Genetic diversity and forensic statistical support for the 12 X-STR markers in the Malaysian Indian population using Qiagen Investigator® Argus X-12 QS kit

X-chromosome short tandem repeats (X-STRs) are useful for human identification, especially in complex kinship scenarios. Since forensic statistical parameters vary among populations and the X-STRs population data for the diverse population of Peninsular Malaysia's are unavailable, this attempt for Indians (n = 201) appears forensically relevant to support the 12 X-STRs markers' evidential value for human identification in Malaysia. The Qiagen Investigator® Argus X-12 QS kit showed that DXS10135 was the most polymorphic locus with high genetic diversity, polymorphism information richness, heterozygosity, and exclusion power. Based on allele frequencies, the strength of discrimination and mean exclusion chance (MECKrüger, MECKishida, MECDesmarais, and MECDesmaraisDuo) values for the Malaysian Indians were ≥0.999997790686228. As for haplotype frequencies, the overall discrimination power and mean exclusion probability (MECKrüger, MECKishida, MECDesmarais, and MECDesmaraisDuo) were ≥0.9999984801951. The genetic distance, neighbor-joining phylogenetic tree, and principal component analysis also supported the evidential value of the 12 X-STRs markers for forensic practical caseworks in Malaysia.

Hunting can increase physical activity of Indigenous peoples in Canada: pixem re yecwme'nstut

This study examined whether Indigenous peoples could achieve the Canadian Physical Activity Guidelines (CPAG) for adults while engaging in the cultural practice of hunting. It was hypothesized that Indigenous hunters would achieve or surpass the physical activity (PA) thresholds set forth by the CPAG on days spent hunting. Step count and heart rate were recorded from six male participants during mule deer hunts and days spent on-reserve. Step count was not statistically different between days spent hunting (28 803 ± 10 657 steps) and on-reserve (15 086 ± 7536 steps) (p = 0.10). Time spent in light (257 ± 45 min; p = 0.04), moderate (118 ± 71 min; p = 0.03), and vigorous (45 ± 42 min; p = 0.04) activities while hunting was greater than on-reserve (light, 180 ± 86; moderate, 71 ± 73; vigorous, 7 ± 10 min). The duration of moderate-to-vigorous PA (119 ± 95 min) for an average day hunting nearly meets the weekly CPAG recommendation of 150 min per week and is 1.8× greater than on-reserve (67 ± 80 min). Data suggest that hunting is probably a viable mode of PA for Indigenous adults to achieve health benefits. A strength of this study is the 10 h of daily recording which includes vehicular transportation to remote hunting areas. The duration of very light/sedentary PA did not differ between hunting (233 ± 211 min) and on-reserve (327 ± 164 min; p = 0.10), and highlights the importance of modernized vehicles in traditional Indigenous activities. A larger sample size would facilitate greater exploration of transportation, as well as success of the hunt on PA. These data suggest that health researchers and clinicians should consider traditional activities such as hunting as a means for Indigenous adults to increase participation in sufficiently vigorous PA to incur health benefits.

Indian immigrants' constructions of mental health and mental illness in the perinatal period: A qualitative study

AIM

The aim of this study is to explore how immigrant women and men from India construct mental health and mental illness in the perinatal period.

DESIGN

Qualitative interpretive design.

METHODS

Data were collected by conducting in-depth interviews with 19 participants. Photo elicitation, free listing and pile sorting were used during the interviews. Purposive sampling was used, and data were collected in 2018 and 2019. Data were analysed using thematic analysis.

FINDING/RESULTS

One major theme and three subthemes were identified. 'We do not talk about it' was the major theme and the subthemes: (1) 'living peacefully and feeling happy' described the views on mental health; (2) 'that's the elephant in the room still' captures how participants felt when talking about mental illness; and (3) 'why don't we talk about it' offers reasons why the Indian community does not talk about mental health and illness.

CONCLUSION

The findings of this study have highlighted the importance of understanding the impact of immigration and being culturally sensitive when assessing mental health in the perinatal period.

IMPACT

The findings of this study identify some of the reasons for non-disclosure of mental health issues by immigrants. Incorporating these findings during psychosocial assessment by health professionals in the perinatal period will help translate the cultural aspects into more effective communication.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public contribution to the study was provided by the Community Stakeholders Group; these were members of the immigrant community from India who had expertise in mental health. They contributed to the study design and the key terms and phrases for the free list used in interviews.

Mind Matters: Exploring the Intersection of Psychological Factors and Cognitive Abilities of University Students by Using ANN Model

Purpose

While previous studies have suggested close association of psychological variables of students withtheir higher-order cognitive abilities, such studies have largely been lacking for third world countries like India, with their unique socio-economic-cultural set of challenges. We aimed to investigate the relationship between psychological variables (depression, anxiety and stress) and cognitive functions among Indian students, and to predict cognitive performance as a function of these variables.

Patients and Methods

Four hundred and thirteen university students were systematically selected using purposive sampling. Widely used and validated offline questionnaires were used to assess their psychological and cognitive statuses. Correlational analyses were conducted to examine the associations between these variables. An Artificial Neural Network (ANN) model was applied to predict cognitive levels based on the scores of psychological variables.

Results

Correlational analyses revealed negative correlations between emotional distress and cognitive functioning. Principal Component Analysis (PCA) reduced the dimensionality of the input data, effectively capturing the variance with fewer features. The feature weight analysis indicated a balanced contribution of each mental health symptom, with particular emphasis on one of the symptoms. The ANN model demonstrated moderate predictive performance, explaining a portion of the variance in cognitive levels based on the psychological variables.

Conclusion

The study confirms significant associations between emotional statuses of university students with their cognitive abilities. Specifically, we provide evidence for the first time that in Indian students, self-reported higher levels of stress, anxiety, and depression are linked to lower performance in cognitive tests. The application of PCA and feature weight analysis provided deeper insights into the structure of the predictive model. Notably, use of the ANN model provided insights into predicting these cognitive domains as a function of the emotional attributes. Our results emphasize the importance of addressing mental health concerns and implementing interventions for the enhancement of cognitive functions in university students.

A Novel Mutation in Frabin (FGD4) Causing a Mild Phenotype of CMT4H in an Indian Patient

Charcot-Marie-Tooth disease 4H(CMT4H) is an autosomal recessive demyelinating form of CMT caused by FGD4/FRABIN mutations. CMT4H is characterized by early onset and slowly progressing motor and sensory deficits in the distal extremities, along with foot deformities. We describe a patient with CMT4H who presented with rapidly progressing flaccid quadriparesis during the postpartum period, which improved significantly with steroid therapy. Magnetic resonance imaging and ultrasonography demonstrated considerable nerve thickening with increased cross-sectional area in the peripheral nerves. A nerve biopsy revealed significant demyelination and myelin outfolding. This is the first report of an Indian patient with a novel homozygous nonsense c.1672C>T (p.Arg558Ter) mutation in the FGD4 gene, expanding the mutational and phenotypic spectrum of this disease.

Woodhouse-Sakati syndrome in an Indian patient with a novel pathogenic variant

Woodhouse-Sakati syndrome consists of hypogonadism, diabetes mellitus, alopecia, ECG abnormalities, and dystonia. This condition is caused by the loss of function of the DCAF17 gene. Most of the patients have been reported from Greater Middle Eastern countries. We report a 38 male from southern India who presented with syncope and massive hemoptysis due to ruptured bronchopulmonary collaterals. He also had alopecia, cataracts, recently diagnosed diabetes and hypogonadism. Whole exome sequencing showed a novel homozygous truncating variant in the DCAF17 gene. Despite embolization of the aortopulmonary collaterals, the patient died of recurrent hemoptysis.

Efficacy and Safety of adjunctive Perampanel in a prospective, real-world, Phase IV study in Indian patients aged ≥12 years for Treatment of focal-onset Epilepsy: Study 508

OBJECTIVE

ESPRITE (Study 508; NCT03836924) evaluated the real-world safety, tolerability, and efficacy of adjunctive perampanel in patients aged ≥12 years with focal-onset seizures (FOS), with or without focal to bilateral tonic-clonic seizures (FBTCS), in India.

METHODS

ESPRITE was a prospective, multicenter, single-arm, observational, Phase IV study with a 6-month Treatment Period. Patients were aged ≥12 years and had been prescribed perampanel for adjunctive treatment of FOS, with or without FBTCS. Assessments included incidence of treatment-emergent adverse events (TEAEs; primary endpoint), median percent reduction in seizure frequency per 28 days from baseline, 50% responder rates, and seizure-freedom rates.

