In vitro and in vivo anthelmintic response of the seeds of Amomum subulatum roxb and Vitex negundo

Abstract The current study was designed to check the anthelmintic activities of some local plants. Seeds of Amomum (A.) subulatum and Vitex (V.) negundo in different solvents were subjected to in vitro (adult motility assay; AMA and egg hatch assay; EHA) and in vivo (faecal egg count reduction test; FECRT) anthelmintic activity testing protocols using Haemonchus (H.) contortus as an experimental model. The results of AMA, EHA, and FECRT were statistically analysed through linear regression and Duncan multiple range test. In AMA test, at 50 mg mL-1 concentration, the percent mortality of H. contortus was higher in A. subulatum than V. negundo, whereas, in EHA test, A. subulatum was proven better ovicidal (LC50=14.2 µg mL-1) than V. negundo (LC50= 65.7405 µg mL-1). The FECRT also indicated the better efficacy of A. subulatum than V. negundo against natural infection of gastrointestinal (GI) parasites. The crude powder of plants used in this study showed 29.6% to 57.7% anthelmintic. The reduction rate was found higher for A. subulatum (3 g kg-1) as compared to V. negundo (7 g kg-1). Reagrding efficacy analysis of solvents used for plants extract, ethyl acetate and chloroform were found better in increasing ovicidal activity in adult worms (in vitro testing), whereas, the crude aqueous methanol was found better than the crude powders in in vivo testing. It will be beneficial to document the indigenous knowledge to standard scientific procedures for their validation. This study will help to motivate the farmers to make a better choice of cultivation of the indigenous plants because of their varying efficacies as an alternative preventive approach against the GI parasitic infections.

Prevalence of diabetes distress and cross-cultural reliability of DDS-17 scale in rural Haryana

Background

Diabetes distress associated with diabetes is an important under-appreciated domain of diabetes management. The aim of the study is to assess the prevalence of diabetes distress among T2DM patients in Jhajjar district of Haryana, using widely accepted DDS-17 scale along with testing the scale's reliability through Cronbach's α.

Material and Methods

This observational study with cross-sectional design was carried out among 503 T2DM patients in district, Jhajjar, Haryana. DDS-17 scale was used for diabetes distress assessment. Data entry and analysis were performed using appropriate software.

Results

37.97% subjects had diabetes distress either in moderate (DDS-17 Score ≥2) or severe (DDS-17 Score ≥3) form. English version of DDS-17 scale showed good internal consistency reliability (α = 0.79).

Conclusions

This study conclusively showed that diabetes distress is very common among T2DM patients as more than one third of the T2DM patients had diabetes distress and diabetes distress scale (DDS-17) is an easy, well-accepted questionnaire with good reliability.

Determinants of quality of life of geriatric population in rural block of Haryana

Background

The quality of life (QOL) of the geriatric population in India is an important issue because of the lack of social security schemes and dilution of Indian culture which ensures due care and regard to the elderly. The primary health care physicians have to face more challenges in handling the elderly patients in comparison to the younger patients because the elderly have more physiological and emotional problems along with medical conditions and illnesses which, in turn, affect their QOL. The study aims to find out the determinants that affect the QOL of the elderly in a rural area of Haryana.

Material and Methods

This observational study with a cross-sectional design was carried out among 400 elderly (60 years and above) in a rural area of district Jhajjar, Haryana. The world health organization quality of life scale (WHOQOL-BREF) scale was used. Data entry and analysis were performed using Statistical Package for Social Sciences (SPSS) version 20.0.

Results

The mean score of the environmental domain was the highest (62.72 ± 14.18), followed by the physical health domain (60.77 ± 15.82). Education, age group, caste, marital status, occupation, and socioeconomic status exhibited significant relationships with different domains of QOL.

Conclusions

With the advancement of age, QOL deteriorates. Higher education and higher socioeconomic status of the study participants help them to live a better QOL. Those participants who were married and were busy in any kind of work experienced a better QOL.

Effect of Yoga on Glucose Control and Quality of Life in Patients of Prediabetes

Objective: The objective of this study was to evaluate effect of yoga on fasting plasma glucose (FPG), postprandial plasma glucose, and hemoglobin A1C (HbA1C) and also on quality of life (QoL). Research Design and Methods: This was a cohort study in which 100 diagnosed cases of prediabetes were recruited for doing specific yoga, and they themselves act as control for the study. The measurement and comparison of FPG, prandial plasma glucose (PPG), and HbA1C were done at three different time intervals, that is, baseline, 3 months, and at 6 months. The assessment of QoL was done using SF-36 scale. Results: One hundred prediabetic cases were selected for the study in which impaired fasting glucose (IFG) was present more in younger population compared to impaired glucose tolerance (IGT) and IFG plus IGT both of which are more prevalent in middle age group. The yoga therapy was found to have favorable effect on FPG, PPG, and HbA1C along with various anthropometry measures studied in this study. After adjusting correlation coefficient for various anthropometry measures, yoga was found to be effective for controlling glycemic parameters in prediabetics. Conclusions: Yoga is a type of exercise known to improve glycemic control by changing anthropometry measures, but our study aids in knowledge about the beneficial effect beyond this known fact through other mechanisms yet to be explored.

Etiological Profile of Short Stature in Children and Adolescents

CONTEXT

The delayed growth of a child is a major cause of concern for the parents. There is a multitude of etiological factors which must be considered in relation to this common aspect of healthcare.

AIM

The study was done to evaluate the etiological profile of short stature in children and adolescents.

SETTINGS AND DESIGN

The cross-sectional study was conducted for 12 months including 111 cases of short stature (out of the 1,058 cases screened), at the endocrinology outpatient department (OPD) of a tertiary care institute in Haryana.

SUBJECTS AND METHODS

As per the inclusion criteria, cases with age <18 years were enrolled. The examination and anthropometric measurements were performed in the presence of parents/guardians.

