Landscaping tuberculosis multimorbidity: findings from a cross-sectional study in India

BACKGROUND

Multimorbidity, the concurrent presence of two or more chronic conditions is an emerging public health challenge. Till date, most of the research have focused on the presence and interaction of selected co-morbidities in tuberculosis (TB). There exist a critical knowledge gap on the magnitude of multimorbidity among TB patients and its impact on health outcomes.

METHODS

We undertook a cross-sectional study to assess the prevalence and patterns of multimorbidity among newly diagnosed TB patients in two states of India. A total of 323 patients were interviewed using a structured multimorbidity assessment questionnaire for primary care (MAQ-PC). MAQ-PC is already validated for Indian population and elicits 22 chronic conditions. We defined TB multimorbidity as the co-existence of TB with one or more chronic conditions and identified commonly occurring dyads (TB + single condition) and triads (TB + two conditions).

RESULTS

More than half (52%) of TB patients reported multimorbidity. Among dyads, depression, diabetes mellitus (DM), acid peptic disease (APD), hypertension, chronic alcoholism, arthritis and chronic back ache (CBA) were the most common co-occurring conditions while 'DM + arthritis', 'depression + APD', 'depression + DM' were the most commonly occurring triads among TB patients. Factors such as increasing age, low levels of education, alcohol abusers, drug-resistant TB and having health insurance were significantly associated with multimorbidity among TB patients.

CONCLUSIONS

Our findings suggest high prevalence of multimorbidity among newly diagnosed TB patients in India. The presence of concordant and discordant conditions with TB may increase the health complexity, thus necessitating appropriate care protocols. Given, the current situation, wherein TB and non-communicable diseases (NCD) services are delivered through collaborative framework between programmes, there is a need for addressing multimorbidity at the healthcare delivery level.

Serum levels of sclerostin in prediabetes and its correlation with bone mineral density

Background

Diabetes is a major burden globally, more commonly so in developing countries, as its complications are detected relatively late due to underdeveloped healthcare systems. These complications, when detected, are more or less irreversible, thereby leading to increased morbidity and mortality. Among these, complications related to bones (mainly osteoporosis) start fairly early (even in the prediabetes stage) but are less emphasized, nonetheless are major contributors to morbidity in diabetics due to increased fracture risk. One of the novel bone markers recently discovered is sclerostin, which helps in the assessment of the effect of hyperglycemia on bone homeostasis. Bone mineral density (BMD) by DXA scan is a good tool to assess the status of bone health but requires modern expensive radiological equipment. In this study, we wanted to see the correlation of serum levels of sclerostin to BMD so that by a simple serum investigation, early detection of poor bone quality in treatment-naive prediabetics can be done.

Objective

The aim of the study was to measure serum levels of sclerostin in prediabetics, compare them with normoglycemic controls, and find the correlation of serum levels of sclerostin with BMD.

Methods

50 prediabetic patients and 50 age, sex, blood pressure, and BMI-matched controls were recruited in the study. In both the groups, serum levels of fasting blood glucose and postprandial glucose, glycated hemoglobin (HbA1c), Vitamin D, fasting insulin, and serum sclerostin levels were measured in both groups using ELISA. The obtained values were compared between the two groups. Bone mineral density is measured by DXA scan in cases and a correlation between BMD and serum levels of sclerostin was observed.

Results

Serum sclerostin was significantly higher in the cases [18.22 (19.42) ng/ml] compared to the control group [11.08 (4.73) ng/ml] with a P value of 0.013. The mean of BMD in prediabetes is 1.06 g/cm2, T score is - 1.02, and Z score is - 0.59. There was a significant negative correlation between serum sclerostin levels and BMD in prediabetes (r = -0.404, P < 0.001).

Conclusion

Serum levels of sclerostin are increased in prediabetes and correlate well with low BMD in prediabetes, and can therefore be used for early recognition of osteoporosis and fractures in diabetes.

Study of neuregulin-4 levels in newly diagnosed type 2 diabetes mellitus

Background

Neuregulin-4 is a recently recognized adipokine acting as ligands to tyrosine kinases receptor of the Erb B family. This adipose tissue augmented endocrine factor participates in the modulation of lipid and glucose metabolism and energy homeostasis. This novel adipokine is associated with insulin resistance, dyslipidemia, obesity, oxidative stress, and inflammation.

Objective

The study aimed to compare plasma levels of neuregulin-4 in newly diagnosed type 2 diabetes mellitus as compared to matched controls and to correlate with glycemic and lipid parameters.

Materials and Methods

100 newly diagnosed T2DM patients and 100 age, sex, and BMI-matched controls after fulfilling all exclusion and inclusion criteria were included in the study. Fasting and postprandial blood glucose levels, glycated hemoglobin (HbA1c), and fasting plasma insulin levels were measured in both cases and controls. HOMA-IR values in both groups were calculated using fasting glucose and insulin levels.

Results

Mean levels of plasma neuregulin-4(pg/mL) in newly diagnosed T2DM were 7949.76 ± 949.76) pg/ml, which was significantly lower as compared to 9143 ±949.76) pg/ml in the control group (P-value <.0001). In the present study, a significant negative correlation was seen between plasma neuregulin-4 (pg/mL) with fasting blood sugar, postprandial blood sugar, HbA1C, and HOMA-IR with a correlation coefficient of -0.303, -0.416, -0.433, and -0.514, respectively. Moreover, a significant positive correlation was seen between plasma neuregulin-4 (pg/mL) with HDL with a correlation coefficient of 0.216. A significant negative correlation was seen between plasma neuregulin-4 (pg/mL) and LDL, with a correlation coefficient -0.208.

Conclusion

Neuregulin levels are significantly lower in diabetics as compared to controls. There levels correlated inversely with HbA1C and HOMA IR.

Association of NOTCH4 and ACHE gene polymorphism in Alzheimer's disease of Gujarat cohort

BACKGROUND

Alzheimer's Disease (AD) is the most common form of dementia, affecting cognitive and behavioral functions. AD is a complex disease resulting from the modest effect of gene interaction and environmental factors, as a result of which the exact pathogenesis is still unknown.

AIM

The aim of the present study was to investigate the association between variants of 98 targeted genes with Alzheimer's disease phenotype.

METHOD

A total of 98 genes from 32 AD cases and 11 controls were genotyped using the Haloplex target enrichment method and the PCR-RFLP approach.Association analysis was performed using the PLINK tool to identify the variant significantly associated with AD. Functional enrichment analysis and network analysis was performed using ClueGo and String database respectively. The Expression Quantitative Trait Loci (eQTL) analysis using the Genotype Tissue Expression (GTEx) dataset to explore the possible implication of the variant on the expression of one or more genes in different brain regions and whole blood.