RESULTS

Overall, 200 patients were enrolled (199 patients in the Safety Analysis Set and 174 patients who completed all visits in the main efficacy analyses). TEAEs (all mild or moderate in severity) were reported in 18.1% (n = 36/199) of patients (the most common were dizziness [3.0%] and irritability [2.0%]). TEAEs leading to discontinuation of perampanel were reported in 2.0% of patients; no deaths or serious TEAEs occurred. At 6 months, median percent reduction in seizure frequency was 100.0%, 50% responder rate was 83.3%, and seizure-freedom rate was 49.4%.

SIGNIFICANCE

Adjunctive perampanel (at a mean daily dose of 4 mg/day) was shown to be well tolerated and effective in patients aged ≥12 years with FOS, with or without FBTCS, from India.

PLAIN LANGUAGE SUMMARY

Many patients do not receive adequate treatment for epilepsy and need effective seizure control medications. In this 6-month clinical study, 199 patients from India, aged 12 years or older, added perampanel to the anti-seizure medications they were already taking. At 6 months, 49% of patients experienced no seizures since starting perampanel and seizure frequency was reduced by half in 83% of patients. Side effects occurred in 18% of patients (most commonly dizziness and irritability) and caused 2% to stop perampanel; no deaths were reported. Perampanel was an effective and generally safe added medication for patients with epilepsy from India.

Effect of Rhinoplasty on Various Angles of Nose on Ideal Position and Alignment in Indian Population

Study of anthropometric measurements of the nose makes possible a qualitative and quantitative analysis of surgical results. Analysis of pre- and post-operative changes in nasal tip projection, rotation and nasofrontal angle may also emphasize the fact of over correction or under correction of deformed nose to surgeon. Aim of our study to compare preoperative and postoperative nasal tip projection, rotation and nasofrontal angle after rhinoplasty. The present study was a 1.5 years prospective interventional study conducted at SMS Medical College, Jaipur, India from January 2021 to July 2022. Total 51 patients with external nasal deformity were included in our study. Pre-operative, immediate post-operative and 6 months follow-up nasofrontal, projection and nasolabial angle were recorded, compared and analyzed objectively. In our study significant improvements were observed in the nasolabial angle from 92.9 ± 16.4 to 101.6 ± 10.4 and 110.3 ± 9.8 and nasal tip projection from 0.74 ± 0.17 to 0.58 ± 0.11 and 0.52 ± 0.09 immediate post-op and at 6-months follow up respectively. Mean Nasofrontal angle at pre-op, intra-op and post-op 6 months was 132.5 ± 11.9, 135.4 ± 9.6 and 134.8 ± 9.4 and this difference was not found to be statistically significant. We would like to conclude that Indian noses which are predominantly small and shorter, our surgical procedure aimed at making them more prominent aesthetically on the face, so in the present study results were satisfactory in term of anthropometric parameter.

Genomic profile of diabetic retinopathy in a north indian cohort

BACKGROUND

Diabetic Retinopathy (DR) is one of the major microvascular complications of diabetes. Being a complex disease, it is important to delineate the genetic and environmental factors that influence the susceptibility to DR in a population. Therefore, the present study was designed to investigate the role of genetic and lifestyle risk factors associated with DR susceptibility in a North-Indian population.

METHODS

A total of 848 subjects were enrolled, comprising of DR cases (n = 414) and healthy controls (n = 434). The Sequenom MassARRAY technology was used to perform target genome analysis of 111 SNPs across 57 candidate genes and 14 intergenic region SNPs that are involved in the metabolic pathways associated with type 2 diabetes (T2D) and DR. Allele, genotype and haplotype frequencies were determined and compared among cases and controls. Logistic regression models were used to determine genotype-phenotype and phenotype-phenotype correlations.

RESULTS

The strongest association was observed with TCF7L2 rs12255372 T allele [p < 0.0001; odds ratio (OR) = 1.81 (1.44-2.27)] and rs11196205 C allele [p < 0.0008; OR = 1.62 (1.32-1.99)]. Genotype-phenotype and phenotype-phenotype correlations were found in the present study.

CONCLUSION

Our study provides strong evidence of association between the TCF7L2 variants and DR susceptibility.

Excess mortality in elderly hip fracture patients: An Indian experience

PURPOSE

Hip fractures in elderly have a high mortality. However, there is limited literature on the excess mortality seen in hip fractures compared to the normal population. The purpose of this study was to compare the mortality of hip fractures with that of age and gender matched Indian population.

METHODS

There are 283 patients with hip fractures aged above 50 years admitted at single centre prospectively enrolled in this study. Patients were followed up for 1 year and the follow-up record was available for 279 patients. Mortality was assessed during the follow-up from chart review and/or by telephonic interview. One-year mortality of Indian population was obtained from public databases. Standardized mortality ratio (SMR) (observed mortality divided by expected mortality) was calculated. Kaplan-Meir analysis was used.

RESULTS

The overall 1-year mortality was 19.0% (53/279). Mortality increased with age (p < 0.001) and the highest mortality was seen in those above 80 years (aged 50 - 59 years: 5.0%, aged 60 - 69 years: 19.7%, aged 70 - 79 years: 15.8%, and aged over 80 years: 33.3%). Expected mortality of Indian population of similar age and gender profile was 3.7%, giving a SMR of 5.5. SMR for different age quintiles were: 3.9 (aged 50 - 59 years), 6.6 (aged 60 - 69 years), 2.2 (aged 70 - 79 years); and 2.0 (aged over 80 years). SMR in males and females were 5.7 and 5.3, respectively.

CONCLUSIONS

Indian patients sustaining hip fractures were about 5 times more likely to die than the general population. Although mortality rates increased with age, the highest excess mortality was seen in relatively younger patients. Hip fracture mortality was even higher than that of myocardial infarction, breast cancer, and cervical cancer.

Investigation and modeling of electric vehicle enablers (EVE) for successful penetration in context to India: mitigating the effect of urban sprawl on transportation

Urban sprawl in context to transportation is a matter of serious concern. It creates unusual environmental challenges for an emerging economy like India, known for geographical spread, population, and use of fossil fuel-based automobiles on road. Indian automotive sector is often held responsible for the emission of greenhouse gasses causing serious environmental deterioration. Government at both central and state levels is dealing with this challenge in two ways-adding more infrastructure for public transport and encouraging electrical vehicles (EVs). Adoption of EVs for public mobility is eco-friendlier and economic. But it is observed that EV penetration in many pockets is not growing and is yet to mature for usage. Regardless of subsidies, it is not picking up as expected and needs to be investigated. Earlier research mainly focused on reporting barriers and did not guide EV penetration enablers. This study bridges the research gap and offers useful insights about EV penetration phenomenon and makes use of both qualitative and quantitative treatments. Accordingly, it models thirteen enablers, guides about tangling interrelationships using an interpretive structural modeling (ISM), and validates it using best worst method (BWM) approach. The study reports six key enablers, which are-developing high-capacity batteries with short recharge time, improving service support, framing promotive government policies, lowering electricity tariffs using sustainable and reliable sources, and reducing dependence on imported raw materials. These enablers need an urgent attention from the industries and researchers for successful EV penetration in Indian context. Authors hope the findings will be useful for other developing countries as well and will influence both researchers and practitioners.

Greater Reduction in Stunting Than Underweight and Wasting in Indian Under-Five Children: A Comparison of Growth Indicators from 4 National Family Health Surveys

OBJECTIVE

To assess change in nutritional status in Indian under-five children from four rounds of national surveys (round 1 to 4).

METHODS

National Family Health Survey data from 4 rounds (1992-2016) were analyzed. Height and weight for age (HAZ, WAZ), and weight for height (WHZ) z scores were calculated. Children under -2 z score were classified as malnourished by HAZ, WAZ and WHZ.

RESULTS

A greater reduction in stunting (from 54 to 38%, p < 0.05) than in underweight (from 44 to 34%, p < 0.05) and wasting (from 19 to 20%, p > 0.1) status over the period of 4 NFHS rounds was observed from 1992 to 2016. In line with this, combination of improved height for age (-2.1 ± 1.8 to -1.5 ± 1.7) but relatively less improved weight for age (-1.8 ± 1.4 to -1.5 ± 1.2), the change in wasting status was either nil or meagre (-0.8 ± 1.4 to -0.9 ± 1.4), (p < 0.05 for all). The percentage of children malnourished by all 3 indicators together reduced from 9 to 6% (p < 0.05). At the 4th NFHS round, higher percentage of boys (8%) than girls (6%) and rural (7%) than urban (5%) children were malnourished by all 3 indicators (p < 0.05).

