Showing papers in "Journal of Postgraduate Medicine in 2016"
TL;DR: An overview on the development path of a novel vaccine candidate based on the expectations of various guidelines issued by the World Health Organization, the European Medicines Agency, and the United States Food and Drug Administration is given.
Abstract: Each novel vaccine candidate needs to be evaluated for safety, immunogenicity, and protective efficacy in humans before it is licensed for use. After initial safety evaluation in healthy adults, each vaccine candidate follows a unique development path. This article on clinical development gives an overview on the development path based on the expectations of various guidelines issued by the World Health Organization (WHO), the European Medicines Agency (EMA), and the United States Food and Drug Administration (USFDA). The manuscript describes the objectives, study populations, study designs, study site, and outcome(s) of each phase (Phase I-III) of a clinical trial. Examples from the clinical development of a malaria vaccine candidate, a rotavirus vaccine, and two vaccines approved for human papillomavirus (HPV) have also been discussed. The article also tabulates relevant guidelines, which can be referred to while drafting the development path of a novel vaccine candidate.
92 citations
TL;DR: Burnout was found to be present in a large number of residents in the cross Sectional study of 558 interns and residents of Government Medical College, Thiruvananthapuram, Kerala, India and showed that as the number of years of residency increased, the burnout also increased in all three dimensions.
Abstract: Background and Rationale: Residents work in emotionally demanding environments with multiple stressors. The risk for burnout is high in them and it has significant negative consequences for their career. Burnout is also associated with consequences in terms of physical and mental health including insomnia, cardiovascular disease, depression and suicidal ideation. Thus, the study aimed to study the prevalence of burn out and its correlates among interns and residents at Government Medical College, Thiruvananthapuram, Kerala, India. Settings and Design: Cross Sectional Study at Government Medical College, Thiruvananthapuram, Kerala, India. Methods: It was a cross Sectional study of 558 interns and residents of Government Medical College, Thiruvananthapuram, Kerala, India. Data was collected which included the Copenhagen Burnout Inventory [CBI]which assesses burnout in the dimensions of Personal burnout, Work burnout and Patient related burnout, with a cut off score of 50 for each dimension. Age, sex, year of study, department the resident belonged to, or an intern, junior resident or a super speciality senior resident (resident doing super speciality course after their post graduate masters degree) were the correlates assessed. Statistical analysis: Univariate analysis. Results: More than one third of the participants were found to have burnout in one or another dimension of the CBI. Burnout was found to be the highest among the interns in the domains of personal burnout (64.05 %) and patient related burnout (68.62 %) and in junior residents for work related burnout (40%). Super specialty senior residents had the least prevalence of burnout in all three dimensions. Among the residents, Non Medical/Non Surgical residents had the least prevalence of burnout in all three dimensions, whereas surgical speciality residents had the highest of personal burnout (57.92 %) and Medical speciality residents had the highest patient related burnout (27.13%). Both medical and surgical specialty residents had equal prevalence of work burnout. The study also showed that as the number of years of residency increased, the burnout also increased in all three dimensions. A between gender difference in burnout was not noticed in our study. Conclusions: Burnout was found to be present in a large number of residents in our study. Nationwide studies and assessment of more correlates will be needed to understand this phenomenon and also for formulating measures for preventing and managing it.
59 citations
TL;DR: JIF was not designed for assessing individual or group research performance, and it seems unsuitable for such purposes, while the g- and h-indices have demonstrated promising outcomes, further developments are needed for their use as academic promotion criteria.
Abstract: Journal Impact Factor (JIF) has been used in assessing scientific journals. Other indices, h- and g-indices and Article Influence Score (AIS), have been developed to overcome some limitations of JIF. The aims of this study were, first, to critically assess the use of JIF and other parameters related to medical education research, and second, to discuss the capacity of these indices in assessing research productivity as well as their utility in academic promotion. The JIF of 16 medical education journals from 2000 to 2011 was examined together with the research evidence about JIF in assessing research outcomes of medical educators. The findings were discussed in light of the nonnumerical criteria often used in academic promotion. In conclusion, JIF was not designed for assessing individual or group research performance, and it seems unsuitable for such purposes. Although the g- and h-indices have demonstrated promising outcomes, further developments are needed for their use as academic promotion criteria. For top academic positions, additional criteria could include leadership, evidence of international impact, and contributions to the advancement of knowledge with regard to medical education.