RESULT

Association analysis showed significant association of 19 variant assigned to 16 genes with Alzheimer's with p-value < 0.05 with rs367398/NOTCH4 only variant that passed multiple test corrections. Functional enrichment analysis showed association of these genes with AD. ClueGo and network analysis utilizing the String database suggested that genes are directly and indirectly linked to the AD pathogenesis. eQTL analysis revealed that the rs367398/NOTCH4 and rs1799806/ACHE variant showed significant eQTL for the neighbouring genes.

CONCLUSION

The present study showed the possible role of 16 genes in AD pathogenesis, especially highlighting the role of rs367398/NOTCH4 and rs1799806/ACHE. However further investigation with large cohort is required to study and validate the implication of these variants in the AD pathogenesis.

The efficacy of oral ketamine in severely depressed patients at high risk of suicide

BACKGROUND

Ketamine is most easily and inexpensively administered by the oral route and in racemic form. Oral racemic ketamine may be an important approach to the emergency management of suicide risk in clinical settings, especially in third world countries, that have a limited range of available healthcare resources.

METHODS

In a prospective, uncontrolled, open-label investigation, we studied 30 severely depressed inpatients who consented to participate in a pilot hospital service offering ketamine for management of high suicide risk. Patients sipped a solution of racemic ketamine (150 mg) across 10-15 min in 3 alternate day sessions. Patients were assessed using the Modified Scale for Suicidal Ideation (MSSI), Montgomery-Asberg Depression Rating Scale (MADRS), and Clinical Global Improvement-Severity (CGI-S) scale at baseline and 1 day after the last ketamine session.

RESULTS

There was statistically and clinically significant improvement on all outcomes. Mean (standard deviation) MSSI scores dropped from 25.1(1.8) to 17.3(5.6), MADRS scores from 28.8(3.4) to 21.9(3.6), and CGI-S scores from 6.0(0.2) to 3.6(0.9). At endpoint, MSSI scores had dropped from severe to low or mild-to-moderate in 67% of patients. The 90 ketamine sessions were uneventful; the treatment was well tolerated and no patient dropped out.

CONCLUSION

Oral racemic ketamine may be a useful and potentially life-saving approach to the emergency management of severely depressed patients at high risk of suicide.

Atmiyata, a community champion led psychosocial intervention for common mental disorders: A stepped wedge cluster randomized controlled trial in rural Gujarat, India

BACKGROUND

While effective lay-health worker models for mental health care have been demonstrated through efficacy trials, there is limited evidence of the effectiveness of these models implemented in rural LMIC settings.

AIM

To evaluate the impact of a volunteer community-led intervention on reduction in depression and anxiety symptoms and improvement in functioning, and social participation among people living in rural Gujarat, India.

METHODS

Stepped-wedge cluster randomized controlled trial was used to assess the effectiveness of delivery of psychosocial intervention across 645 villages in Mehsana district of Gujarat, India between April 2017 and August 2019. The primary outcome was an improvement in depression and/or anxiety symptoms assessed using GHQ-12 at 3-month follow-up. Secondary outcomes were improvement in (a) depression and anxiety (Patient Health Questionnaire, (PHQ-9), Generalized Anxiety Disorder (GAD-7) & Self-Reporting Questionnaire-20 (SRQ-20); b) quality of life (EQ- 5D); c) functioning (WHO-DAS-12), and social participation (Social Participation Scale SPS). Generalized linear mixed-effects models were used to assess the independent effect of the intervention.

RESULTS

Out of a total of 1191 trial participants (608- intervention & 583-control), 1014 (85%) completed 3-month follow-up. In an adjusted analysis, participants in the intervention condition showed significant recovery from symptoms of depression or anxiety (OR 2.2; 95% CI 1.2 to 4.6; p<0.05) at the end of 3-months, with effects sustained at 8-month follow-up (OR 3.0; 95% CI 1.6 to 5.9). Intervention participants had improved scores on the PHQ-9 (Adjusted mean difference (AMD) -1.8; 95%CI -3.0 to -0.6), and SRQ-20 (AMD -1.7; 95%CI -2.7 to -0.6), at 3-months and PHQ-9, GAD-7, SRQ-20, EQ-5D and WHO-DAS at 8 months follow-up.

CONCLUSION

Findings suggest that Atmiyata had a significant effect on recovery from symptoms of depression and anxiety with sustained effects at 8-month follow-up.

TRIAL REGISTRATION

Trial registration details. The trial was registered prospectively with the "Clinical Trial Registry in India" (registry number: CTRI/2017/03/008139).

Cost of implementing the QualityRights programme in public hospitals in Gujarat providing mental healthcare

Background & objectives

Investment in mental health is quite meagre worldwide, including in India. The costs of new interventions must be clarified to ensure the appropriate utilization of available resources. The government of Gujarat implemented QualityRights intervention at six public mental health hospitals. This study was aimed to project the costs of scaling up of the Gujarat QualityRights intervention to understand the additional resources needed for a broader implementation.

Methods

Economic costs of the QualityRights intervention were calculated using an ingredients-based approach from the health systems' perspective. Major activities within the QualityRights intervention included assessment visits, meetings, training of trainers, provision of peer support and onsite training.

Results

Total costs of implementing the QualityRights intervention varied from Indian Rupees (₹) 0.59 million to ₹ 2.59 million [1United States Dollars (US $) = ₹ 74.132] across six intervention sites at 2020 prices with 69-79 per cent of the cost being time cost. Scaling up the intervention to the entire State of Gujarat would require about two per cent increase in financial investment, or about 7.5 per cent increase in total cost including time costs over and above the costs of usual care for people with mental health conditions in public health facilities across the State.

Interpretation & conclusions

The findings of this study suggest that human resources were the major cost contributor of the programme. Given the shortage of trained human resources in the mental health sector, appropriate planning during the scale-up phase of the QualityRights intervention is required to ensure all staff members receive the required training, and the treatment is not compromised during this training phase. As only about two per cent increase in financial cost can improve the quality of mental healthcare significantly, the State government can plan for its scale-up across the State.