CONCLUSION

Greater reduction in stunting than underweight and wasting was observed over the period of 4 rounds. There is a need for more focused efforts to combat malnutrition in rural children and boys.

Characteristics of multiple sclerosis and demyelinating disease in an Asian American population

BACKGROUND

Race and ancestry influence the course of multiple sclerosis (MS).

OBJECTIVES

Explore clinical characteristics of MS and neuromyelitis optica spectrum disorder (NMOSD) in Asian American patients.

METHODS

Chart review was performed for 282 adults with demyelinating disease who self-identified as Asian at a single North American MS center. Demographics and clinical characteristics were compared to non-Asian MS patients and by region of Asian ancestry.

RESULTS

Region of ancestry was known for 181 patients. Most (94.7%) preferred English, but fewer East Asian patients did (80%, p = 0.0001). South Asian patients had higher neighborhood household income (p = 0.002). Diagnoses included MS (76.2%) and NMOSD (13.8%). More patients with NMOSD than MS were East and Southeast Asian (p = 0.004). For MS patients, optic nerve and spinal cord involvement were similar across regions of ancestry. Asian MS patients were younger at symptom onset and diagnosis than non-Asian MS patients. MS Severity Scale scores were similar to non-Asian MS patients but worse among Southeast Asians (p = 0.006).

CONCLUSIONS

MS severity was similar between Asian American patients and non-Asian patients. Region of ancestry was associated with differences in sociodemographics and MS severity. Further research is needed to uncover genetic, socioeconomic, or environmental factors causing these differences.

Ten-year predictors of major adverse cardiovascular events in patients without angina

BACKGROUND

Longstanding cardiovascular risk factors cause major adverse cardiovascular events (MACE). Major adverse cardiovascular events prediction may improve outcomes. The aim was to evaluate the ten-year predictors of MACE in patients without angina.

METHODS

Patients referred to Inkosi Albert Luthuli Hospital, Durban, South Africa, without typical angina from 2002 to 2008 were collected and followed up for MACE from 2009 to 2019. Survival time was calculated in months. Independent variables were tested with Cox proportional hazard models to predict MACE morbidity and MACE mortality.

RESULTS

There were 525 patients; 401 (76.0%) were Indian, 167 (31.8%) had diabetes at baseline. At 10-year follow up 157/525 (29.9%) experienced MACE morbidity, of whom, 82/525 (15.6%) had MACE mortality. There were 368/525 (70.1%) patients censored, of whom 195/525 (37.1%) were lost to follow up. For MACE morbidity, mean and longest observation times were 102.2 and 201 months, respectively. Predictors for MACE morbidity were age (hazard ratio [HR] = 1.025), diabetes (HR = 1.436), Duke Risk category (HR = 1.562) and Ischaemic burden category (HR = 1.531). For MACE mortality, mean and longest observation times were 107.9 and 204 months, respectively. Predictors for MACE mortality were age (HR = 1.044), Duke Risk category (HR = 1.983), echocardiography risk category (HR = 2.537) and Ischaemic burden category (HR = 1.780).

CONCLUSION

Among patients without typical angina, early ischaemia on noninvasive tests indicated microvascular disease and hyperglycaemia, predicting long-term MACE morbidity and MACE mortality.Contribution: Diabetes was a predictor for MACE morbidity but not for MACE mortality; patients lost to follow-up were possibly diabetic patients with MACE mortality at district hospitals. Early screening for ischaemia and hyperglycaemia control may improve outcomes.

Sarcomeric gene variants among Indians with hypertrophic cardiomyopathy: A scoping review

Hypertrophic cardiomyopathy (HCM) is a genetic heart muscle disease that frequently causes sudden cardiac death (SCD) among young adults. Several pathogenic mutations in genes encoding the cardiac sarcomere have been identified as diagnostic factors for HCM and proposed as prognostic markers for SCD. The objective of this review was to determine the scope of available literature on the variants encoding sarcomere proteins associated with SCD reported among Indian patients with HCM. The eligibility criteria for the scoping review included full text articles that reported the results of genetic screening for sarcomeric gene mutations in HCM patients of Indian south Asian ancestry. We systematically reviewed studies from the databases of Medline, Scopus, Web of Science core collection and Google Scholar. The electronic search strategy included a combination of generic terms related to genetics, disease and population. The protocol of the study was registered with Open Science Framework (https://osf.io/53gde/). A total of 19 articles were identified that reported pathogenic or likely pathogenic (P/LP) variants within MYH7, MYBPC3, TNNT2, TNNI3 and TPM1 genes, that included 16 singletons, one de novo and one digenic mutation (MYH7/ TPM1) associated with SCD among Indian patients. Evidence from functional studies and familial segregation implied a plausible mechanistic role of these P/LP variants in HCM pathology. This scoping review has compiled all the P/LP variants reported to-date among Indian patients and summarized their association with SCD. Single homozygous, de novo and digenic mutations were observed to be associated with severe phenotypes compared to single heterozygous mutations. The abstracted genetic information was updated with reference sequence ID (rsIDs) and compiled into freely accessible HCMvar database, available at https://hcmvar.heartfailure.org.in/. This can be used as a population specific genetic database for reference by clinicians and researchers involved in the identification of diagnostic and prognostic markers for HCM.

Clinical and autoantibody profiles of systemic sclerosis patients: A cross-sectional study from North India

Objectives This cross-sectional study was designed to assess the clinical profile and frequency of associated autoantibodies in all consecutive patients classified as systemic sclerosis (SSc) at Medanta-the Medicity Hospital, Gurgaon, India. Methods Between August 2017 and July 2019, we identified a total of 119 consecutive patients meeting the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) 2013 criteria for SSc and 106 patients consented to this study. Their clinical and serological data at the time of enrolment were analysed. Results Our cohort had a mean age at symptom onset of 40 ± 13 years with a median symptom duration of 6 years. We had 76 patients (71.7%) with interstitial lung disease (ILD), which was a higher proportion compared to European cohorts. 62 patients (58.5%) had diffuse cutaneous involvement which was significantly associated with anti-Scl70 antibodies (p < 0.001), digital ulcers (p = 0.039) and the presence of ILD (p = 0.004). 65 patients (61.3%) had anti-Scl70 and 15 patients (14.2%) had anti-centromere (anti-CENP) antibodies. Scl70 positivity was associated with the presence of ILD (p < 0.001) and digital ulcers (p = 0.01). Centromere antibodies had a negative association with ILD (p < 0.001), but was a risk factor for calcinosis (p < 0.001) and pulmonary arterial hypertension (PAH) (p = 0.01). The combination of diffuse cutaneous disease and Scl70 antibodies was the strongest predictor of ILD and digital ulcers (p = 0.015). sm/RMP, RNP68 and Ku antibodies correlated with musculoskeletal involvement (p < 0.01), while all seven of the patients with Pm/Scl antibodies had ILD. Renal involvement was noted in only two patients. Limitations A single-centre study may not capture the true prevalence of disease characteristics in the population. Referral bias for patients with diffuse cutaneous disease has been noted. Data on RNA-Polymerase antibodies have not been provided. Conclusion North Indian patients have some characteristic differences in disease phenotype as compared to their Caucasian counterparts with a larger proportion of patients presenting with ILD and Scl70 antibodies. Antibodies against Ku, RNP and Pm/Scl occur in a minority of patients, but may be associated with musculoskeletal features.

Post mastectomy pain syndrome at an Indian tertiary cancer centre and its impact on quality of life

Background

Literature on Post mastectomy pain in the Indian population is scarce. Most literature is from the West. The current study aimed to identify the incidence of post-mastectomy pain syndrome (PMPS), pain severity, and its impact on quality of life in Indian patients.

Method

Prospective observational study of 120 women undergoing mastectomy between March and December 2017, followed until 6 months after surgery. The Brief Pain Inventory (BPI) questionnaire and the quality of life questionnaire (QLQ) by the European Organization for Research and Treatment of Cancer (EORTC) and known as (EORTC-QLQ 30) were used to identify the impact on function and quality of life.