RESULTS

Out of the 1,058 cases screened; 111 cases of short stature were recruited as per the inclusion and exclusion criteria. The prevalence was about 10.49% of the total population. The mean age of the sample was 12.34 ± 3.19 years. The endocrine causes were the most common followed by normal variants of growth and delay, chronic systemic illness, and nutritional and skeletal causes. Among the endocrine causes, hypothyroidism was the most common followed by growth hormone deficiency and type 1 diabetes mellitus (T1DM).

CONCLUSIONS

The mean chronological age of 12.34 ± 3.19 years suggests the delayed detection of short stature in the population. This highlights the importance of educating parents so that timely therapeutic intervention can be done to achieve the potential height.

Body composition and handgrip strength in patients with prediabetes: A case-control study from Haryana, North India

BACKGROUND AND AIMS

Previous studies suggest that body composition and handgrip strength are significantly altered in individuals with type 2 diabetes mellitus. Only few studies are available in prediabetic individuals. The aim is to study the change in body composition in adult individuals with prediabetes and compare it with age and sex-matched normoglycemic individuals.

METHODS

100 diagnosed cases of prediabetes and 100 age and sex-matched normoglycemic controls were recruited in the study. Body composition was assessed with Omron HBF 510w and Slim guide skinfold caliper. Handgrip strength was assessed with Camry digital dynamometer.

RESULTS

Out of 100 subjects with prediabetes; 53 were female and 47 were male. In this study, there was higher mean body fat percentage (29.37 ± 5.65 vs 25.46 ± 5.27) and visceral fat (11.21 ± 1.92 vs 7.27 ± 2.82) in individuals with prediabetes compared to normoglycemic individuals. Also, there was a lower mean of skeletal muscle percentage (27.21 ± 4.32 vs 31.19 ± 4.63) and handgrip strength (29.61 ± 6.38 vs 33.75 ± 6.8) in individuals with prediabetes compared to normoglycemic individuals. In this study, body fat percentage was positively correlated (r = 0.3385) with prediabetes. The skeletal muscle percentage (r = -0.40721) and handgrip strength (r = -0.301) were negatively correlated with prediabetes.

CONCLUSIONS

It can be concluded that there is a significant change in body composition and handgrip strength in the individuals with prediabetes, and changes in body composition and handgrip strength can be included as a primary care strategy to motivate lifestyle modifications.

Quality of Life among Diabetics: A Cross-Sectional Study in a Tertiary Care Center of Rohtak, Haryana

Introduction:

The most severe health threats dominating the low- and middle-income countries are no longer the dreaded communicable diseases; but, they are everyday diseases due to changes in lifestyle, which are the noncommunicable diseases. Quality of life (QOL) is defined by the World Health Organization as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. QOL assessment in health system is a multidimensional construct that can be measured by evaluating objective levels of health status filtered by the subjective perceptions and expectations of the individual.

Aim and Objective:

To assess the QOL among diabetics attending the endocrine outpatient department (OPD) in a tertiary care hospital of Haryana.

Materials and Methods:

A hospital-based cross-sectional study was conducted at endocrinology OPD of Pt. B. D. Sharma PGIMS Rohtak, Haryana from May 2014 to April 2015. Five hundred diabetics (Type 1 and 2) were recruited for the study. Patients registered on the day of interview were selected using systematic random sampling. A predesigned, pretested, semi-structured schedule which included sociodemographic variables of the study participants along with information about family history of diabetes was filled by interviewing the study subjects in their vernacular language individually. Generic instrument, SF-36 v2 was used to assess the QOL.

Results:

The mean age of the study participants was 50.41 ± 9.1 years. The mean disease duration was 6.12 ± 5.55 years. Majority of our respondents belonged to Hindu religion (97.4%). The mean scores for the bodily pain domain (79.52 ± 28.15) and social functioning domain (76.47 ± 26.10) of QOL were the highest.

Conclusion:

The mean scores for the bodily pain domain and social functioning domain of QOL were the highest. Assess the QOL in patients with diabetes by measuring the multiple domains involving physical, psychological and social aspects.

Prevalence of Metabolic Syndrome in Prediabetes

Aims: To study the prevalence of metabolic syndrome and its components in prediabetes and to compare the anthropometric indices [waist circumference (WC), hip circumference, waist-hip ratio, waist-height ratio] as predictors of metabolic syndrome in prediabetes. Methods: A total of 300 subjects (200 prediabetic cases and 100 matched normoglycemic controls) in the age group of 18-70 years were recruited for the study. Among the cases, there were 38% of males and 62% of females; and there were 33% of males and 67% of females in the control group. Prediabetes was diagnosed using the American Diabetic Association (ADA) criteria, and metabolic syndrome was diagnosed using the International Diabetes Federation criteria. Results: Prevalence of metabolic syndrome was 63% among the cases and 26% among the normoglycemic controls. Among cases, 56.5% of males and 66.9% of females, and among the controls, 36.3% of males and 20.9% of females had metabolic syndrome. The prevalence of metabolic syndrome increased with age and increasing body mass index among both the cases and controls. Central obesity was found to be the most common component of metabolic syndrome among prediabetic males (80.2%) and females (82.2%). The most common cluster of abnormality among the cases and controls was found to be increased WC plus low high-density lipoprotein plus increased triglycerides. Logistic regression analysis was applied to anthropometric indices, and it was found that increased WC had the maximum predictive power for metabolic syndrome among the subjects with prediabetes. Conclusion: Metabolic syndrome was more prevalent in the prediabetic population in comparison to the normoglycemic individuals with increased WC being the most prevalent component. Increased WC had the maximum predictive power for occurrence of metabolic syndrome among prediabetic subjects.

Asian BMI criteria are better than WHO criteria in predicting Hypertension: A cross-sectional study from rural India

BACKGROUND

International Obesity Task Force proposed lower body mass index (BMI) cut-off values for defining overweight and obesity in Asian population. However, there is an absence of unanimity regarding the definition of overweight and obesity that is confusing while estimating disease burden, resource allocation, and priority setting. Therefore, the primary aim of the study was to assess the prevalence of overweight and obesity and its predictors as per different criteria (WHO criteria, Modified Asian criteria of BMI classification and BF% estimation by bioelectric impedance analysis technique). The secondary aim was to assess the concordance of overweight and obesity as diagnosed using these three methods.