Effects of oral probiotic and lactoferrin interventions on iron-zinc homeostasis, oxidant/antioxidant equilibrium and diarrhoea incidence of neonatal piglets

The objective of this study was to examine the effects of early-life host specific probiotic and lactoferrin (LF) supplementations on diarrhoea incidence, iron (Fe)-zinc (Zn) balance and antioxidant capabilities in serum of neonatal piglets. A total of eight sow litters obtained from parity matched sows were randomly divided into four groups and assigned to one of the four interventions: control (2.0 ml normal saline), bovine lactoferrin (bLF) (100 mg bLF in normal saline), probiotic (Pb) (1×10⁹ cfu of swine origin Pediococcus acidilactici FT28 strain) and bLF+Pb (both 100 mg bLF and 1×10⁹ cfu of P. acidilactici FT28). All the piglets received supplementations once daily orally for first 7 days of life. The incidence of diarrhoea markedly decreased in bLF group compared to control group. Notably, no incidences of diarrhoea were recorded in Pb and bLF+Pb groups. The Zn and Fe concentrations were significantly increased from day 7 to 21 in bLF and on day 21 in bLF+Pb group. No such changes were noted in Pb group. Total antioxidant capacity (TAC) in serum was significantly increased on days 7 and 15 in bLF group and on days 7 and 21 in bLF+Pb group. Malonaldehyde concentration was markedly reduced from day 7 to 21 in bLF and bLF+Pb groups. The concentrations of nitrate on days 15 and 21 and malonaldehyde on day 7 were significantly higher in Pb group, but mean TAC was unaltered from day 0 to 21. Although no correlation between the incidence of diarrhoea and Zn/Fe and oxidant/antioxidant homeostasis was noted in the Pb group, the supplementation of P. acidilactici FT28 alone was sufficient to prevent the incidence of diarrhoea in neonatal piglets. Taken together, it is concluded that strategic supplementation of P. acidilactici FT28 in early life could help in preventing diarrhoea until weaning of piglets.

Serum Levels of Activin A: Predictor of Insulin Resistance and Atherosclerosis in Prediabetics

BACKGROUND

Pathological effects of dysglycemia and insulin resistance on atherosclerosis and cardiac remodeling starts as early as in the prediabetic state before the onset of overt diabetes. Activin A is a molecule with multiple functions, including an important part in glucose homeostatic mechanisms as well as inflammatory processes and is therefore being researched as a useful novel biomarker for prompt recognition of the risk of cardiovascular disease (CVD) in prediabetic individuals, thereby helping in disease prognostication and early institution of therapeutic measuresObjective: The study aimed to measure serum levels of activin A in prediabetic patients and evaluate them in comparison to normoglycemic controls. The association of activin A with carotid intima media thickness (CIMT), left ventricular diastolic dysfunction (LVDD), and homeostatic assessment of insulin resistance (HOMA-IR) was also studiedMaterials and methods: A total of 60 prediabetic cases and 60 normoglycemic control subjects [matched as per age, gender, and body mass index (BMI)] were recruited. Measurement of serum glucose levels (fasting and postprandial) and fasting insulin levels and glycated hemoglobin (HbA1c) levels were done in all the subjects. The values of HOMA-IR were computed using established formulae. Enzyme-linked immunosorbent assay (ELISA) kits were used for the evaluation of serum levels of activin A in both groups. Parameters for the two groups were compared. In the cases, CIMT (using B-mode ultrasound) and LVDD (using two-dimensional (2D) echocardiography) were measured and correlated with activin A levelsResults: Serum fasting insulin (mIU/L) was considerably higher in cases than in the controls (p &lt; 0.001). HOMA-IR median [interquartile range (IQR)] was 4 (3.25-4.93) in some cases, and that in the control group was 1.2 (0.88-1.5) (p &lt; 0.001). Serum activin A levels in the cases group had a median (IQR) of 263.55 (227.1-279.5) ng/mL, which was substantially greater as compared to the control group 159.9 (150.7-178.7) ng/mL (p &lt; 0.001). A significant positive association of serum activin A levels with HOMA-IR (ρ = 0.75, p &lt; 0.001) and CIMT (ρ = 0.50, p &lt; 0.001) was found. In LVDD grade I and II groups, the serum levels of activin A were 257.86 (219.3-271.2) ng/mL and 269 (244.19-291.5) ng/mL, respectively (p = 0.12)Conclusion: A substantial proportion of morbidity and mortality related to dysglycemic states can be attributed to cardiovascular complications. Elevated levels of activin A in prediabetes can act as an indicator of subclinical CVD leading to early diagnosis and intervention.

Serum levels of Activin A: Marker of insulin resistance and cardiovascular risk in prediabetics

Background

A substantial proportion of health burden in diabetic individuals can be attributed to cardiovascular complications. The increasing risk of cardiovascular complications along the spectrum of dysglycemia warrants the need to devise novel markers for early assessment and management. Activin A is a multifunctional cytokine with an important role in glucose homeostasis and vascular diseases. It can thus serve as a guide for early identification of cardiovascular disease (CVD) risk in prediabetes.

Objective

The aim of the study was to measure serum levels of activin A in prediabetics, compare them with normoglycemic controls and find the correlation of activin A with markers of insulin resistance such as the homeostatic model assessment of insulin resistance (HOMA-IR).

Methods

Sixty prediabetic patients and similar age-, sex-, blood pressure-, and BMI-matched controls were recruited in the study. In both groups, serum levels of fasting blood glucose and post prandial glucose, glycated hemoglobin (HbA1c) and fasting insulin were measured. HOMA-IR values were calculated. Serum activin A levels were measured in both groups using ELISA. The obtained values were compared between the two groups.

Results

The median (IQR) of s. fasting insulin (mIU/L) in the case group was 15.3 (12.2-18.62) which was significantly higher than that in the control group, which was 6 (4.2-7.3). The median (IQR) of s. activin A (ng/mL) in the case group was 263.55 (227.18-279.56) which was significantly higher than that in the control group, which was 159.9 (150.73-178.75) (P < 0.001). There was a very strong positive correlation of s. activin A (ng/mL) with s. fasting insulin (mIU/L) and HOMA-IR (rho = 0.67 and 0.75, respectively, P < 0.001).

Conclusion

Activin A, if combined with other atherosclerotic markers, might improve the assessment of insulin resistance and cardiovascular risk in prediabetics and lead to focus on lifestyle modifications and preventive medical therapy, thereby contributing to the prevention of CVD-related mortality and morbidity in these patients.