Results

A 35.8% PMPS incidence was identified at 6 months after mastectomy. Pain was located in the anterior chest wall (41.8%), axilla (32.6%), and medial upper arm (25.6%). Most (48.8%) patients described it as dull aching and of mild intensity (55.8%). No significant association of age, BMI, surgery, Intercostobrachial nerve (ICBN) dissection, postoperative pain severity, pain history {dysmenorrhea, headache}, and postoperative radiotherapy with PMPS was found. Pain interfered with daily activities and quality of life in those with PMPS, as deduced from BPI and EORTC-QLQ.

Conclusion

PMPS is very much a problem affecting the quality of life in our set of patients. Most women tried to cope and accept the pain as part of the treatment process. This shows the need for creating awareness about PMPS among healthcare providers and patients alike. Early identification and treatment of post mastectomy pain should be an essential aspect of patient care.

Predictive equation for six-minute walk test in Indian children, adolescents, and adults

Background

Post-COVID residual dysfunction has been observed in a majority of people, with reduction in cardiopulmonary endurance emerging as a primary symptom. The Six-Minute Walk Test is a simple, reliable, and valid test that is used routinely on people with chronic respiratory dysfunction. In the current COVID-19 pandemic situation, reference values and a predictive equation developed from a large sample across a large age group, from 6 to 75 years, will enable one to establish goals of treatment for post-COVID rehabilitation.

Methods

Following institutional ethical clearance, we recruited 1369 participants for the study (685 females and 684 males). Participants were classified according to biological age into group 1 (6-12 years), group 2 (13-17 years), group 3 (18-40 years), group 4 (41-65 years), and group 5 (>65 years). Informed consent was sought and participants were screened using a health history questionnaire. Demographic features, namely, age, height, weight, and body mass index (BMI) were noted. The Six-Minute Walk Test was administered as per ATS guidelines. Clinical parameters, namely, pulse rate, respiratory rate, systolic blood pressure, diastolic blood pressure, and rate of perceived exertion were recorded.

Results

The Six-Minute Walk Test (6MWT) was significantly influenced by age and gender (r = 0.257, P = 0.00 and r = 0.501, P = 0.00, respectively). Walking distance was longest in 13-17-year-old males, whereas females demonstrated a linear decline after 12 years. In each age group, males walked a greater distance than females. Stepwise linear regression analysis was used to derive the following predictive equation: 6MWT = 491.93 - (2.148 × age) + (107.07 × gender) (females = 0, males = 1).

Conclusion

The study confirmed variability of the Six-Minute Walk Test, with age and gender being predominant predictors. Reference values, equations, and percentile charts generated from the study can be utilised to guide clinical decision-making while exercise prescription for patients with post COVID dysfunction.

Targeting the Hedgehog Pathway in Rhabdomyosarcoma

Aberrant activation of the Hedgehog (Hh) signalling pathway is known to play an oncogenic role in a wide range of cancers; in the particular case of rhabdomyosarcoma, this pathway has been demonstrated to be an important player for both oncogenesis and cancer progression. In this review, after a brief description of the pathway and the characteristics of its molecular components, we describe, in detail, the main activation mechanisms that have been found in cancer, including ligand-dependent, ligand-independent and non-canonical activation. In this context, the most studied inhibitors, i.e., SMO inhibitors, have shown encouraging results for the treatment of basal cell carcinoma and medulloblastoma, both tumour types often associated with mutations that lead to the activation of the pathway. Conversely, SMO inhibitors have not fulfilled expectations in tumours-among them sarcomas-mostly associated with ligand-dependent Hh pathway activation. Despite the controversy existing regarding the results obtained with SMO inhibitors in these types of tumours, several compounds have been (or are currently being) evaluated in sarcoma patients. Finally, we discuss some of the reasons that could explain why, in some cases, encouraging preclinical data turned into disappointing results in the clinical setting.

Echocardiographic nomograms and Z-scores for term Indian neonates

Background

The availability of nomograms is crucial for the correct interpretation of pediatric and neonatal echocardiograms. Echocardiographic Z-score applications/websites use Western nomograms as reference, which may not be an appropriate standard for gauging Indian neonates. Currently available Indian pediatric nomograms either have not included neonates or have not been specifically designed for neonates. This gross underrepresentation of neonates renders available nomograms unreliable for use as standards for comparison.

Objectives

The objective of this study was to collect normative data for the measurement of various cardiac structures using M-Mode and two-dimensional (2D) echo in healthy Indian neonates and to derive Z-scores for each measured parameter.

Methods

Echocardiograms were performed on healthy term neonates (within first 5 days of life). Birth weight and length were recorded, and body surface area was calculated using Haycock's formula. Twenty M-mode and 2D-echo parameters were measured (including left ventricular dimensions, atrioventricular valves, and semilunar valves' annuli sizes, pulmonary artery and branches, aortic root, and arch).

Results

We studied 142 neonates (73 males) with a mean age of 1.83 ± 1.12 days and mean birth weight of 2.89 ± 0.39 Kg. Regression equations with linear, logarithmic, exponential and square root models were tested to select the best model of fit for the relationship between birth weight and each echocardiographic parameter. Scatter plots and nomogram charts with Z-scores were prepared for each echocardiographic parameter.

Conclusions

Our study provides nomograms with Z-scores for term Indian neonates weighing between 2 kg and 4 kg at birth, within first 5 days of life, for a set of echocardiographic parameters that are frequently used in clinical practice. This nomogram has poor predictability for babies at extremes of birth weight. There is a need for further indigenous studies to include neonates at extremes of weight, both term, and preterm.

Indian Traditional Treatments for Psoriasis: A Critical Appraisal of Available Evidence Supporting Efficacy

OBJECTIVE

To examine data from studies supporting the clinical efficacy of medical approaches from India traditional systems of medicines like Ayurveda, Unani, Siddha, and Homeopathy for psoriasis using outcome indicators employed in clinical practice and research.

METHODS

Searches were conducted between December 2019 and September 2020 in databases PubMed, Scopus, Web of Science and Ovid Medline using search terms including traditional, complementary, psoriasis, Kushtha, Ayurveda, Siddha, Unani, Homeopathy and clinical. Controlled trials, case series and case reports published from India were included.

RESULTS

Data of 17 selected studies were extracted. Treatment efficacy in terms of improvement in Psoriasis Area and Severity Index (PASI) score or/and percentage reduction in score (PASI 50, PASI 75 and PASI 90) or/and patient-reported outcomes using instruments like Dermatology Life Quality Index and Psoriasis Disability Index were noted. All studies reported good improvement as per the study specific outcome. However, study characteristics, including study design, sample size, follow-up period, inclusion and exclusion criteria were heterogeneous, and the choice of outcome measures was not adequate to conclude the effectiveness of intervention. The use of some herbs as common ingredients in several formulations across different systems of medicines were noted in analyzing individual formulation.

CONCLUSIONS

Future studies must incorporate a comprehensive study design with specific outcome measures like PASI, PASI 75, PASI 90, quality of life parameters, compliance to medications, adverse reactions, remission period, relapse rate and cost-effectiveness with long term follow-up. The currently available evidence on the roles of these herbs at molecular level in psoriasis is preliminary.

Genotyping Indian patients with primary cardiomyopathies-analysis of database

INTRODUCTION

Each population has its own unique genotype. Genotyping data on Indian cardiomyopathy patients is lacking.

METHODS

We aimed to create and analyse a database of sequence variations in Indian patients with primary cardiomyopathies. This included all data of the cardiomyopathy cohort at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. In addition, all published papers in Pubmed containing sequence variations in Indian cardiomyopathy patients till December 2020 using specific search terms were included. Affected genes and sequence variations, methodologies and quality of clinical data was analysed. Novel sequence variations were documented.

RESULTS

A database of 493 datasets including 417 different sequence variations was created. Of these, the PGIMER database had 137 datasets consisting of 94 different variants. Only 63 publications included genotyping data of Indian cardiomyopathy cohort from 2000 to 2020 reporting 335 sequence variations. Five (7.9%) studies were from institutions abroad. Of published variations, 35.1% were novel. Most studies carried out selective genotyping. Comprehensive genotyping using cardiomyopathy panels or whole exome sequencing was reported in only 9 (14.3%) publications.

CONCLUSION

Database of 417 different sequence variations in Indian cardiomyopathy patients was analysed. Over a third of all reported sequence variations in Indians were novel.