METHODOLOGY

A community-based cross-sectional study was conducted in a rural area of Rohtak, north India over a period of 1 year with a sample size of 1080. Anthropometric measurements including height, weight, blood pressure, body fat % analysis were recorded using standard protocols.

RESULTS

The prevalence of overweight and obesity were observed to be 49.62% (N = 536) as per the modified criteria for the Asian Indians (BMI ≥23 kg/m2) and 34.62% (N = 374) according to WHO criteria (BMI ≥25 kg/m2). A total of 18.3% of the study population were hypertensive. Modified criteria of BMI classification for Asian Indians had high sensitivity (67%) as compared to WHO criteria (55%) in predicting, diagnosing hypertension, and resembled sensitivity estimate obtained through direct body fat percentage estimation (69%).

CONCLUSION

Modified criteria of overweight and obesity classification are better in terms of reducing comorbid dysmetabolic conditions, as exemplified by hypertension.

Severe 25(OH)vitamin-D deficiency: A risk factor for development of gestational diabetes mellitus

OBJECTIVE

To estimate the level of 25 (OH)vitamin D in gestational diabetes mellitus (GDM) and to find the correlation between level of 25(OH)vitamin D and GDM.

MATERIALS AND METHODS

The study was conducted on 50 diagnosed patients of GDM attending antenatal clinic in the obstetrics and gynecology department of Pt. B.D. Sharma PGIMS, Rohtak. 50 age and gestational age matched normoglycemic women were taken as control group. Procedure of study was explained to the participants and informed consent was taken.

RESULTS

GDM women had higher age, BMI, and positive family history of type 2 DM as compared to pregnant women without GDM. The mean vitamin D in GDM women was 32.64 ± 24.33 nmol/L while in controls it was 39.90 ± 21.86 nmol/L(P = 0.033). The prevalence of severe vitamin D deficiency(<25 nmol/L) was found to be 44% among GDM women (22 out of 50 GDM women) and 20% among women with normoglycemia (10 out of 50 normoglycemic controls) with significant p value of 0.010 and odds ratio of 1.833. GDM women with BMI>25 kg/m² had 1.799 times chances to be severely deficit in vitamin D than women with BMI<25 kg/m² 6 GDM women had mild vitamin D deficiency (>50 but <75 nmol/L) and 16 had moderate deficiency (>25 but <50 nmol/L). Only 6 GDM patients were found to be sufficient for vitamin D(>75 nmol/L).

CONCLUSION

Severe vitamin D deficiency in second trimester of pregnancy is significantly associated with elevated risk for GDM.

Prediabetes Risk Evaluation Scoring System [PRESS]: A simplified scoring system for detecting undiagnosed Prediabetes

OBJECTIVE

To develop a simplified scoring system for detecting undiagnosed prediabetes among healthy adult population of Haryana, India.

MATERIAL & METHODS

This cross-sectional study was a household survey which involved 892 healthy adults >18year of age who were subjected to an oral glucose tolerance test. Sensitivity, specificity, positive and negative predictive value and area under the receiver operating characteristic (ROC) curve and the optimal cut off points for identifying undiagnosed prediabetes were calculated.

RESULTS

Out of 892 subjects studied, 459 were males and 433 were females and 160 were found to be prediabetic (17.93%). At an optimal score of >45 the area under the ROC curve is 0.785 with sensitivity, specificity, positive and negative predictive value of 84.37%, 58.47%, 30.75 and 94.48% respectively.

CONCLUSIONS

Prediabetes Risk Evaluation Scoring System (PRESS) a simple and non-invasive screening tool to identify adult individuals having undiagnosed prediabetes.

Validation of simplified Indian Diabetes Risk Score for screening undiagnosed diabetes in an urban setting of Haryana

BACKGROUND AND OBJECTIVES

Identification of at risk individuals using simple screening tools like Indian Diabetes Risk Score (IDRS) and appropriate life style interventions could greatly help in preventing or delaying the onset of diabetes and thus reducing the burden of disease.

MATERIAL AND METHOD

450 individuals >20years who consented to participate were selected randomly from three anganwadis of urban area of Rohtak city. Demographic characteristics and anthropometric measurements such as weight, height and waist circumference were taken. BMI was calculated. IDRS developed by Mohan et al. was applied for categorizing the individuals as high risk, moderate risk and low risk. World Health Organization (WHO) criterion of fasting blood glucose ≥126mg/dl was used for diagnosing diabetes.

RESULTS

54% of individuals were categorized as high risk followed by 37.6% as moderate risk as per IDRS risk score. Prevalence of diabetes was more in ≥50years age group (28.6%) as compared to 35-49 years (14.2%) and 20-35 years age group (6.0%). Individuals with no physical activity had significantly high prevalence of diabetes as compared to mild or moderate physical activity (P 0.004). Similarly, males with waist circumference ≥100cm and females with ≥90cm had significantly high prevalence of diabetes (P 0.000 and P 0.005). On multiple logistic regression analysis age, family history of diabetes and BMI were independent predictors of diabetes.

CONCLUSION

Diabetes is a rising epidemic. Early screening and appropriate interventions at the start are needed for control of disease and risk factor modifications.

Neck Circumference: Independent Predictor for Overweight and Obesity in Adult Population

BACKGROUND

Neck circumference (NC) measurement, an index of upper body fat (BF) distribution, seems promising as a community-based screening measure for overweight and obesity in want of evidence on its validity as a screener.

OBJECTIVE

The objective of this study was to determine the validity of NC as a screener for overweight and obesity in adults in community settings against BF percentage (BF%).

MATERIALS AND METHODS

This cross-sectional community-based study involved data collection on a predesigned, pretested, and semi-structured schedule that included the sociodemographic characteristics and anthropometric measurements of respondents.