42 citations
TL;DR: PLR is almost equal to the ordinary logistic regression when the sample size is large and is superior in small cell values and simulation experiment shows that the estimated coverage probability of this method is near the nominal level of 95% even for small sample sizes and for a large number of covariates.
Abstract: Background and Objective: In the analysis of dichotomous type response variable, logistic regression is usually used. However, the performance of logistic regression in the presence of sparse data is questionable. In such a situation, a common problem is the presence of high odds ratios (ORs) with very wide 95% confidence interval (CI) (OR: >999.999, 95% CI: 999.999). In this paper, we addressed this issue by using penalized logistic regression (PLR) method. Materials and Methods: Data from case-control study on hyponatremia and hiccups conducted in Christian Medical College, Vellore, Tamil Nadu, India was used. The outcome variable was the presence/absence of hiccups and the main exposure variable was the status of hyponatremia. Simulation dataset was created with different sample sizes and with a different number of covariates. Results: A total of 23 cases and 50 controls were used for the analysis of ordinary and PLR methods. The main exposure variable hyponatremia was present in nine (39.13%) of the cases and in four (8.0%) of the controls. Of the 23 hiccup cases, all were males and among the controls, 46 (92.0%) were males. Thus, the complete separation between gender and the disease group led into an infinite OR with 95% CI (OR: >999.999, 95% CI: 999.999) whereas there was a finite and consistent regression coefficient for gender (OR: 5.35; 95% CI: 0.42, 816.48) using PLR. After adjusting for all the confounding variables, hyponatremia entailed 7.9 (95% CI: 2.06, 38.86) times higher risk for the development of hiccups as was found using PLR whereas there was an overestimation of risk OR: 10.76 (95% CI: 2.17, 53.41) using the conventional method. Simulation experiment shows that the estimated coverage probability of this method is near the nominal level of 95% even for small sample sizes and for a large number of covariates. Conclusions: PLR is almost equal to the ordinary logistic regression when the sample size is large and is superior in small cell values.
42 citations
TL;DR: The study findings indicated the high prevalence of LBW babies in rural areas of Assam and illiterate teenage mothers, grand multipara, anemic mothers, and short interpregnancy intervals were the important risk factors for LBW.
Abstract: Background and Rationale: Low birth weight (LBW) leads to high neonatal and infant deaths. There is also high prevalence of childhood morbidities and mortalities that are consequences of LBW. Objectives: To find out the prevalence of LBW babies among the study population and to find out the effect of certain maternal and socio-demographic characteristics on birth weight. Materials and Methods: This cross-sectional study was carried out in a rural block of Assam. Cluster sampling was done to choose 30 villages and 15 infants were selected randomly from each village to get a sample size of 450. Results: Prevalence of LBW was found to be 21.8%. Percentage of LBW babies was more among the teenage mothers (36%) and primipara mothers (27%). Maternal anemia [odds ratio (OR) 1.93; confidence interval (CI) 1.3-2.9], short interpregnancy interval (OR 3.93; CI 2.16-7.13), and teenage pregnancy (OR 3.93; CI 2.16-6.45) were found to be the independent risk factors associated with LBW of the babies. Discussion: The study findings indicated the high prevalence of LBW babies in rural areas of Assam and illiterate teenage mothers, grand multipara, anemic mothers, and short interpregnancy intervals were the important risk factors for LBW.
31 citations
TL;DR: The increase in free radicals may be the event that led to the reduction of antioxidant status in HNC, thus explaining the oxidative damage of DNA and the severity of disease.