Color stability of aligner materials on exposure to indigenous food products: An in-vitro study

Background

In the recent day, there has been an exponential growth in the usage of clear aligners for orthodontic treatment. As with any removable appliance, the compliance of patients to remove it during ingestion of food is, at times, poor. Thus, the stability of the clear aligner to be "clear" becomes questionable. This in-vitro study examined how the clear aligners changed colour on exposure to various indigenous food products used in everyday life.

Methods

Aligners from 5 different companies (K Line, Clearbite Aligners, The Aligner Company, iAligners and MaxDent CA Digital) were exposed for 12 hours and 24 hours to various indigenous substances (tea, green tea, coffee, turmeric, saffron and Kashmiri red chili powder) and a control solution (distilled water) in-vitro. The color change was assessed with the help of VITA Easyshade compact colorimeter based on Commission Internationale de I'Eclairage L*a*b* color system. Values were then modified to NBS units for clinical relevance.

Results

The hue of the transparent aligners was noticed to change in a statistically meaningful way when exposed to turmeric, saffron, Kashmiri red chili powder and coffee in decreasing order and mild color change in tea and green tea at both 12 hours and 24 hours intervals.

Conclusion

Aligners are prone to color change when exposed to indigenous foods that contain staining properties.

Value of Environmental Health During the COVID-19 Pandemic: A Story From Indian Country

The coronavirus disease 2019 (COVID-19) pandemic challenged not only the health-care industry, but also the public health infrastructure in new and wide-ranging ways. Environmental health (EH) professionals have proven to be an essential component of the interdisciplinary public health solution required to prevent, respond, and recover from the COVID-19 pandemic. The Indian Health Service's Division of Environmental Health Services is a community-based program offering a broad scope of environmental health services and technical assistance. Significant COVID-19 workload activities were recorded from March 2020 through March 2021. A total of 62.7% of the Division's federal staff completed a 24-question survey in February/March 2021. Primary roles relating to community-based EH, institutional EH, and incident command system support/teams became apparent. Results indicated Division of Environmental Health Services staff provided critical leadership and used their established, trusted, interdisciplinary partnerships to help ensure critical resources and services were available in Indian Country.

Case report of a rare purine synthesis disorder due to 5-aminoimidazole-4-carboxamide ribonucleotide formyltransferase (AICAR) deficiency

BACKGROUND

AICA (5-aminoimidazole-4-carboxamide) ribosiduria is an inborn error in purine biosynthesis caused due to biallelic pathogenic variants in the 5-aminoimidazole-4-carboxamide ribonucleotide-formyltransferase/imp cyclohydrolase (ATIC) gene located on chromosome 2q35. ATIC codes for a bifunctional enzyme, AICAR transformylase and inosine monophosphate (IMP) cyclohydrolase, which catalyse the last two steps of de novo purine synthesis. This disorder has been previously reported in only 4 cases worldwide, and herein, we report the first from India.

CASE REPORT

The proband presented with global developmental delay, developmental hip dysplasia (DDH), acyanotic heart disease and nystagmoid eye movements. Whole exome sequencing (WES) identified compound heterozygous pathogenic variants in the ATIC. A novel splice site variant; c.1321-2A > G and a previously reported missense variant; c.1277A > G (p.Lys426Arg) were identified. Segregation analysis of parents showed the father to be a heterozygous carrier for the splice site variant and the mother, a heterozygous carrier for the missense variant.

CONCLUSION

This case of a rare genetic disorder of purine biosynthesis of ATIC deficiency is the first case reported from India. Early diagnosis lead to early interventional therapy and genetic counselling.

Determination of exophthalmometry values in the North Indian population

Purpose

To determine exophthalmometry values (EV) in the north Indian population and to find its correlation with the age, gender, height, weight, body mass index (BMI), locality, and base value of the population.

Methods

A total of 1000 eligible participants with 504 females and 496 males with age >5 years were included in this observational cross-sectional study. Age, gender, and locality of the subjects were noted. Hertel's exophthalmometry was performed on all subjects. The exophthalmometry values and base values were recorded. Height and weight were measured for all participants. BMI was calculated using the parameters.

Results

The overall mean exophthalmometry value (mm) was 14.94 ± 2.43 mm with a range between 8 and 22 mm. There was no significant difference in EV between the two eyes. Males recorded a significantly higher mean EV of 15.4 ± 2.51 mm as compared to females with a value of 14.49 ± 2.27 mm. Base value of Hertel's exophthalmometer had a mean value 100.78 ± 5.63 mm and a range of 84-120 mm. Age, height, weight, BMI, and locality of the subjects were found to have a significant effect on the exophthalmometry as well as the base value of the population. A significant correlation was also seen between exophthalmometry values and base values of the population.

Conclusion

Our study provided the normal exophthalmometric range for the north Indian population and also demonstrated the relationship of age, gender, height, weight, BMI, locality, and base value with the exophthalmometric values.

Efficacy and safety of brolucizumab versus aflibercept in patients with neovascular age-related macular degeneration: a randomized trial in Indian patients

BACKGROUND

The current standard treatment for neovascular age-related macular degeneration (nAMD) involves intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents. The aim of the present study was to compare the effectiveness and safety of two anti-VEGF drugs: brolucizumab and aflibercept, in treatment-naïve nAMD Indian patients over a period of 48 weeks.

METHODS

A prospective, randomized, single-centre, single-blinded, two-arm comparative study was conducted between March 2021 and February 2022. Of the 114 patients, 56 received intravitreal injections of brolucizumab (6 mg/50 µL) while 58 received aflibercept (2 mg/50 µL). The patients received 03 initial loading doses at 4-week intervals of both the agents and then respective therapies were given as individualized pro re nata (PRN) regimen based on the signs of active macular neovascularization. The functional and anatomical outcomes measured were mean change in best-corrected visual acuity (BCVA, logMAR), central macular thickness (CMT, µm), presence of intraretinal fluid, subretinal fluid or subretinal hyper-reflective material. Furthermore, the average number of additional injections required after the loading doses, the injection-free interval and safety of both the drugs were also assessed.

RESULTS

Brolucizumab was found to be non-inferior to aflibercept in terms of mean change in BCVA (-0.13 ± 0.21 logMAR vs. -0.10 ± 0.15 logMAR) and reduction in CMT (-112.59 ± 81.23 µm vs. -86.38 ± 71.82 µm). The percentage of eyes with IRF and SHRM was comparable between both the groups while fewer eyes treated with brolucizumab indicated SRF presence than aflibercept after the loading doses. These beneficial effects of brolucizumab were observed with significant (p < 0.0001) lesser number of injections (1.8 ± 1.1 vs. 3.8 ± 1.5) from week 12 to week 48. Moreover, the probability of no injections after the loading doses was significantly higher with brolucizumab compared to aflibercept indicating prolonged injection-free intervals. The average ocular side effects were comparable in the two groups. One adverse event of severe vitritis requiring treatment with oral steroids occurred in Brolucizumab group, while no such event occurred in Aflibercept group.

CONCLUSION

The results of the present study suggest non-inferiority of brolucizumab PRN regimen to aflibercept PRN regimen in treatment naïve nAMD Indian patients while achieving longer inter-injection intervals. Trial registration Clinical Trial Registration of India (CTRI/2021/06/034415). Registered 03 March, 2021, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=54328&EncHid=&userName  = .

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Sural Sensory Nerve Action Potential: A Study in Healthy Indian Subjects at Tertiary Care Center of North-West India

Objectives

This study was done to obtain the reference data for the sural SNAP amplitude and latency at distances of 14, 12, and 10 cm from the active recording electrode in Indian healthy subjects for different age groups.

Material and Methods

Two hundred forty-four healthy subjects (18-80 years) were included in this cross-sectional study. Subjects were divided into six groups according to age. Sural SNAP was recorded antidromically stimulating at three sites (14, 12, and 10 cm from the recording electrode). The quantitative variables were expressed as Mean ± SD/Median (IQR) and compared using t test/ANOVA. Transformed data for amplitude were analyzed with the use of paired t test. P < 0.05 was considered statistically significant. SPSS version 20.0 software was used for statistical analysis.

Results

Mean age of included subjects was 43.28 years. Maximum leg girth was at 14 cm. Analysis showed a significant difference in the leg girth at all three sites (P < 0.001). Sural SNAP latency at each stimulating site was compared in different age groups, no significant difference was found between groups (P = 0.19). Maximum amplitude was in the 18-30-years age group and amplitude was minimum in the 71-80-years age group (4.34 and 2.79, respectively). The difference in the amplitude recorded in the different age groups was found to be statistically different (P < 0.001). The difference in the amplitude recorded at each site was found to be statistically different (P < 0.001).