RESULTS

NC correlated positively with body weight, waist circumference, and hip circumference. NC was found to have good discriminatory power with cutoff values of 36.55 cm for males and 34.05 cm for females, with maximum sensitivity and specificity to predict overweight and obesity in comparison to direct BF% estimation on receiver operating characteristic analysis.

CONCLUSION

NC has a fair validity as a community-based screener for overweight and obese individuals in the study context. Further studies may be carried out to explore the generalizability of this observation.

Prevalence and predictors of depression and anxiety in patients of diabetes mellitus in a tertiary care center

BACKGROUND

Diabetes is one of the most common chronic diseases and affects virtually every organ of the human system. Depression and anxiety is common among patients with diabetes and associated with worse diabetes outcomes.

AIMS AND OBJECTIVE

To study the prevalence and predictors of depression and anxiety in patients of Type 2 diabetes mellitus (T2DM) in Pt. B.D. Sharma, PGIMS, Rohtak, Haryana, India, a tertiary care center in Northern India.

MATERIALS AND METHODS

Four hundred ten consecutive patients having T2DM and 410 healthy controls matched for age and sex attending the endocrine out-patient department of a tertiary care center of Northern India were included in the study. Sociodemographic and relevant clinical variables were collected. They were evaluated for depression and anxiety using Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale respectively.

RESULTS

It was found that a significantly larger proportion of diabetic patients had depression (26.3% vs. 11.2%, P = 0.001), anxiety (27.6% vs. 12.7%, P = 0.001) and comorbid depression and anxiety (21.0% vs. 7.3%, P = 0.001) as compared to healthy controls. Diabetic women had higher depression (17.1% vs. 9.3%) and anxiety (17.6% vs. 10.0%) than men. The major predictors for a severe form of depression and anxiety among T2DM cases were age, female sex, insulin therapy, retinopathy, nephropathy, and ischemic heart disease.

CONCLUSION

The present findings reveal that diabetic cases had significantly higher depression and anxiety as compared to healthy controls. The risk factors for depression and anxiety were age, female sex, insulin therapy, and diabetic complications.

Correlation between the percentage of body fat and surrogate indices of obesity among adult population in rural block of Haryana

INTRODUCTION

The increasing prevalence of overweight and obesity has raised concerns regarding the importance of different techniques, which are used to assess body growth composition that can be used at the level of primary health care settings with minimal knowledge. The purpose of this study was to evaluate the relationship between different surrogate indices of fatness (body mass index [BMI], waist circumference [WC], waist-to-hip ratio [WHR], waist-to-height ratio [WHtR], and body fat percentage [BF%]) with the percentage of body fat and their usefulness as a predictor of obesity among adult population.

MATERIALS AND METHODS

The community-based cross-sectional study done over a period of 1-year involved 1080 adult participants from a rural area in Haryana. Anthropometry, along with BF% (using hand held analyzer) were recorded using standard procedures.

RESULTS

The prevalence of overweight and obesity as per the modified criteria of BMI for the Asian Indians was found to be 15.0% and 34.6%, respectively. Positive correlation was seen among all the indices except between the WHR and body adiposity index (BAI) using Pearson's correlation analysis. Maximum correlation was seen between WHtR and WC (r = 0.923), whereas WHtR depicted maximum correlation (r = 0.810) with BF%. Receiver operating characteristic curve analysis revealed that the WHtR was the most sensitive and specific indicator for the study population to predict overweight and obesity comparable to that calculated by body fat analyser followed by BAI, BMI, and WHR.

CONCLUSION

A single value of WHtR irrespective of gender and the area of residence can be used as a universal screening tool for the identification of individuals at high risk of development of metabolic complications.

Prevalence of thyroid dysfunction among women during the first trimester of pregnancy at a tertiary care hospital in Haryana

BACKGROUND

Undetected and untreated thyroid disorders are associated with adverse maternal and fetal outcomes. There are limited data on the prevalence of newly diagnosed thyroid disease during pregnancy from India. Therefore, this study was designed to evaluate the prevalence of thyroid dysfunction, especially hypothyroidism during the first trimester of pregnancy.

MATERIALS AND METHODS

The present cross-sectional study was conducted at Department of endocrinology and antenatal clinic in the Obstetrics and Gynecology Pt. B.D. Sharma PGIMS, Rohtak over a period of 1-year. The total sample population comprised of 461 pregnant women with uncomplicated intrauterine singleton pregnancies in the first trimester of gestation without any history of thyroid disease or intake of any thyroid medication. Morning blood samples from the participants were analyzed for thyroid function tests, which included FT3, FT4, thyroid-stimulating hormone (TSH) and anti-thyroid peroxidase antibodies (TPO).

RESULTS

A total of 461 women were enrolled for this study. Mean maternal age was 23.79 ± 3.47 years. Median gestational age was 8 weeks 5 days. The median FT3, FT4 and TSH were 3.3 pg/mL, 1.25 ng/dL, and 1.40 mIU/L, respectively. Anti-TPO was elevated in 128 (27.8%) pregnant women. 99 (21.5%) women had sub-clinical hypothyroidism and 39 (39.4%) among them were positive for anti-TPO (P ≤ 0.001). 2 (0.4%) of women had overt hyperthyroidism, whereas 15 (3.3%) of the women had sub-clinical hyperthyroidism.

CONCLUSION

Considering the immense impact that maternal thyroid dysfunction has on maternal and fetal outcomes, prompt identification of thyroid dysfunction and its timely treatment is essential. Thus, universal screening of pregnant women for thyroid dysfunction should be considered especially in a country like India due to the high prevalence of thyroid dysfunction.

Prevalence and correlates of overweight/obesity among adolescents in an urban city of north India

Background and objectives:

Obesity and overweight is a growing pandemic affecting millions of adolescents in developed as well as developing countries. Obesity is associated with the onset of major chronic diseases leading to complications and also psychosocial problems in adolescents. The greater concern is that the risks of obesity during childhood will persist into adolescence and adulthood. The objectives of the study were to assess the prevalence of being overweight and obesity and to study the associated risk factors.