Ilioinguinal Nerve Neurectomy vs Nerve Preservation in Lichtenstein Tension Free Mesh Hernioplasty: A Randomised Clinical Trial at a Tertiary Care Hospital in Udaipur, Rajasthan, India

Introduction: A Lichtenstein tension-free mesh hernioplasty is the most commonly performed surgery for an inguinal hernia. Chronic inguinodynia is the most prevalent surgical complication, with a 25% overall incidence. The second most common complication is hypoesthesia. Ilioinguinal neurectomy has been proven in several studies to alleviate chronic inguinodynia. Aim: To compare the postoperative inguinal pain and aesthesia in Ilioinguinal Nerve (IIN) preservation patients with neurectomy patients in Lichtenstein tension-free mesh hernioplasty. Materials and Methods: This randomised clinical trial was conducted at GMCH, Udaipur, Rajasthan, India during January 2020 to June 2021 on 70 individuals (35 in each group). The IIN was excised in group A, while it was preserved in group B. Pain and aesthesia was assessed at day seven, one month and three month follow-up. Chi-square test was used for data analysis. A p-value<0.05 was considered significant. Results: Mean age of the study sample was 55.95±15.61 years in group A and 55.4±17.22 years in group B. At Postoperative Day-7 (POD-7), 33 (94.28%) patients in group A and 18 (51.43%) patients in group B reported mild pain after vigorous activity, whereas 2 (5.71%) patients in group A and 15 (42.8%) patients in group B reported moderate pain after vigorous activity, and 2 (5.7%) patients in group B reported severe pain after vigorous activity. At POD-7, 2 (5.7%) patients in group A reported hypoaesthesia, out of them only 1 (2.85%) patient reported hypoaesthesia at one month and at three months of follow-up, whereas no patients in group B reported hypoaesthesia at POD-7, one month, or three months of follow-up. Conclusion: It was evident in this study that prophylactic ilioinguinal neurectomy resulted in considerable reduction in incidence of post operative neuralgia, compared to nerve preservation.

TG/HDL Ratio: A marker for insulin resistance and atherosclerosis in prediabetics or not?

Background:

The spectrum of Diabetes Mellitus and various complications associated with it have been regarded as major global health challenges. Raised TG/HDL has been regarded as one of the valid markers for Insulin resistance. It leads to increased risk of CVD by causing Insulin resistance and also by its own effect on the vessel wall. Detection of raised TG/HDL ratio and early intervention before the patients develop clinical disease can help in mitigation of future consequences of CVD.

Aims:

The aim of our study was to compare TG/HDL ratio between prediabetics and controls and further to look for any correlation between the TG/HDL ratio value with HOMA-IR and Carotid Intima Media Thickness (CIMT) in prediabetics.

Settings and Designs:

A cross sectional study

Methods and Material:

Study was done at ABVIMS and Dr RML Hospital, New Delhi. 60 prediabetics and 60 age, sex, BMI matched controls were employed. In both cases and controls fasting and postprandial blood glucose, glycated Hemoglobin (HbA1C) and fasting Insulin levels were measured. HOMA-IR values in both the groups were calculated using fasting glucose and Insulin levels. Serum lipid profile was obtained and TG/HDL ratio was analysed in two groups. Values obtained were compared between the two groups. CIMT was only measured in cases using B mode ultrasonography.

Statistical Analysis and Results:

Median (IQR) of fasting plasma Insulin (μIU/ml) in cases was 11.3 (10.175-13.505) versus that in controls being 5.73 (4.3-7.1). HOMA-IR (IQR) values in cases and controls were 3.12 (2.73 - 3.595) and 1.21 (0.918 – 1.505) respectively. Median (IQR) for TG/HDL ratio was 3.26 (2.712 – 4) for cases and 2.05 (1.755- 2.502) for controls. However no correlation was observed between either the mean CIMT (mm) or HOMA-IR with TG/HDL ratio.

Conclusions:

Diabetes Mellitus and its various complications are of a great burden to society. Diagnosing the risk factors early before the onset of these manifestations can help us in combating these major issues. One of the risk factors among them is raised TG/HDL ratio. Early detection of elevated TG/HDL in prediabetics may serve in early detection of atherosclerotic complications and help physicians in framing primary preventive strategies for tackling ASCVD in patients with prediabetes and full-blown Diabetes.

A rare case of nephrotic syndrome with chylothorax

Chylothorax is an infrequent cause of pleural effusion that is most commonly caused by the obstruction or disruption of the thoracic duct. Chylothorax is rare in nephrotic syndrome. Unilateral chylothorax of the right side is due to the transdiaphragmatic shunting of chylous ascites. It is usually transient and self-limiting but a massive chylothorax requiring therapeutic thoracentesis can also be encountered. Here, we present a rare cause of chylous ascites–nephrotic syndrome resulting in chylothorax, where initially therapeutic thoracentesis is done followed by the management of nephrotic syndrome with modified Ponticelli regimen. This case highlights the need to consider chylous ascites as a cause of chylothorax via transdiaphragmatic shunting in patients with nephrotic syndrome to institute the appropriate treatment.

Characterisation and comparison of immune response mechanisms in an indigenous and a commercial pig breed after classical swine fever vaccination

The live attenuated classical swine fever (CSF) vaccine has been successfully used to prevent and control CSF outbreaks for 6 decades. However, the immune response mechanisms against the vaccine remain poorly understood. Moreover, very few reports exist regarding the breed differences in the response to CSF vaccine. In this study, we generated the peripheral blood mononuclear cell transcriptomes of indigenous Ghurrah and commercial Landrace pig breeds, before and 7 days after CSF vaccination. Subsequently, between and within-breed differential gene expression analyses were carried out. Results revealed large differences in pre-vaccination peripheral blood mononuclear cell transcriptome profiles of the two breeds, which were homogenised 7 days after vaccination. Before vaccination, gene set enrichment analysis showed that pathways related to antigen sensing and innate immune response were enriched in Ghurrah, while pathways related to adaptive immunity were enriched in Landrace. Ghurrah exhibited greater immunomodulation compared to Landrace following the vaccination. In Ghurrah, cell-cycle processes and T-cell response pathways were upregulated after vaccination. However, no pathways were upregulated in Landrace after vaccination. Pathways related to inflammation were downregulated in both the breeds after vaccination. Key regulators of inflammation such as IL1A, IL1B, NFKBIA and TNF genes were strongly downregulated in both the breeds after vaccination. Overall, our results have elucidated the mechanisms of host immune response against CSF vaccination in two distinct breeds and revealed common key genes instrumental in the global immune response to the vaccine.

Transthyretin - A Novel Biomarker for Insulin Resistance and Atherosclerosis Risk in Prediabetics

OBJECTIVE

The aim of the study was to compare serum levels of Transthyretin in prediabetics and controls and to correlate levels of same with HOMA-IR and mean CIMT Method: It was a case control study in which 60 prediabetic patients and 60 controls (age, sex, BMI matched) were employed. Plasma levels of glucose (fasting and postprandial), glycated hemoglobin (HbA1c), and serum levels of insulin (fasting) were measured in both cases and controls. HOMA-IR values in both the groups were calculated using fasting plasma glucose and serum insulin levels. Serum Transthyretin levels were measured using ELISA. The values obtained were compared between cases and controls. In cases, obtained serum levels of Transthyretin were correlated with HOMA-IR values and mean CIMT (measured in cases only using B-mode ultrasonography).