Conclusion

This is the first study with a large sample size (244 subjects) to provide age-stratified reference data for SNAP in the Indian population by using three sites of stimulation at distances of 14, 12, and 10 cm from the recording electrode. This study shows that sural SNAP amplitude varies with the age of the subject and distance from stimulation.

Delayed Diagnosis of Klippel-Trénaunay Syndrome in a 23-year-old African American Male

Description Klippel-Trénaunay syndrome is a rare genetic disorder that typically presents as a triad of symptoms consisting of venous malformations (varicosities), capillary malformations (port-wine stain), and limb overgrowth. We followed a 23-year-old African American male with a past medical history of peripheral vascular disease, who was visiting the dermatology clinic for a persistent skin lesion on his thigh. During physical examinations, we noted a subtle port-wine stain on his right leg, right leg hypertrophy, and peripheral vascular disease. Skin findings were difficult to observe on his darker skin tone, Fitzpatrick skin type VI, which may have led to the delayed diagnosis of Klippel-Trénaunay syndrome. The lesion of concern was removed during a follow-up visit and was consistent with an angiokeratoma. Our patient had not suffered any serious complications from his new diagnosis of Klippel-Trénaunay syndrome; however, there was a concern for thrombotic events.

Estimation of premorbid intelligence: Demographical and current neurocognitive functioning based algorithms

BACKGROUND & AIM

Establishing a premorbid level of intellectual functioning is crucial for determining the severity level of impairment and prognosis for patients in clinical setting. Therefore, the study aimed to develop a method to estimate premorbid IQ of Hindi speaking Indian population.

METHODS AND MATERIALS

A Hindi vocabulary test was developed (N = 60) and standardized (N = 100). The regression algorithm has been developed using VAIS, WAPIS, RPMT, and a newly developed Vocabulary test, and validated on 100 normal individuals and on 39 brain injury patients.

RESULTS

The estimated premorbid Verbal IQ and performance IQ equation was developed by using demographic variables combine with Hindi vocabulary scores and Matrix Reasoning raw scores respectively. Both the estimated premorbid verbal and performance IQ were found to be significant and valid in estimating verbal and performance IQ in normal and brain injury population.

CONCLUSION

These equations for estimating verbal and performance IQ were found significantly accurate in predicting verbal and performance IQ.

Profiles of indigenous patients with epilepsy in a Brazilian village

INTRODUCTION

Identifying epilepsy in local indigenous populations and describing its epidemiological, etiological, electroencephalographic, and therapeutic aspects can assist public health policies planning toward epilepsy in indigenous communities.

METHODS

This descriptive, cross-sectional study investigated epilepsy among indigenous people residing in Jaguapirú Village, Dourados, Mato Grosso do Sul, Brazil. Participants had their clinical histories reviewed and physical examination performed, as well as one or more electroencephalograms (EEG) registered. Other laboratory tests and neuroimaging data available were analyzed and patients with nonepileptic paroxysmal events were additionally identified.

RESULTS

Out of 2,994 respondents, 49 had a confirmed diagnosis of epilepsy (2.37%) and 22 had self-limited epileptic syndromes, a rate that exceeds the global prevalence but is close to other data reported in the Brazilian population. Focal epilepsy, predominantly from temporal lobe origin, was the most prevalent epileptic syndrome (71.4%). Febrile seizures occurred in only 0.4% of respondents, much lower rate than reported in the general population, which can be attributed to the cross-sectional study design. The etiology of epilepsy was undetermined in 82.6% of cases, with the remaining cases attributed to head trauma, hypoxic-ischemic encephalopathy, and brain malformations. A history of delayed neuropsychomotor development was significantly associated with epilepsy. Monotherapy with first-generation antiseizure medications was greatly effective in most epilepsy cases (87.7%). Electroencephalogram helped to define focal epilepsies and diagnose seizures of nonepileptic origin; the latter mostly included cases of psychogenic seizures and, less frequently, syncope.

CONCLUSION

Diagnosing epilepsy, its clinical presentation, and therapeutical response profile in traditional communities is essential for the establishment of public health policies in developing countries and may help community involvement for successful treatment.

Cerebral creatine deficiency disorders - A clinical, genetic and follow up study from India

INTRODUCTION

Cerebral creatine deficiency syndromes (CCDS) are a group of potentially treatable neurometabolic disorders. The clinical, genetic profile and follow up outcome of Indian CCDS patients is presented.

MATERIALS AND METHODS

This was a retrospective cohort of CCDS patients seen over six-years. Diagnosis was based either on low creatine peak on proton magnetic resonance spectroscopy (MRS) and/or genetic evaluation.

RESULTS

Thirteen patients were eligible [8 creatine transporter deficiency (CTD), 4 guanidinoacetate methyltransferase (GAMT) deficiency and 1 could not be classified]. The mean (±SD) age at diagnosis was 7.2(±5.0) years. Clinical manifestations included intellectual disability (ID) with significant expressive speech delay in all. Most had significant behavior issues (8/13) and/or autism (8/13). All had history of convulsive seizures (11/13 had epilepsy; 2 patients only had febrile seizures) and 2/13 had movement disorder. Constipation was the commonest non-neurological manifestation (5/13 patients). Cranial MRI was normal in all CTD patients but showed globus pallidus hyperintensity in all four with GAMT deficiency. MRS performed in 11/13 patients, revealed abnormally low creatine peak. A causative genetic variant (novel mutation in nine) was identified in 12 patients. Three GAMT deficiency and one CTD patient reported neurodevelopmental improvement and good seizure control after creatine supplementation.

CONCLUSION

Intellectual disability, disproportionate speech delay, autism, and epilepsy, were common in our CCDS patients. A normal structural neuroimaging with easily controlled febrile and/or afebrile seizures differentiated CTD from GAMT deficiency patients who had abnormal neuroimaging and often difficult to control epilepsy and movement disorder.

Socioeconomic determinants of smokeless tobacco use among Indian women: An analysis of global adult tobacco survey-2, India

INTRODUCTION

The predominant form of tobacco consumption among women from many Asian countries, including India, is smokeless tobacco (SLT). The present study aimed to assess the prevalence and socioeconomic determinants of SLT use among Indian women.

METHODOLOGY

The study used data from the Global Adult Tobacco Survey-2, India, conducted during 2016-2017, with a sample size of 40,265 women aged 15 years and above. Chi-square test and binary logistic regression were applied with the current use of SLT as the dependent variable to find the sociodemographic factors associated with it.

RESULTS

Overall, 12.8% (95% confidence interval [CI]; 12.4-13.1) of all women and 7.4% (CI: 6.0-8.8) of pregnant women reported SLT use. Its use was higher among women >50 years (23.1%, CI: 22.2-23.8), and those from northeast India (34.9%, CI: 33.8-36.0). Adjusted odds of using SLT were higher among older women (adjusted odds ratio [AOR]: 5.8, CI: 4.5-7.3), women from rural areas (AOR: 1.5, CI: 1.4-1.7), and women belonging to scheduled tribe (AOR: 2.4, CI: 2.2-2.7) as compared to their counterparts. In addition, poor (AOR: 2.6; 95% CI, 2.4-2.8) and middle class (AOR: 1.8; 95% CI, 1.7-2.0) women were more likely to use SLT compared to their rich counterparts. The use of SLT within 30 min of waking up in the morning was seen in 57.2 percent of women users. SLT prevalence was highest among Mizo-speaking women (46.1%, CI: 42.6-49.6), followed by Manipuri (38.9%, CI: 35.5-42.2), Odiya (34.4%), and Khasi (34%, CI: 29.8-38.2).

CONCLUSIONS

There is an imperative need for women-centric schemes on SLT cessation, with special attention to older women, pregnant women, from rural areas, poor households, and the north-eastern region of India.

Analysis of root morphology and internal anatomy of 400 maxillary first premolars using cone-beam computed tomography in an Indian Dravidian subpopulation: An ex vivo study

Background

There have been numerous cone-beam computed tomography (CBCT) studies done over the years to analyze the canal configurations among various racial and ethnic population groups. Several of these studies have highlighted a certain consistency in the incidence of particular features within these population subsets.

Aim

The study aimed to analyze the root morphology and canal configurations of the maxillary first premolar (Mx1PM) in the Indian Dravidian subpopulation using CBCT.

Setting and Design

This study involved a retrospective analysis of 200 CBCT scans, which included 400 Mx1PM.