Materials and Methods:

1900 adolescents in the age group of 10–19 years were included in the study. A predesigned and pretested questionnaire which included the variables such as going to school by bus or cycle, eating habits, playing video/computer games or outdoor games and sibling count were recorded. Body weight and height were recorded in subjects for calculating body mass index (BMI). International Obesity Task Force (IOTF) classification was used for the estimation of being overweight and obese.

Results:

The mean age of the study subjects was 14.84 years (SD = 2.81). Mean weight increased from 34.7 to 55.09 kg from the age group 10–13 to 17–19 years. Mean height also increased from 1.34 to 1.57 m from the age group 10–13 to 17–19 years. Similarly, the mean body mass index was 19.23 at 10–13 years, followed by 21.11 at 14–16 years and 22.46 at 17–19 years. On binary logistic regression analysis, female gender, bus as a mode of transport, not playing games, and single sibling were found to have independent association with prevalence of being overweight.

Waist height ratio: A universal screening tool for prediction of metabolic syndrome in urban and rural population of Haryana

AIMS

To compare waist circumference (WC), body mass index (BMI), waist hip ratio (WHR), and waist-to-height ratio (WHtR) and define an appropriate cut-off, which is most closely predictive of the non-adipose components of the IDF metabolic syndrome (MetS) definition.

METHODS AND RESULTS

A total of 3,042 adults (1,693 in rural area and 1,349 in urban area) were screened for the presence of MetS according to the IDF definition. Among 3,042 adults selected as subjects, 1,518 were male and 1,524 were female. The receiver operating curve (ROC) analysis was done to determine the optimal cut-off value and the best discriminatory value of each of these anthropometric parameters to predict two or more non-obese components of metabolic syndrome. The area under ROC (AURC) for WC was superior to that for other anthropometric variables. The optimal cut-off value of WC in urban and rural males was >89 cm, which is higher than that in urban and rural females at 83 cm and 79 cm, respectively; the optimal cut-off for WHtR was >0.51 in rural females, 0.52 in rural males, and 0.53 in both urban males and females. Both parameters were found to be better than BMI and WHR. ROC and AURC values for WC were better than those for WHtR in men and women in both urban and rural areas (P = 0.0054); however, when the entire study cohort was analyzed together, irrespective of gender and place of residence, then at a value of 0.52, WHtR scored over WC as a predictor of metabolic syndrome (P = 0.001).

CONCLUSION

Although the predictive value of different gender-specific WC values is clearly superior to other anthropometric measures for predicting two or more non-adipose components of MetS, a single value of WHtR irrespective of gender and the area of residence can be used as a universal screening tool for the identification of individuals at high risk of development of metabolic complications.

Prevalence of gestational diabetes mellitus in rural Haryana: A community-based study

BACKGROUND AND OBJECTIVES

Gestational diabetes mellitus (GDM) is a global health concern as it affects health status of both mother and fetus. In India, prevalence of GDM varies in different populations and no data is available from rural Haryana. This study was undertaken to determine the prevalence of GDM and risk factors associated with it in rural women of Haryana.

MATERIALS AND METHODS

Nine hundred and thirteen women, with estimated gestational age above 24 weeks from a rural block of Haryana who consented to participate were given a standardized 2-h 75-g oral glucose tolerance test (OGTT). Pro forma containing general information on demographic characteristics, educational level, gravida, family history of diabetes, and past history of GDM was filled-up. A World Health Organization (WHO) criterion for 2-h 75-g OGTT was used for diagnosing GDM.

RESULTS

GDM was diagnosed in 127/913 (13.9%) women with higher mean age as compared to non-GDM women. Majority (78.4%) of the women were housewives, rest engaged in agriculture (9.2%) and labor (5.5%). Women with gravida ≥3 and positive family history of diabetes had significantly higher prevalence of GDM. History of macrosomia (birth weight ≥4 kg) was significantly associated with prevalence of GDM (P = 0.002). On multiple logistic regression analysis, risk factors found to be significantly associated with GDM were maternal age >25 years, gravida >3, history of macrosomic baby, and family history of diabetes.

CONCLUSION

The prevalence of GDM has been found quite high in rural Haryana. Appropriate interventions are required for control and risk factor modifications.

Congenital malaria--a neglected problem

Congenital malaria is the least known manifestation of malaria and a much neglected area of research. Most of the existing information is limited to case reports in children born to non-immune women. Congenital malaria can be acquired by transmission of parasitised maternal erythrocytes across the placenta due to microdamage. Congenital malaria has been documented for many years but it was previously thought to be uncommon especially in indigenous populations. Many gaps in knowledge remain. There is a need of considering congenital malaria as differential diagnosis even in low endemic areas, especially in countries where there is social practice of moving the pregnant woman to her native place for childbirth, which may be endemic for malaria. Physicians should judge each case individually, considering such factors as reliability of follow-up and access to medical care and advice accordingly.

Prevalence of gestational diabetes mellitus & associated risk factors at a tertiary care hospital in Haryana

BACKGROUND & OBJECTIVES

Prevalence of gestational diabetes mellitus (GDM) is known to vary widely depending on the region of the country, dietary habits, and socio-economic status. This study was undertaken to determine the prevalence of GDM and risk factors associated with it, in women attending an antenatal care (ANC) clinic at a tertiary care hospital in Haryana.

METHODS

This study enrolled women, with their estimated gestational age between 24th and 28th week, attending antenatal care (ANC) clinic at a tertiary care hospital in Rohtak. After informing, women who consented to participate were given a standardized 2-h 75 g oral glucose tolerance test (OGTT). A proforma containing general information on demographic characteristics, socio-economic status, education level, parity, family history of diabetes and/or hypertension and past history of GDM was filled up. American Diabetes Association (ADA) criteria for 75 g 2-h OGTT was used for diagnosing GDM.