Abstract: Background: Free radicals such as reactive oxygen species (ROS), which induce oxidative stress, are the main contributors to head and neck carcinogenesis (HNC). The present study was conducted with the aim to assess the oxidant/antioxidant status and DNA damage analysis in head and neck cancer/control patients. Materials and Methods: This prospective study was conducted on 60 patients with biopsy-proven HNC and 17 patients of head and neck disease (HND). The total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) were determined by novel automatic colorimetric methods from tissue homogenate. DNA damage analysis was determined by single cell gel electrophoresis (SCGE). Results: The mean age of the study cohort was 46.65 ± 14.84 years for HNC patients, while it was 49.41 ± 13.00 years for HND patients. There were no significant differences found between the two groups with respect to demographic presentation except tobacco addiction. The association between oxidative stress parameters and DNA damage analysis with study group revealed the following. (A) DNA damage - tissue homogenate TOS and OSI were significantly higher in HNC subjects than in HND (16.06 ± 1.78 AU vs 7.86 ± 5.97 AU, P < 0.001; 53.00 ± 40.61 vs 19.67 ± 21.90, P < 0.01; 7.221 ± 5.80 vs 2.40 ± 2.54, P < 0.01, respectively), while TAS was significantly decreased. (B) Aggressive histological features were identified, more commonly with higher TOS and lower TAS [probability (P) = 0.002, relative risk (RR) = 11.838, 95% confidence interval CI = 2.514-55.730 and P = 0.043, RR = 0.271, 95% CI = 0.077-0.960, respectively]. Conclusion: The increase in free radicals may be the event that led to the reduction of antioxidant status in HNC, thus explaining the oxidative damage of DNA and the severity of disease. Increased OSI represents a general mechanism in its pathogenesis.
30 citations
TL;DR: This article reviews recently published literature, focused on possible protective influence of the centrally active ACE-Is, in the elderly population, at risk for cognitive decline.
Abstract: Alzheimer's disease (AD) is a neurodegenerative disease, in which an accumulation of toxic amyloid beta in the brain precedes the emergence of clinical symptoms. AD spectrum consists of presymptomatic, early symptomatic, and symptomatic phase of dementia. At present, no pharmacotherapy exists to modify or reverse a course of AD, and only symptomatic treatments are available. Many elderly patients, diagnosed with multiple medical conditions (such as cardiovascular diseases, Type 2 diabetes mellitus, and cerebrovascular diseases) are at increased risk of the development of mild cognitive impairment (MCI), AD, and vascular dementia. Studies have revealed reduced rates of cognitive decline, in elderly patients, who were treated with centrally active angiotensin-converting enzyme inhibitors (ACE-Is) (that have an ability to cross the blood–brain barrier). This article reviews recently published literature, focused on possible protective influence of the centrally active ACE-Is, in the elderly population, at risk for cognitive decline.
28 citations
TL;DR: The history of how Indian medicine was transformed in the backdrop of colonialism and hegemony is traced to show how six decades after independence, India has still been unable to convincingly shrug off the colonial yoke.
Abstract: The cross-cultural exchanges between the people of India and their colonial rulers provides a fascinating insight into how these encounters shaped medicine and medical education in India. This article traces the history of how Indian medicine was transformed in the backdrop of colonialism and hegemony. It goes on to show how six decades after independence, we have have still been unable to convincingly shrug off the colonial yoke. India needs to work out a national medical curriculum which caters to our country's needs. A symbiotic relationship needs to be developed between the indigenous and allopathic systems of medicine.
25 citations
TL;DR: Lethality of the attempt increases with the increase in hopelessness, and the mean suicidal intent in the participants was 25.14, when correlated with hopelessness score significant positive correlation was found.
Abstract: Background: Suicide is a psychiatric emergency. Stressors in life and social variables (like marital status, family, and social support) are among the determinants of suicide. Hopelessness and suicidal intent are among the psychological variables that have shown promise in the prediction of suicide. Aims and Objectives: To assess stressful life events, hopelessness, suicidal intent, and sociodemographic variables in patients of attempted suicide. Materials and Methods: Fifty consecutive patients admitted with attempted suicide were interviewed. Presumptive Stressful Life Event Scale, Beck Hopelessness Scale, and Beck Suicidal Intent Scale were used along with a semistructured pro forma for interview. Data were analyzed with statistical tests. Results: Sixty-six percent of the participants were females, 72% were less than 30 years of age. Sixty-six percent of the patients had stressful life event score between 101 and 200 with the mean score of 127. The stressful life event score in those who considered they are in need of psychiatric help was significantly high. Most of the patients had mild (34%) and moderate (40%) degrees of hopelessness, and the mean score was 9.64. The mean suicidal intent in the participants was 25.14, when correlated with hopelessness score significant positive correlation was found. Conclusion: Lethality of the attempt increases with the increase in hopelessness.