RESULTS

Median (IQR) of serum levels of insulin (fasting in µIU/ml) in cases {11.3 (10.175-13.505)} was significantly higher than that of controls {5.73 (4.3-7.1)}. HOMA-IR median (IQR) in cases and controls was 3.12 (2.73-3.595) and 1.21(0.918- 1.505) respectively. Median (IQR) for serum levels of Transthyretin was also significantly higher in cases as compared to controls [46.74 (30.43-81.225) and 22.38 (16.628-27.89) respectively]. Significant positive correlations were observed between serum levels of Transthyretin with both HOMA-IR and mean CIMT (with correlation coefficients being 0.288 and 0.536 respectively). Univariate linear regression analysis showed that with increase in serum Transthyretin by 1 mg/ dl, mean CIMT increases by 0.001 mm.

CONCLUSION

Individuals with impaired glucose tolerance have been found to have increased risk of atherosclerosis as compared to normoglycemics after excluding other risk factors. Assessment for the risk of same with the help of novel markers can help in diagnosis and intervention at an early stage and thereby preventing risk of further complications.

Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial

Aims 

Fractional flow reserve (FFR_CT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFR_CT would improve economic and clinical outcomes compared with standard care.

Methods and results 

Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFR_CT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFR_CT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P = 0.01).

Conclusion 

A strategy of CTCA with selective FFR_CT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography.

Serum Retinol Binding Protein-4 Levels in Prediabetics - Novel Biomarker of Insulin Resistance and Atherosclerosis

BACKGROUND

Atherosclerotic cardiovascular diseases are the leading cause of morbidity and mortality in both diabetics and prediabetics. In insulin resistant states, increased levels of various adipose derived cytokine (adipokine) have been found to have an important role in the process of atherosclerosis. One such novel adipokine is RBP4, (belonging to lipokalin family) which also by exerting an inflammatory process has a role in the pathogenesis of insulin resistance and CVD.. Early detection of all these inflammatory cytokines may immensely help us in prognosticating the pace of disease besides instituting early interventional manuevers.

OBJECTIVE

The aim of the study was to compare serum levels of RBP4 in prediabetics and controls and to correlate levels of RBP4 with HOMA-IR and CIMT.

METHODS

60 prediabetic patients and 60 age, sex, BMI matched controls were employed in the case control study. In both cases and controls serum levels of fasting and postprandial blood glucose, glycated hemoglobin (HbA1c) and fasting insulin levels were measured. HOMA-IR values in both the groups were calculated using fasting glucose and insulin levels. Serum RBP4 levels were measured using ELISA. The values obtained were compared between cases and controls. CIMT was only measured in cases using B-mode ultrasonography.

RESULTS

Median (IQR) of fasting plasma insulin levels (uIU/ml)in cases was 11.3 (10.175-13.505) versus that of controls which was 5.73 (4.3-7.1). HOMA-IR median (IQR) in cases and controls was 3.12 (2.73-3.595) and 1.21(0.918-1.505) respectively. Median (IQR) for RBP4 in cases was 67.4 (46.166-111.088) which was significantly higher as compared to controls 33.92 (23.902-52.45). Significant positive correlation was seen between RBP4 with both, HOMA-IR and mean CIMT with correlation coefficients of 0.3693 and 0.621 respectively. On performing univariate linear regression analysis it was found that with increase in serum RBP4 levels by 1 mg/L, HOMA-IR and mean CIMT significantly increased by 0.007 units and 0.001 mm respectively.

METHODS

60 prediabetic patients and 60 age, sex, BMI matched controls were employed in the case control study. In both cases and controls serum levels of fasting and postprandial blood glucose, glycated hemoglobin (HbA1c) and fasting insulin levels were measured. HOMA-IR values in both the groups were calculated using fasting glucose and insulin levels. Serum RBP4 levels were measured using ELISA. The values obtained were compared between cases and controls. CIMT was only measured in cases using B-mode ultrasonography.

CONCLUSION

Prediabetics have been found to have more risk of cardiovascular events as compared to normoglycemics. Early assessment of the same with the use of novel biomarkers like RBP4 can be considered for early detection of atherosclerosis in prediabetic individuals. It may further help in early intervention and thus prevention from future complications.

Acute arthritis, skin rash and Lofgren's syndrome

Sarcoidosis is an autoimmune multisystem granulomatous disorder of unknown aetiology, which mainly affects the adults in the age group of 20–39 years. The disease can affect any organ in the body but mainly presents as bilateral hilar lymphadenopathy, pulmonary infiltrates, cutaneous lesions, ocular manifestations and arthropathy. Lofgren’s syndrome is an uncommon initial presentation of sarcoidosis which is recognised by the classical triad of acute arthritis, erythema nodosum and bilateral hilar lymphadenopathy. We describe a newly diagnosed case of sarcoidosis who presented as Lofgren’s syndrome. Acute sarcoid arthritis should be kept as one of the differential diagnoses for patients presenting with acute arthritis and skin lesions; and chest X-ray should be considered to rule out bilateral hilar lymphadenopathy in these patients. Early suspicion and identification of classical clinical features are essential to establish early diagnosis.

Scrub typhus and lateral rectus palsy: an uncommon presentation of a common illness

Scrub typhus is a zoonosis, which usually manifests as an acute febrile illness. It is caused by a rickettsia, Orientia tsutsugamushi, which is endemic in the Asian region. It can present with varied clinical manifestations, ranging from acute febrile illness to life-threatening multiorgan dysfunction syndrome. Central nervous system involvement in the form of altered sensorium and/or meningitis is frequently observed in scrub typhus. However, isolated cranial nerve involvement is uncommon and so far only a few such cases have been reported in the literature. We present a rare case of scrub typhus with fever and diplopia at presentation, which completely improved with doxycycline-based treatment.

126 White-Eyed Blowout Fracture in The Paediatric Patient Thought to Be A Head Injury – A Missed Diagnosis

White eyed blowout fracture or ‘trapdoor fracture’ is an orbital floor injury caused by blunt force trauma directly to the orbit causing ocular muscle entrapment between fractured bones of the floor of the orbit. It is most commonly encountered in the paediatric patient population and presents acutely with little to no periorbital signs of injury. This serious diagnosis is frequently missed at initial presentation due to a lack of obvious soft tissue pathology, termed “White Eyed” blow out fracture. It is frequently misdiagnosed as a head injury due to presenting nausea and vomiting and failure to examine eye movements.