RESULTS

A total of 607 women participated in the study and GDM was diagnosed in 43 (7.1%) women. A single abnormal value was observed in additional 66 (10.87%) women. On bivariate analysis risk factors found to be significantly associated with GDM were age, educational level, socio-economic status, pre-pregnancy weight and BMI, weight gain, acanthosis nigricans, family history of diabetes or hypertension and past history of GDM but on multivariate analysis only upper middle class and presence of acanthosis nigricans were found to be significantly associated with GDM.

INTERPRETATION & CONCLUSIONS

The prevalence of GDM was found to be 7.1 per cent in a tertiary care hospital in Haryana. Appropriate interventions are required for control and risk factor modifications.

Utility of HbA1c for diagnosis of gestational diabetes mellitus

OBJECTIVE

To evaluate the utility of HbA(1c) in combination with OGTT for diagnosis of GDM.

MATERIALS AND METHODS

607 pregnant women with their estimated gestational age between 24 and 28 weeks were evaluated for GDM using OGTT based on ADA criteria. HbA(1c) was also done at the same time.

RESULTS

The mean HbA(1c) value in women with GDM was significantly higher than women without GDM (5.73 ± 0.34% compared to 5.34 ± 0.35%). The area under ROC curve of HbA(1c) to detect GDM was 0.805 and an HbA(1c) cutoff value of ≥5.95% had sensitivity of 28.6% and specificity of 97.2% in diagnosing GDM while an HbA(1c) cutoff value of ≥5.45% had sensitivity of 85.7% and specificity of 61.1% in diagnosing GDM. For women with an HbA(1c) value between 5.45% and 5.95%, an OGTT should be performed to correctly identify women with GDM. Using this methodology 85.7% of the GDM cases would have been detected and only 2.8% of normal women would have been wrongly labeled as having GDM. Also, this methodology would have obviated an OGTT in 61.8% women in our study.

CONCLUSION

HbA(1c) in combination with OGTT can obviate the need of OGTT in almost two-thirds of women with GDM.

Pentavalent vaccine: a major breakthrough in India's Universal Immunization Program

Immunization is one of the most important public health interventions and a cost effective strategy to control the infectious diseases especially in children. Complete immunization coverage in India has increased from below 20% in the 1980s to nearly 61% at present, but still more than 1/3rd children remain un-immunized. Advent of combination vaccines has facilitated incorporation of additional vaccines into immunization schedule. Pentavalent vaccine, against five killer diseases-diphtheria, pertussis, tetanus, hepatitis B and Hemophilus influenza type B (Hib), has been introduced in almost all GAVI eligible countries by 2011. Government of India introduced the vaccine in two states in pilot phase and has given green signal to six more states. The use of pentavalent vaccine automatically raises the coverage level of hepatitis B and Hib vaccines. If the vaccines are provided individually, the coverage of hepatitis B and Hib vaccines usually lags behind DPT coverage. This gap can be filled by using pentavalent vaccine in routine immunization programmes.

India is on the way forward to maternal and neonatal tetanus elimination!

Tetanus is an acute, potentially fatal disease, caused by a bacterium, Clostridium tetani. The disease usually occurs in newborns through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. NT contributes to 5-7% of neonatal mortality worldwide. Several thousand mothers are also estimated to die annually of maternal tetanus. MNT elimination relies on promotion of maternal tetanus immunization along with safe delivery and avoidance of unsafe abortion and umbilical cord care practices. The Government of India (1983) introduced at least two doses of tetanus toxoid vaccine (TT) to all pregnant women during each pregnancy as a part of its nationwide immunization policy. To date, a total of 15 States including union territories of the India have achieved NT elimination. The remaining Indian States need to strengthen TT coverage to save the lives of neonates as well as mothers from tetanus.

Malaria vaccine: a bright prospect for elimination of malaria

Malaria remains one of the few diseases those continue to scourge human civilization despite the significant advances in disease control strategies over the last century. Malaria is responsible for more than 500 million cases and 1-3 million deaths annually. Approximately 85% of these deaths are among children, mostly in Africa, primarily due to P. falciparum. Whole cell vaccines, irradiated sporozoites and genetically attenuated sporozoites have demonstrated long lasting, sterile protection against plasmodium infection in animal and experimental clinical studies. Atypical membrane protein 1 and merozoite surface protein 1 are the two most extensively studied asexual blood stage vaccine candidates. The most promising candidate vaccine under development is RTS, S combined with AS01 adjuvant. Initial results from phase III trials of this candidate vaccine show 50% reduction of malaria in 5-17 mo aged children during the 12 mo after vaccination. WHO anticipates that the RTS,S/AS01 vaccine will be recommended for the 6-14 week age group for co-administration together with other vaccines as part of routine immunization programs in malaria endemic countries. Malaria vaccine could play an important role in elimination and eventual eradication of malaria.

Effect of vitamin D supplementation of low birth weight term Indian infants from birth on cytokine production at 6 months

BACKGROUND/OBJECTIVES

Vitamin D deficiency has been associated with impaired resistance to infection, which may be mediated by alterations in cytokine responses. We investigated the effect of vitamin D supplementation to infants on whole blood in-vitro cytokine production and on the inflammatory marker, plasma C-reactive protein (CRP).

SUBJECTS/METHODS

Blood samples were taken at 6 months of age from infants participating in the DIVIDS (Delhi Infant Vitamin D Supplementation) randomized controlled trial of weekly vitamin D supplements (1400 IU = recommended intake) from birth to 6 months with the aim of decreasing mortality and severe morbidity. We measured plasma CRP and whole blood in-vitro production of tumour necrosis factor-α (TNFα), interferon-γ (INFγ), interleukin (IL)-10 and IL-13 following no stimulation or stimulation with lipopolysaccharide or phytohemagglutinin.

RESULTS

Although the intervention improved vitamin D status in a severely deficient population, there were no differences between treatment groups in plasma CRP or in the production of any of the cytokines in either unstimulated or stimulated cultures. Recent illness had limited association with immunological markers. Plasma 25-hydroxyvitamin D levels were not associated with CRP or production of any cytokines.