Methods

The CBCT images were evaluated, and the number of roots and canal configurations was recorded as per the Vertucci's classification.

Statistical Analysis

Variations in the number of roots and canal anatomies were statistically interpreted using the Chi-square test of association with the significance level set at P < 0.05.

Results

Among the 400 Mx1PM studied, 116 (29%) teeth displayed single roots and 284 (71%) showed the presence of two roots. The single-rooted premolars revealed a varied canal configuration with a predominance of Vertucci's Type II configuration in around 53.4% of the Mx1PM. The two-rooted premolars revealed 100% Type I canal configuration.

Conclusion

The Mx1PM studied predominantly showed the two-rooted morphology with independent canals in each root. There was no significant difference between the teeth on either side of the same arch. The CBCT is an excellent nondestructive modality that can help us study the internal anatomy of pulp space accurately.

Heterogeneity in cardio-metabolic risk factors and atherosclerotic cardiovascular disease among Asian groups in the United States

OBJECTIVE

The Asian American population in the U.S. comprises various, ethnically diverse subgroups. Traditionally, this population has been studied as a single, aggregated group, potentially masking differences in risk among subgroups. Analyses using disaggregated data can help better characterize the health needs of different Asian subpopulations and inform targeted, effective public health interventions. We assessed the prevalence of cardiovascular disease (CVD) risk factors and atherosclerotic CVD (ASCVD) and their associations with socioeconomic factors among Chinese, Asian Indian, Filipino and Other Asian subjects, compared with non-Hispanic White (NHW) subjects in the U.S.

METHODS

: Cross-sectional study using data from 298,286 adults from the National Health Interview Survey (NHIS) from 2007 to 2018. We utilized chi-squared tests to compare characteristics across subgroups. Weighted proportions and unadjusted and adjusted logistic regression models were utilized to examine the associations between Asian subgroups, self-reported CVD risk factors and self-reported ASCVD, as well as between socioeconomic factors within each Asian subgroup.

RESULTS

: Asian Indian subjects had the highest prevalence of diabetes (12.5%), while Filipino subjects had the highest prevalence of hyperlipidemia (27.7%), hypertension (29.8%) and obesity (19.8%). Despite this, the prevalence of self-reported ASCVD was lower in all Asian groups compared with NHWs. Chinese subjects had the lowest odds of having each of the CVD risk factors assessed.

CONCLUSION

: We found considerable heterogeneity in the distribution of risk factors as well as ASCVD among Asian subgroups in the US. Compared with health system or community-based reports, the prevalence of risk factors and ASCVD may be underestimated in some Asian NHIS subgroups. There is an urgent need for efforts to improve recruitment of Asian participants of heterogeneous socioeconomic backgrounds in national surveys, as well as to perform a thorough assessment of risk factors and disease in this population, not relying solely on self-report.

A cross-sectional study to determine the normal corneal epithelial thickness in Indian population using 9-mm wide optical coherence tomography scans

Purpose

To study the corneal epithelial thickness with 9-mm scans of optical coherence tomography in normal Indians with appropriate representation of all age groups.

Methods

This was a cross-sectional observational study. 263 patients were divided into the age groups 5-20 years, 21-35 years, 36-50 years and more than 51 years were recruited for the study. All patients underwent a detailed ophthalmic examination. Patients found to have any ocular surface or intraocular disease condition (except cataract and refractive error), or who had undergone any ophthalmic surgery in the past, or had corneal topography changes suggestive of corneal ectasias (screened in patients with astigmatism more than 3 diopters) or had been continuously using any topical medication in either eye for a period of 3 months or more with the last instillation being within 1 month of inclusion in the study were excluded. All subjects underwent corneal epithelial thickness measurement with anterior segment optical coherence tomography (AS-OCT) on the Avanti OCT (Model RTVueXR1002, Optovue, USA). The corneal epithelial thickness (CET) data from 25 sectors in each eye were analyzed.

Results

263 right and left eyes of 263 patients were analyzed in the study. Mean CETs in the central 2 mm zone were 54.13 ± 4.51 μm and 54.37 ± 3.75 μm for the right and left eyes, respectively. The superior peripheral sectors and inferior paracentral sectors were the thinnest and the thickest sectors, respectively, in both eyes.

Conclusion

CET parameters for Indian eyes are comparable to those reported from racially distinct and geographically distant study subjects.

Exploring multilevel determinants of co-occurring violence, HIV, mental health and substance use problems

Multiple factors contribute to co-occurring issues such as violence, HIV, and mental disorders among people who inject drugs (PWID), particularly those residing in limited resource settings. Using an ecological framework, this study explored multilevel determinants of co-occurring violence, HIV, mental health, and substance use issues among PWID. Data were collected via semi-structured in-depth interviews with 31 men and women PWID in India. Findings revealed factors at the community (e.g., stigma), interpersonal (e.g., abusive partners), and individual (e.g., financial stress) levels. Findings highlight the need for prevention and intervention programs addressing factors at multiple ecological levels to reduce comorbidity among PWID.

Geographical separation and ethnic origin influence the human gut microbial composition: a meta-analysis from a Malaysian perspective

Ethnicity is consistently reported as a strong determinant of human gut microbiota. However, the bulk of these studies are from Western countries, where microbiota variations are mainly driven by relatively recent migration events. Malaysia is a multicultural society, but differences in gut microbiota persist across ethnicities. We hypothesized that migrant ethnic groups continue to share fundamental gut traits with the population in the country of origin due to shared cultural practices despite subsequent geographical separation. To test this hypothesis, the 16S rRNA gene amplicons from 16 studies comprising three major ethnic groups in Malaysia were analysed, covering 636 Chinese, 248 Indian and 123 Malay individuals from four countries (China, India, Indonesia and Malaysia). A confounder-adjusted permutational multivariate analysis of variance (PERMANOVA) detected a significant association between ethnicity and the gut microbiota (PERMANOVA R2=0.005, pseudo-F=2.643, P=0.001). A sparse partial least squares - discriminant analysis model trained using the gut microbiota of individuals from China, India and Indonesia (representation of Chinese, Indian and Malay ethnic group, respectively) showed a better-than-random performance in classifying Malaysian of Chinese descent, although the performance for Indian and Malay were modest (true prediction rate, Chinese=0.60, Indian=0.49, Malay=0.44). Separately, differential abundance analysis singled out Ligilactobacillus as being elevated in Indians. We postulate that despite the strong influence of geographical factors on the gut microbiota, cultural similarity due to a shared ethnic origin drives the presence of a shared gut microbiota composition. The interplay of these factors will likely depend on the circumstances of particular groups of migrants.

Normative Transesophageal Echocardiographic Values of Cardiac Structures in the Indian Population-Indian Normative TEE Measurements (INTEEM) Study

OBJECTIVES

Information on normative reference values for cardiac structures is critical for the accurate application of echocardiography for guiding clinical decision-making. Many studies using transthoracic echocardiography (TTE) have shown that Indians have smaller diameters of various cardiac structures. There are no normative studies for transesophageal echocardiography (TEE). The authors observed dimensions of various cardiac structures in healthy Indian patients under general anesthesia using TEE and compared them with existing guidelines from non-Indian data.

DESIGN

The Indian Normative TEE Measurements study was a multicenter, prospective observational study conducted in India.

SETTING

Operating rooms for noncardiac surgeries in tertiary care-level hospitals.

PARTICIPANTS

Adult patients undergoing noncardiac surgery who were free from any cardiac, respiratory, and renal diseases and had no contraindications for TEE.

INTERVENTIONS

After inducing general anesthesia and achieving stable hemodynamic conditions, a comprehensive TEE examination was performed and various measurements were made.

MEASUREMENTS AND MAIN RESULTS

For each of the 83 patients undergoing noncardiac surgery, 39 various measurements for left ventricle, right ventricle, both atria, and all valves were made. This included diameters and functional parameters. They were analyzed in a vendor-neutral software off-line. The absolute values of many of the measurements were higher in men, but when indexed to body surface area (BSA) they were similar in both sexes. The values were lower than most of the Western data but matched previous Indian studies using TTE.

CONCLUSIONS

The authors present normative values of various echocardiographic parameters using TEE. Because of its variations, it is recommended to use India-specific data to make decisions in Indian patients. It may be prudent to use BSA-indexed values during decision-making.

The Association of Myositis Specific Antibodies in Patients with Inflammatory Myositis: Preliminary Data in Indian Patients

CONTEXT

Autoantibodies have a role in the diagnosis and prognosis in Autoimmune Inflammatory Myositis (AIM).