The authors present a case of a 15-year-old male who suffered blunt force trauma to the orbit and a white eyed blowout fracture ensued. This was not identified in the emergency department and the patient consequently suffered permanent motility deficit of the globe. We outline recommendations for emergency department practitioners to help identify such presentations and see their timely surgical management.

Systematic evaluation of the QualityRights programme in public mental health facilities in Gujarat, India

BACKGROUND

Recognising the significant extent of poor-quality care and human rights issues in mental health, the World Health Organization launched the QualityRights initiative in 2013 as a practical tool for implementing human rights standards including the United Nations Convention on Rights of Persons with Disabilities (CRPD) at the ground level.

AIMS

To describe the first large-scale implementation and evaluation of QualityRights as a scalable human rights-based approach in public mental health services in Gujarat, India.

METHOD

This is a pragmatic trial involving implementation of QualityRights at six public mental health services chosen by the Government of Gujarat. For comparison, we identified three other public mental health services in Gujarat that did not receive the QualityRights intervention.

RESULTS

Over a 12-month period, the quality of services provided by those services receiving the QualityRights intervention improved significantly. Staff in these services showed substantially improved attitudes towards service users (effect sizes 0.50-0.17), and service users reported feeling significantly more empowered (effect size 0.07) and satisfied with the services offered (effect size 0.09). Caregivers at the intervention services also reported a moderately reduced burden of care (effect size 0.15).

CONCLUSIONS

To date, some countries are hesitant to reforming mental health services in line with the CRPD, which is partially attributable to a lack of knowledge and understanding about how this can be achieved. This evaluation shows that QualityRights can be effectively implemented even in resource-constrained settings and has a significant impact on the quality of mental health services.

Unique collaboration of modern medicine and traditional faith-healing for the treatment of mental illness: Best practice from Gujarat

Background and Aims:

Modern psychiatry brings tremendous value to the treatment of mental illness, however, at times is inadequate in providing holistic care within a patient's broader cultural framework. Traditional healing and modern psychiatry together offer a comprehensive, patient-centred approach to treatment, which encompass a patient's spiritual and religious beliefs. In this context, “Dava-Dua” intervention—combination of psychiatric medicine and faith healing—is implemented by the Government of Gujarat at Mira Data Dargah in Mehsana District. The study assesses intervention outcomes, understand implementation challenges and patients' perspectives on the treatment.

Methods:

Using a multi-method research approach, case records from July 2008 to March 2018 were retrieved for secondary analysis of patients' profile and outcomes; 26 patients from three groups: Dava, Dua and Dava-Dua; and 6 mental health service providers were interviewed to assess perspectives of patients and service providers on mental health, implementation barriers and facilitators.

Results:

Despite some implementation challenges, the findings indicate that collaboration of modern psychiatry medicine and faith-based treatment practices certainly benefit patients with otherwise limited access to mental health care thereby protects human rights of patients.

Conclusion:

Dava-Dua model compliments existing primary healthcare services. It provides an access to modern medicine without compromising patients' religious and spiritual practices. It has the potential to scale-up and replicate where faith-healing is the prime treatment modality to cure mental illness provided implementation challenges are proactively addressed.

Hyponatremic Unconsciousness as a Presenting Symptom of COVID-19: A Case Series

The novel Coronavirus Disease-2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection can present with a multitude of clinical symptoms. The virus, disease symptomatology, pathogenesis and complications are being studied and new concepts are evolving rapidly. The current worldwide situation caused by the disease makes it exceedingly important to recognise varied presentations of the disease. Three cases are being discussed hereby, wherein the patients presented with altered sensorium secondary to hyponatremia as the initial and only presentation of SARS-CoV-2 infection, in the absence of fever or any respiratory involvement. Acute symptomatic hyponatremia is an under-recognised presentation with only a few cases reported till date and needs further awareness and understanding.

The Great Masquerade: A Rare Presentation of Spinal Tuberculoma

Spinal tuberculomas form a meagre fraction of cases of Tuberculosis (TB). Most common presentation of spinal tuberculoma is weakness. A 45-year-old female presented with dysthesias, gait instability and numbness involving both lower limbs for a period of 7-10 days. Patient was vitally stable (blood pressure of 128/78 mm of Hg, pulse rate of 86 beats per minute and respiratory rate of 18 breaths per minute with a normal pattern), alert and co-operative. Neurological examination suggested non length dependant sensory involvement of lower limbs, sensory ataxia and areflexia, level of lesion being at the Dorsal Root Ganglia (DRG) (sensory neuronopathy). Contrast Enhanced Magnetic Resonance Imaging (CEMRI) spine revealed tuberculoma at D9 spinal level. Patient responded to Antitubercular Therapy (ATT) and recovered. The intention of sharing the clinical experience is with the sole purpose of remembering the fact that common pathologies may at times be great mimickers. In the present case, while a lot of rare causes (autoimmune, neoplastic) were searched for, tuberculoma happened to be the culprit.

H-FABP: A beacon of hope for prediabetic heart disease

Background:

Prediabetes is increasingly being studied in the context of its association with cardiovascular disease (CVD). Besides raised HbA1c and sugar levels, the major underlying defect seems to be insulin resistance (IR). Subclinical atherosclerosis, measured by high sensitivity C reactive protein (hsCRP) and carotid artery intima media thickness (CIMT) underlies the pathogenesis of CVD in prediabetes. Heart-type fatty acid binding protein (H-FABP), a novel cardiac biomarker also might have a role in predictin prediabetic heart disease.

Aims:

The aim of the study is to compare serum levels of H-FABP in prediabetics and controls and correlate them with the atherosclerotic markers, hsCRP and CIMT.

Setting and Design:

50 prediabetic patients and 50 age, sex and BMI matched controls were employed in the case control study. Serum F & PPBS, (HbA1c), fasting insulin levels were measured in cases and controls. Serum H-FABP was measured in both cases and controls. All cases and controls were subjected to bilateral CIMT measurements and Serum hsCRP levels. The values were compared between both the groups and subjected to appropriate statistical analysis.

Statistical Analysis Used:

Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean ± SD and median. Normality of data was tested by Kolmogorov-Smirnov test. If the normality was rejected then non parametric test was used. Quantitative variables were compared using Independent t test/Mann-Whitney Test (when the data sets were not normally distributed) between the two groups. Qualitative variables were correlated using Chi-Square test/Fisher's Exact test. Spearman rank correlation coefficient was used to find out the correlation of various parameters with each other. Univariate linear regression was used to find out the cause and effect relationship between various parameters. A p <0.05 was considered statistically significant. The data analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0.