CONCLUSIONS

Vitamin D supplementation did not affect plasma CRP or whole blood cytokine production of vitamin D-deficient low birth weight infants. This is consistent with the lack of effect of vitamin D on mortality and severe morbidity among infants in the DIVIDS trial.

Introduction of a second dose of measles in national immunization program in India: a major step towards eradication

Measles is a highly infectious, acute respiratory illness that is caused by a virus of the genus Morbillivirus. The disease infects nearly 30 million children each year, and deaths usually occur from complications related to pneumonia, diarrhea and malnutrition. A systematic review of published Indian literature depicts the median case fatality ratio (CFR) of measles to be 1.6%. Through immunization, measles deaths dropped a remarkable 78% from 733,000 in 2000 to 164,000 in 2008. As of 2008, 192 of 193 Member States of WHO use 2 doses of measles vaccine in their national immunization programs, India being the only exception. The Millennium Development Goal (MDG) 4 aims to reduce by two-thirds between 1990 and 2015 the under-five mortality rate (U5MR) in the world. Per the draft comprehensive Multi Year Strategic Plan (cMYP, 2010–17) for immunization of India, the country aims to reduce measles-related mortality by 90% by 2013 when compared to 2000. As recommended by the National Technical Advisory Group on Immunization (NTAGI), the implementation strategy of the second dose of measles vaccine at the state level is determined by the underlying performance of the routine immunization program. The second dose in the national immunization schedule gives extra immunity against measles infection that renders children more susceptible to secondary pneumonia and diarrheal diseases, which are the primary causes of under-5 child mortality in India.

Hepatitis B Vaccine in national immunization schedule: a preventive step in India

Hepatitis B is a disease of the liver caused by Hepatitis B virus (HBV) infection. HBV is transmitted through contact with infected blood or body fluids, unprotected sexual intercourse and the perinatal route but not through casual contact. About two billion people worldwide have been infected with the virus, an estimated 360 million live with chronic infection, and at least 600,000 people die annually from acute or chronic consequences of Hepatitis B, such that Hepatitis B is a major public health problem worldwide. HBV is 50 to 100 times more infectious than HIV. It has been estimated that, of the 25 million infants born every year in India, over one million run the lifetime risk of developing chronic HBV infection. Every year over 100,000 Indians die due to illnesses related to HBV infection. Following the launch of the Global Alliance for Vaccines and Immunization (GAVI) to intensify National Immunization Programs (NIPs) in developing countries worldwide. World Health Organization (WHO) recommends that Hepatitis B vaccine should be given to all infants. Several cost-effectiveness analyses of inclusion of Hepatitis B vaccine in India's NIP have been performed. These indicate that universal childhood Hepatitis B immunization in India will be highly cost-effective. The Government of India is also supporting planned state programs for introducing new vaccines as part of routine immunization. The current immunization schedule for hepatitis B vaccine includes a dose given as early as possible after birth, preferably within 24 hours for all institutional deliveries because the birth dose of Hepatitis B vaccine is effective in preventing perinatal transmission of Hepatitis B. Irrespective of the birth dose, 3 doses are to be given at 6, 10, 14 weeks at the same time as DPT and OPV.

CEPHEUS SA: a South African survey on the undertreatment of hypercholesterolaemia

AIM

The aim of the CEntralised Pan-South African survey on tHE Under-treatment of hypercholeSterolaemia (CEPHEUS SA) was to evaluate the current use and efficacy of lipidlowering drugs (LLDs), and to identify possible patient and physician characteristics associated with failure, if any, to achieve low-density lipoprotein cholesterol (LDL-C) targets.

METHODS

The survey was conducted in 69 study centres in South Africa and recruited consecutive consenting patients who had been prescribed LLDs for at least three months. One visit was scheduled for data collection, including fasting plasma lipid and glucose levels. Physicians and patients completed questionnaires regarding their knowledge, awareness and perceptions of hypercholesterolaemia and the treatment thereof.

RESULTS

Of the 3 001 patients recruited, 2 996 were included in the final analyses. The mean age was 59.4 years, and 47.5% were female. Only 60.5 and 52.3% of patients on LLDs for at least three months achieved the LDL-C target recommended by the NCEP ATP III/2004 updated NCEP ATP III and the Fourth JETF/South African guidelines, respectively. Being male, older than 40 years, falling into the lower-risk categories, compliance with the medication regimen, and patient knowledge that the LDL-C goal had been reached, were associated with the highest probability of attaining LDL-C goals.

CONCLUSION

The results of this survey highlight the sub-optimal lipid control achieved in many South African patients taking lipid-lowering therapy.

New generation typhoid vaccines: an effective preventive strategy to control typhoid fever in developing countries

Typhoid fever is a serious systemic infection, caused by the enteric pathogen Salmonella enterica serovar Typhi, a highly virulent and invasive enteric bacterium. This disease occurs in all parts of world where water supplies and sanitation are substandard. These pathogens then travel to food, drinks and water through house-flies and other vectors. Globally, an estimated 12-33 million cases of enteric fever occur with 216,00-600,000 deaths per year, almost exclusively in the developing countries. Health surveys conducted by the Health Ministry of India in the community development areas indicated a morbidity rate varying from 102-2219/100,000 population in different parts of the country. A limited study in an urban slum showed 1% of children up to 17 years of age suffer from typhoid fever annually. The continued high burden of typhoid fever and the alarming spread of antibiotic resistant strains led the World Health Organization (WHO), almost ten years ago, to recommend immunization using the two new-generation vaccines in school- aged children in areas where typhoid fever posed a significant problem and where antibiotic resistant strains were prevalent. Morbidity and mortality due to high incidence of typhoid fever favors the introduction of typhoid vaccine in routine immunization in India. This vaccine should be given at the age of 2 years with Vi antigen vaccine and at least one more dose be given at 5 years of age.

Should the chickenpox vaccine be included in the National Immunization Schedule in India?