AIMS

The aim of this work was to study the prevalence and clinical correlation of myositis specific and associated antibodies (MSA and MAA) in AIM.

SETTING AND DESIGN

This was a cross-sectional observational study.

METHODS AND MATERIALS

Consecutive AIM patents were divided into groups as dermatomyositis (DM), polymyositis (PM), CTD-associated myositis (CTD-M), cancer-associated myositis (CAM) and juvenile myositis (JM). Their data along with serum samples were collected after obtaining informed consent. Sera was analyzed for IgG antibodies against Jo-1, PL-7, PL-12, EJ, SRP, Mi-2, MDA-5, TIF1γ, SAE1, SAE2, NXP2 and SSA/R052kD using the microELISA technique. The institutional ethics committee approved the study.

STATISTICAL ANALYSIS

SPSS software (version 24.0) was used. P value < 0.05 was considered statistically significant.

RESULTS

There were 48 patients (DM = 19, PM = 19, CTD-M = 5, CAM = 2, JM = 3) included. MSA were positive in 37.5% patients. Antibodies against Mi-2 were present in 6 (12.5%), Jo-1 in 5 (10.4%), 2 (4.1%) each had PL-7 and SRP antibodies. One patient (2%) each had MDA-5, NXP2 and TIf1g antibodies. Jo-1 antibody was associated with mechanic's hands and ILD. There was a significant association of rash in the Mi-2 group with none of the patients having ILD. Malignancy screening was negative in NXP2 and TIF1g antibody-positive patients. Ro52 was the most common MAA (33.3%) and was associated with mechanic's hand.

CONCLUSION

MSA was present in almost 40% of the cohort. Anti Jo-1 antibody was associated with mechanic's hands and ILD. None of the Mi-2 patients had ILD, which may point to a protective role of this antibody for ILD. The association of newer antibodies in Indian patients needs to be further studied in larger cohorts.

Visual morbidity in thyroid eye disease in Asian Indian patients

Purpose:

To describe visual morbidity in thyroid orbitopathy in Asian Indians and the factors influencing its onset.

Methods:

A retrospective chart review was performed for patients with thyroid related orbitopathy seen between May 2014 and April 2019. Three hundred and one patients were included in the study. Relevant history, clinical findings, investigations, and treatment were documented.

Results:

Nineteen percent of patients had at least 1 visual morbidity feature such as compressive optic neuropathy, exposure keratopathy or diplopia, requiring intravenous glucocorticoid. Male gender, older age, and diabetes were the significant risk factors for high visual morbidity (all P < 0.05). Systemic thyroid status, degree of proptosis, and duration of disease were not significant. Average dose of intravenous glucocorticoid needed was 3.8 g; 24 (7.9%) patients required orbital decompression, and 13 (4.3%) needed eyelid surgery. At the last follow-up, 97% of patients had vision 6/12 or better in both eyes.

Conclusion:

There is significant visual morbidity found in Indian patients with TED, even with moderate proptosis and systemic control of thyroid status. This is the first set of data on the subject.

Efficacy of part-time occlusion in amblyopia in Indian children

Purpose:

To study the effectiveness of part-time occlusion (PTO) in different types of amblyopia in Indian population.

Methods:

Prospective case series of consecutive cases of amblyopia from a tertiary care center were subjected to PTO of the better eye and monitored periodically for 6 months. Those who failed to improve by 6 months were shifted to full-time occlusion of the better eye and followed for a further 3 months.

Results:

175 eyes of 175 patients with amblyopia underwent PTO for 6 months. The mean age of the patients was 10.47 ± 4.69 years (range: 3–26 years). Major subgroups included 94 eyes with strabismic amblyopia and 70 with anisometropic amblyopia. Overall, 168 (96%) children benefited from PTO (improvement being defined as a gain of at least one line of Snellen's visual acuity). The improvement rates for strabismic amblyopes (97.9%) was significantly more than anisometropia (94.3%); P = 0.027. Of the seven patients not responding to PTO, six did not benefit even after full-time patching.

Conclusion:

PTO is a viable and effective modality of management of amblyopia in Indian patients. Strabismic amblyopia was the commonest and responded best to the occlusion therapy in our cohort.

Polymorphous Light Eruption- An Indian Scenario

Polymorphous light eruption (PMLE) is the most common, idiopathic, acquired photodermatosis, characterized by abnormal, recurrent, and delayed reaction to sunlight. Polymorphous light eruption is common worldwide but the morphology, distribution, and pigmentary changes are unique in Indian skin which is discussed in this review. The prevalence of PMLE is around 10–20% in the general population. It commonly occurs in females between 20and 30 years of age. It is the most common photodermatosis in school-going children. Visible light sensitivity is an important phenomenon in PMLE. It typically presents as recurrent and chronic lesions over photoexposed sites. Initially, patchy erythema occurs with pruritus. Most of the Indians belong to type IV to type VI skin and pigmentary changes are commonly seen. The unique feature of PMLE in Indian skin is the pigmentary change which varies from hypopigmented to hyperpigmented lesions. These pigmentary changes may occur alone or in combination with erythematous or skin-colored lesions. The pigmentary lesions are seen in more than 50% of lesions. The histopathology of PMLE is characterized by the presence of hyperkeratosis, spongiosis with or without the presence of liquefactive degeneration in the epidermis. Dermal changes in the upper and mid dermis include the presence of dense perivascular lymphocytic infiltrate. The management of PMLE includes both preventive measures and medical management. Topical sunscreens, topical steroids, hydroxychloroquine and antioxidants play a very important role.

Normative reference values for the timed up-and-go test in Indian children aged four to 11 years old and their correlation with demographic characteristics: A cross-sectional study

Background

The timed up-and-go test (TUGT) is a quick, reliable, and valid assessment tool for evaluating functional mobility or dynamic balance.

Aims

The purpose of this study was to establish the normative values for TUGT in children aged 4 to 11 years old in Surat, India.

Methods

A total of 420 children (210 boys and 210 girls) were included. Subjects were divided into seven age groups. In each age group, 60 (30 males and 30 females) subjects were included. Subjects were randomly recruited from primary schools and underwent three trials of the TUGT. Then, the mean of the three TUGT trials was calculated for each participant.

Results

We formulated normative reference values for each of the seven age groups. The mean and standard deviation of the TUGT score across the total population was 6.00 ± 1.15 seconds. TUGT scores were compared between age groups and genders. Between boys and girls, we found no significant differences. Among the age groups, however, we found significant differences, with a P value of less than 0.001. Thus, only age showed a moderate negative correlation with TUGT score.

Conclusions

This study provides normative reference values for the TUGT among Indian children aged four to 11 years old. We found that no differences existed between the TUGT results according to genders. Conversely, age had a moderate negative correlation: a comparison of TUGT scores among the ages revealed significant differences between the age groups.

Comparison of Nutritional Status of Under-Five Indian Children (NFHS 4 Data) Using WHO 2006 Charts and 2019 Indian Synthetic Charts

INTRODUCTION

There is a growing body of evidence against using World Health Organization (WHO) charts for developing nations. Our objectives were: 1) To compare nutritional status of <5-year-old Indian children using WHO charts and synthetic Indian charts (SC) 2019. 2) To study nutritional status across wealth index categories. 3) To study nutritional status of predominantly breast-fed infants <6 months of age using both charts.

MATERIALS AND METHODS

Data from 4th National Family Health Survey (n ~ 236117, 0--59-month-old children) were used for assessing nutritional status using the WHO charts and SC. Z-scores were calculated for length/height, weight, and weight-for-height (WAZ) using both charts. Children were classified into degrees of malnutrition using appropriate cutoffs.

RESULTS

Stunting, wasting, and underweight were significantly higher using WHO charts. The prevalence of stunting (height for age) and wasting (WHZ) changed from high to medium and critical to poor when the reference changed from WHO to SC. All Z-scores showed an improving trend with increasing wealth index. On SC, almost all WHZ (wasting) from the richest to poorer were >-0.5 (clinically significant), whereas on WHO charts all wealth classes had WHZ <-0.5. For children under the age of 6 months, WHZ from richest to poorest was between -0.97 and -0.89 by WHO and 0.27 and 0.38 by SC.

CONCLUSIONS

Use of Indian synthetic growth charts for growth monitoring of under-five children may be more appropriate; infants under 6 months and children from well off families performed well on these charts.