Results:

The mean serum levels of H-FABP among cases and controls were 6.38± 2.76ng/ml and 3.24 ± 2.47 ng/ml respectively (p <0.0001). Mean CIMT was found to be higher in prediabetics (0.59 ± 0.11 mm ) compared to controls (0.45 ± 0.07mm) (p<0.0001). Serum hsCRP levels were also statistically higher in prediabetics (5.75± 4.16 mg/l) then that of controls (1.86± 1.67 mg/l) (p <0.0001). The correlations of the two variables, hsCRP and CIMT with H-FABP were both strongly positive (r = 0.687) & (r = 0.779) respectively [both cases (p < 0.0001)].

Conclusion:

The novel cardiac biomarker H-FAPB might be a good predictor of cardiovascular risks in prediabetics.

The great masquerader: Hemophagocytic lymphohistiocytosis secondary to cytomegalovirus infection in an immunocompetent young man

Hemophagocytic lymphohistiocytosis (HLH) is a rare, poorly recognized and underdiagnosed syndrome of excessive immune activation, which is rapidly fatal. HLH can occur as a familial or secondary disorder. Secondary HLH is most commonly associated with infections, malignancies, or autoimmune diseases. It primarily affects patients with a compromised immune system and rarely presents in immunocompetent individuals. Acute cytomegalovirus (CMV) associated HLH in the immunocompetent individual is extremely rare and only documented in five case reports till date. We, hereby, report a case of 18 years old young immunocompetent man who was diagnosed to have HLH secondary to CMV infection.

Evaluation of the SPIRIT Integrated Suicide Prevention Programme: study protocol for a cluster-randomised controlled trial in rural Gujarat, India

BACKGROUND

Suicide is a major public health challenge globally and specifically in India where 36.6% and 24.3% of all suicides worldwide occur in women and men, respectively. The United Nations Sustainable Development Goals uses suicide rate as one of two indicators for Target 3.4, aimed at reducing these deaths by one third by 2030. India has no examples of large-scale implementation of evidence-based interventions to prevent suicide; however, there is a sizeable evidence base to draw on for suicide prevention strategies that have been piloted in India or proven to be effective regionally or internationally.

METHOD

The SPIRIT study is designed as a cluster-randomized superiority trial and uses mixed methods to evaluate the implementation, effectiveness and costs of an integrated suicide prevention programme consisting of three integrated interventions including (1) a secondary-school-based intervention to reduce suicidal ideation among adolescents, (2) a community storage facility intervention to reduce access to pesticides and (3) training for community health workers in recognition, management, and appropriate referral of people identified with high suicidal risk.

DISCUSSION

Combining three evidence-based interventions that tackle suicide among high-risk groups may generate a synergistic impact in reducing suicides at the community level in rural areas in India. Examination of implementation processes throughout the trial will also help to prepare a roadmap for policymakers and researchers looking to implement suicide prevention interventions in other countries and at scale.

TRIAL REGISTRATION

Clinical Trial Registry of Indian Council of Medical Research, India: CTRI/2017/04/008313. Registered on 7 April 2017. http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=18256&EncHid=&userName=SPIRIT Trial registry was last modified on 28 June 2019.

AB1151 COMPLIANCE/CONCORDANCE WITH MYCOPHENOLATE MOFETIL IN PATIENTS WITH CONNECTIVE TISSUE DISORDERS IN COVENTRY

Background:

Connective tissue disorders like Systemic lupus erythematosus (SLE) are multi-organ systemic conditions characterised by disordered immune function. Mycophenolate Mofetil (MMF) is commonly used for treatment of SLE1and other connective tissue disorders like Sjogren’s syndrome, myositis and Scleroderma. Compliance with drugs remains a significant issue in management of these conditions and varying reports from across the world2,3continue to show significant lack of concordance resulting in increased disease activity and damage.

Objectives:

The aim of this study was to investigate the compliance/concordance specifically with MMF treatment among patients attending clinics at University Hospitals Coventry and Warwickshire NHS Trust (UHCW)with SLE and other connective tissue disorders.

Methods:

Ethical approval was obtained through research and development department within the Trust. This is a retrospective study collating non-identifiable hospital pharmacy data in patients who requested the prescription for MMF drug between January 2015 and December2018. Since MMF was required to be prescribed from the hospital (i.e. General practitioners within the region were unable to prescribe it), we have records for all prescriptions for these patients. We extracted information on sample size, frequency of prescription requested and length of follow up. Clinical data were obtained from paper and electronic notes of the patients. Data were analysed using the data analysis tool pack for linear regression, on Microsoft Excel package version 16.29.1.

Results:

We recruited 144 patients into this study, (74%) of these are females. Age range for this group was 2-89 years, median age was 45 (±11.2) years with a mean (±SD) age of 35.6 (±11.2) years and a disease duration of 8.8 (±6.2) years. 73.1% were White British, the remaining included 8.3% Indian, 5.5% Pakistani, 2.7% Black British, 2% Caucasian, 2.1% Chinese, and 6.3% other. Overall, we had 54 patients with SLE and 90 Patients with other connective tissue disorders. Good compliance (81-100%) with MMF therapy was seen in 49 patients, (34%). Poor compliance (0-20%) was seen in 13 patients, (9%). We found a significant correlation between lack of compliance and risk of flares (r= 0.25,p< 0.002), displayed in Figure 1. We also found a significant difference in compliance patters depending on diagnosis and also on age. SLE patients were 34% less compliant with MMF in comparison to other connective tissue disorders. Demographics suggested the degree of compliance increased with age. Patients between 40-69 years of age were 65% more compliant in comparison to the age 20-39 years (p< 0.002).

Conclusion:

SLE and connective tissue disorder patients within Coventry continue to have issues relating to compliance/concordance with MMF treatment and this appears to be worse in patients with SLE and in the 20-39 years of age. These patients also appear to be getting flares hence, this remains a major problem in the management of these conditions.

References:

[1]Gordon C, Amissah-Arthur MB, Gayed M et al. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatol 2017; doi: 10.1093/rheumatology/kex286.

[2]Alsowaida N, Alrasheed M, Mayet A, Alsuwaida A and Omair M A. Medication adherence, depression and disease activity among patients with systemic lupus erythematosus. Lupus 2018,27(2), 327–332. doi:10.1177/0961203317725585.