Varicella (chickenpox) is an acute, highly contagious viral disease with worldwide distribution. The highest prevalence occurs in the 4-10 year age group but tends to be more severe in adults. It may be fatal in neonates, immunocompromised persons, and normal adults, especially smokers. Varicella is usually a benign childhood disease, and rarely rated as an important public health problem, but this can be severe and even fatal in otherwise healthy children (< 1 out of every 10,000 cases). Chickenpox can cause pneumonia (23 out of every 10,000 cases), and is an important risk factor for developing severe invasive "strep" (group A streptococcal disease). Complications of varicella include bacterial infections (up to 5% of cases), decreased platelets, arthritis, hepatitis, pneumonia (more commonly in adults) or encephalitis (1 in 10,000 cases), which may cause a failure of muscular coordination, sometimes resulting in persistent sequelae or death. Varicella is the leading cause of vaccine-preventable death in children. Universal vaccination can cause a dramatic reduction in the incidence of varicella, associated complications, hospitalizations and fatality rates. In India, due to the high cost of the vaccine, it would be difficult to vaccinate a large percentage of the children. The government of India should consider the inclusion of varicella vaccine in the National Immunization Schedule with the help of International agencies.

Can Levothyroxine Be Taken as Evening Dose? Comparative Evaluation of Morning versus Evening Dose of Levothyroxine in Treatment of Hypothyroidism

152 drug naïve primary hypothyroid patients were divided into morning (Group 1) and evening (Group 2) dosing group and evaluated for change in biochemical profile, physical functioning and Quality of Life during the course of 12 weeks of study. At the end of 12 weeks 70 (90.90%) subjects in Group 1 and 72 (96%) in Group 2 achieved euthyroidism. On evaluation clinical symptoms and total clinical scores improved in both the groups at the end of 6 and 12 weeks. Significant improvement in thyroid profile was seen in both the groups at the end of 6 and 12 weeks (P value <.0001). On intergroup comparison, no significant difference in thyroid profile was seen at 6 and 12 weeks between the morning and the evening dose group. Similar dose of levothyroxine was required to achieve euthyroidism in both the groups. Though an early restoration of euthyroidism was seen in evening group, the difference when compared to the morning group was not statistically significant. On assessment of QoL, statistically significant improvement in various parameters was seen in both the groups. Hence, from the study we inferred that evening dose is as efficacious as morning dose and provides an alternate dosing regimen.

Intra-dermal administration of rabies vaccines in developing countries: at an affordable cost

Rabies is a virtually 100% fatal acute viral encephalitis. Rabies occurs in more than 150 countries and territories. Globally there are 17.4 million animal bite cases and more than 55,000 deaths annually. India's 20,000 deaths accounts for 36% of global and 65% of the Asian (31,000) deaths. The Intradermal Rabies Vaccine (IDRV) was first started in Thailand in 1984. In 1992, World Health Organization approved it for use in developing countries which face a shortage of rabies vaccine due to paucity of funds. Vaccines like Purified Vero cell vaccine (PVRV), Purified chick embryo cell vaccine (PCECV) and Human diploid cell vaccine (HDCV) that can be injected by the intradermal route for Post Exposure Prophylaxis as approved by WHO. The regimen approved by the WHO/DCGI India is the Updated Thai Red Cross Regimen, which involves injection of 0.1 mL of reconstituted vaccine per ID site and on two such ID site per visit on Days 0, 3, 7 and 28 (2-2-2-0-2). All reconstituted vaccine unused at the end of 6-8 h must be discarded. The ID route is ideal in terms of economic benefits, safety and efficacy. This reduces the cost of vaccination by about 68%, which is clearly an attractive option for resource-starved countries like India.

The threat of vaccine associated poliomyelitis in India: medicolegal issues involved

India is among the world's large reservoirs of wild poliovirus (WPV) with 559 confirmed cases of poliomyelitis (wild virus) being reported in 2008. The World Health Organization's program for the eradication of poliomyelitis in third world countries like India is associated with major ethical and medico-legal implications. Two vaccines are available in India for poliomyelitis i.e. oral polio vaccine (OPV) and inactivated polio vaccine (IPV), of which OPV is used in the eradication campaign, the case count for 2009 being 36 out of a total of 384 reported cases globally, the case count for mid 2010 being 19 cases out of 84 reported globally. There are widespread reports of vaccine derived poliomyelitis as well as vaccine associated poliomyelitis (VAP) from different parts of the country, which can be linked to resurgence of polio in several states or to the failure of the polio drive (Polio Sundays). Though an extended comprehensive polio campaign is on and both money and manpower are being dumped for achieving the goal of polio eradication, the ground reality is entirely different. The argument that wild polio strains have surfaced to hamper the drive cannot account for all post vaccination cases. The Indian Academy of Paediatrics has forcefully suggested replacement of OPV by IPV, as the effectiveness of IPV far exceeds the cost benefit of OPV. IPV has by and large replaced OPV in many parts of the world. The second issue is the threat of litigation on the health department once the post vaccination cases rise even further. There are certain other socio-ethical issues discussed in this paper on a subject which has an important bearing on the health statistics of this country.

Telemedicine: socio-ethical considerations in the Indian milieu

Telemedicine is the rapidly developing application of clinical medicine by telephone, the internet or other networks for the purpose of consulting, and on occasions carrying out examinations or medical procedures. Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and video-conferencing equipment to conduct a real-time consultation between medical specialists in two different countries. Telemedicine offers real benefits in a country as vast as India where the majority of the population lives in remote areas with no access to even the most basic healthcare. As the practice of telemedicine spreads, maintaining standards, security and privacy, will be a challenge especially with regard to legal and regulatory measures and who will be held responsible if telemedicine-assisted surgery fails due to failure in connectivity? Is it the surgeon, the satellite provider or the software/hardware engineer? What is the legal status of telemedicine-based diagnosis and treatment? Other legal issues involve conflicting national laws and information piracy, the dangers of prescription drugs that are banned in one country but not in another and quacks who offer medical advice and prescribe drugs over the internet. This paper discusses some of the legal, ethical and social considerations in the Indian context.