 10 mg hyperbaric bupivacaine in the sitting position would not provide adequate analgesia for Caesarean section when using a single space combined spinal extradural technique.

A comparison of the effects of captopril and flosequinan in patients with severe heart failure

Angiotensin converting enzyme inhibitors have greatly improved the treatment of patients with chronic heart failure but they are not effective in all patients, and their use may be limited by side effects. There is, therefore, a need to investigate new drugs and to compare their efficacy with angiotensin converting enzyme inhibitors. Flosequinan is a new direct-acting vasodilator that has been shown to be effective in placebo-controlled studies. Patients with chronic heart failure in NYHA classes II or III who remained symptomatic despite at least 80 mg of frusemide daily were recruited from two centers. Following a single-blind placebo run-in period, the patients were randomized double blind to either the addition of captopril or flosequinan for 6 weeks. Following a further 2-week placebo washout period, they were then given the alternative treatment. Symptom-limited treadmill exercise times, scores of perceived exertion, and corridor walk tests were measured at two weekly intervals during the study. Twenty-five patients entered the study, 16 of whom completed without a change in diuretic dose. Five patients were withdrawn while taking captopril and two while taking flosequinan; two were withdrawn during the placebo washout period. For those patients who completed the study, flosequinan increased treadmill exercise tolerance from a mean (SEM) placebo time of 11.5 (1.0) minutes by 2.4 (0.6) (p = 0.0002) and captopril from 12.0 (0.8) minutes by 1.2 (0.6) minutes (p = 0.08). Comparison of the other measures of efficacy revealed no difference between the groups. In this short-term study flosequinan appeared to be equal in efficacy to captopril.

The pulmonary physician and critical care. 2. The injured lung: conventional and novel respiratory therapy

Several alternatives to conventional ventilation in acute lung injury are now available and have been investigated to a varying degree. The assessment of all such techniques is limited by difficulties in designing proper comparative studies and by the time needed to recruit a large number of appropriate patients with acute lung injury. A common theme of lung volume maintenance combined with strategies designed to limit the extent of ventilator induced lung damage has emerged and should encourage reassessment of the conventional approach. The results of several large prospective comparative studies are eagerly awaited. Meanwhile we may reasonably suggest that improvements in respiratory support, together with advances in microbiological and pharmacological treatment, have the potential for improving the persistently disappointing survival rate in acute lung injury.

The transmission of signals by auditory-nerve fiber discharge patterns

Recent developments in the theory of point processes are used to analyze the accuracy by which signals are conveyed by the discharges of single auditory-nerve fibers. It is shown that the only spike trains which can convey a signal without distortion are those well-described by a Poisson process model. Theoretical predictions are made of the distortion present in the transmission of signals by auditory-nerve fiber discharge patterns. Absolute refractory effects are shown to result in more distortion than relative refractory ones. Procedures are developed to compensate for these distortions. The procedures designed to compensate for absolute refractory effects operate on the PST histogram. Computer simulations are used to confirm the theoretical predictions and to assess the accuracy of the compensation techniques.