[3]Chehab G, G M Sauer, J G Richter, R Brinks, R Willers, R Fischer-Betz, B Winkler-Rohlfing, and M Schneider. Medical Adherence in Patients with Systemic Lupus Erythematosus in Germany: Predictors and Reasons for Non-Adherence – a Cross-Sectional Analysis of the LuLa-Cohort.” Lupus (September 2018),1652–60. doi:10.1177/0961203318785245.

Disclosure of Interests:

None declared

Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery

AIM

Patients who undergo radical pelvic surgery often have problems with perineal wound healing and pelvic collections. While there is recognition of the perineal morbidity, there also remains uncertainty around the benefit of vertical rectus abdominus myocutaneous (VRAM) flaps due to the balance between primary healing and the complications associated with this form of reconstruction. This study aimed to evaluate factors associated with significant flap and donor site related complications following VRAM flap reconstruction for radical pelvic surgery.

METHOD

A retrospective analysis of VRAM flap related complications was undertaken from prospectively maintained databases for all patients undergoing radical pelvic surgery (2001- 2017) in two cancer centres.

RESULTS

In all, 154 patients were identified [median age 62 years (range 26-89 years), 80 (52%) men]. Thirty-three (21%) patients experienced significant donor or flap related complications. Major complications (Clavien-Dindo ≥ 3) related to the abdominal donor site occurred in nine (6%) patients, while those related to the flap or perineal site occurred in 28 (18%) patients. Only smoking (P = 0.003) and neoadjuvant radiotherapy (P = 0.047) were associated with the development of significant flap related complications on univariate analysis. Flap related complications resulted in a significantly longer hospital stay (P < 0.001).

CONCLUSION

Careful patient selection is required to balance the risks vs the benefits of VRAM flap reconstruction. Immediate VRAM reconstruction in patients undergoing radical pelvic surgery can achieve early healing and stable perineal closure; it has a low but significant morbidity. Major flap related complications are significantly associated with smoking status and neoadjuvant radiotherapy and result in a prolonged length of hospital stay.

Serum Heart Type Fatty Acid Binding Protein Levels in Prediabetes-An Invaluable Cardiovascular Biomarker

BACKGROUND

The pathophysiological effects of diabetes on the heart and the rest of the cardiovascular system begins much earlier in its precedent stage of prediabetes and one major underlying defect is insulin resistance. Heart-type fatty acid binding protein (H-FABP) is a recently studied molecule inherent to the cardiac myocytes found to rise in both coronary and non-coronary heart diseases. The utility of the molecule in prediabetes and its relationship with insulin resistance is being studied.

OBJECTIVE

The aim of the study is to compare serum levels of H-FABP in prediabetics and controls and correlate them with Homeostatic model assessment - insulin resistance (HOMA-IR).

METHODS

50 prediabetic patients and 50 age, sex and BMI matched controls were employed in the case control study. Serum fasting and postprandial blood sugars, glycosylated hemoglobin (HbA1c), fasting insulin levels were measured in cases and controls. HOMA-IR index was calculated from fasting glucose and insulin values. Serum H-FABP was measured in both cases and controls using Immunoturbidimetric method with anti- H-FABP coated latex reagent kits. The values were compared between both the groups.

RESULTS

The mean serum fasting insulin level among cases was 12.22mIU/ml and that of the control group was 5.37mIU/ml (p value <0.0001). HOMA- IR mean values were 3.31 ± 1.56 and 1.16 ± 0.44 in cases and controls respectively (p- <0.001). The mean serum levels of H-FABP among cases and controls were 6.38± 2.76ng/ml and 3.24 ± 2.47 ng/ml respectively (p <0.0001). The correlation between the two variables, HOMA-IR and H-FABP was also found to be strongly positive (r=0.675). Linear regression analysis showed that for 1 unit increase in HOMA-IR, H-FABP increased by 1.095 and for 1 unit increase in Fasting insulin, H-FABP increased by 0.038.

CONCLUSION

Prediabetics have a higher risk of cardiovascular morbidity when compared to normoglycemics with insulin resistance being the single most important contributor. Serum H-FABP levels are elevated in prediabetes representing a marker of subclinical cardiovascular disease (CVD).

Psychosocial rehabilitation of people living with mental illness: Lessons learned from community-based psychiatric rehabilitation centres in Gujarat

Introduction:

Psychosocial rehabilitation is the process that facilitates opportunities for persons with chronic mental illness to reach their optimal level of independent functioning in society and for improving their quality of life. However, such psychosocial rehabilitation centers are limited in India.

Aims:

The present study assesses psychosocial rehabilitation centers (of urban day-care and rural residential rehabilitation center) operated by Ashadeep Charitable Foundation, a civil service organization and its effect on health outcomes of patients living with chronic mental illness.

Materials and Methods:

Records of 170 cases were retrieved for secondary analysis of demographic information, diagnosis, duration of stay, and health outcomes.

Results:

Rehabilitation activities included yoga, light physical exercises, group discussion, training for daily living skills, social skills, life skills, vocational training, individual, and family counseling. In addition, extensive outreach activities, mental health camps were also integral part of the rehabilitation activities. Patients who have accessed rehabilitation services were diagnosed with schizophrenia, psychosis, bipolar disorder, depression, and intellectual disability. The average duration of rehabilitation of patients (other than persons with intellectual disability) was ranged from three to four months. Out of those rehabilitated, 69% of them were successfully re-integrated with the family.

Conclusion:

Combination of pharmacological and psychosocial interventions are effective for re-integrate patients with mental illness to the family. This model of community-based rehabilitation has potential for scale-up.

Innovative mental health initiatives in India: A scope for strengthening primary healthcare services

Mental health burden is a major health concern worldwide. In the last few decades, we are witnessing innovations that are successfully addressing gaps in the mental health service delivery in Indian context. This is an opportune time to explore existing innovative mental health initiatives in the country and integrate viable interventions to primary healthcare facilities to strengthen public mental healthcare delivery. The descriptive review of literature on innovative mental health programs in India was carried out. The initial search from google scholar and PubMed database yielded 1152 articles, of which 1114 were excluded that did not meet inclusion criteria. Full texts of 38 articles were reviewed and finally 22 studies were included for the study. Based on the review, most innovations are broadly summarized into five categories: (1) quality improvement mental health programs; (2) community-based mental health programs; 3) non-specialist mental health programs, 4) mobile-technology based mental health programs, 5) tele-mental health programs. These promising innovations in treatment and care can be customized as per the context for scale up and integrated into the primary healthcare system through District Mental Health Programme. The innovative approach not only makes mental health services more accessible and affordable but also empowering in nature by encouraging community members in early detection, prevention of mental illness and appropriate treatment referral to existing primary health care services.