22 citations
TL;DR: Classic triad of encephalopathy, ataxia, and ocular signs was seen in four out of five patients and high signal in medial thalamus and surrounding the aqueduct was the most common abnormality.
Abstract: Hyperemesis gravidarum-induced Wernicke's encephalopathy (WE) is an underestimated condition. The purpose of this study is to improve its awareness and early diagnosis. We report five cases of WE secondary to hyperemesis gravidarum. Classic triad of encephalopathy, ataxia, and ocular signs was seen in four out of five patients. Two unusual features noted in this series were papilledema in one patient and severe sensory-motor peripheral neuropathy in one patient. Magnetic resonance imaging (MRI) was abnormal in all the five patients, and high signal in medial thalamus and surrounding the aqueduct was the most common abnormality (5/5). Involvement of caudate nucleus was seen in two patients with severe psychosis, and two patients had bilateral cerebellar peduncle involvement. Median time delay between onset of neurological symptoms and diagnosis was 7 days. All patients improved with thiamine, but minor sequelae were seen in four patients at 12 months follow-up. One patient had a fetal demise. Hyperemesis gravidarum-induced WE is a common cause of maternal morbidity. Typical MRI findings of symmetric medial thalamic and periaqueductal signal changes may permit a specific diagnosis. A delay in diagnosis, therefore treatment, leads to worse prognosis.
20 citations
TL;DR: Hormone bases of paternal behavior in both human and nonhuman mammalian species are summarized and studies on the regulatory role of prolactin in occurrence of paternalbehavior in humans are focused on.
Abstract: In all mammalian species, a combination of neuroendocrine and experiential factors contributes to the emergence of remarkable behavioral changes observed in parental behavior. Yet, our understanding of neuroendocrine bases of paternal behavior in humans is still preliminary and more research is needed in this area. In the present review, the authors summarized hormonal bases of paternal behavior in both human and nonhuman mammalian species and focused on studies on the regulatory role of prolactin in occurrence of paternal behavior. All peer-reviewed journal articles published before 2015 for each area discussed (parental brain, hormonal bases of maternal behavior, hormonal bases of paternal behavior and the role of prolactin in regulation of paternal behavior in nonhuman mammalian species, hormonal bases of paternal behavior and the role of prolactin in regulation of paternal behavior in humans) were searched by PubMed, Medline, and Scopus for original research and review articles. Publications between 1973 and 2015 were included. Similar to female parents, elevated prolactin levels in new fathers most probably contribute to child-caring behavior and facilitate behavioral and emotional states attributed to child care. Moreover, elevated parental prolactin levels after childbirth decrease the parents' libidos so that they invest more in parental care than in fertility behavior. According to the available clinical studies, elevation in the amounts of prolactin levels after childbirth in male parents are probably associated with paternal behavior observed in humans.
TL;DR: Microscopy performed better and is more reliable than first response (RDT) in areas with low parasite density among patients ≥6 years of age and rapid diagnostic tests could be useful in aareas with high parasite density as an alternative to smear microscopy.
Abstract: Background: Current malaria control strategies are based on early diagnosis and appropriate treatment of malaria cases. The study aimed at comparing the performance of blood film microscopy and rapid diagnostic test (RDT) in Plasmodium falciparum detection in patients ≥6 years of age. Materials and Methods: A total of 154 consecutive pyretic patients aged 6-62 years were enrolled, sampled, and tested for malaria using RDT (first response) and microscopy by Giemsa staining. Genomic DNA was extracted after saponin hemolysis and nested polymerase chain reaction (PCR) was used to detect Plasmodium falciparum. The endpoints were sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: Of the 154 patients, 80 (51.9%) had fever of ≥37.5°C. 106 (68.8%) were positive by First response ® , 132 (85.7%) by microscopy, and 121 (78.6%) by PCR. The sensitivity, specificity, PPV, and NPV of first response compared to microscopic method were 82.2%, 100.0%, 100.0%, and 34.3%, respectively, while it was 75.4%, 75.0%, 95.3%, and 31.2%, respectively, when compared to PCR. The sensitivity, specificity, PPV, and NPV of the microscopic method compared to PCR were 92.3%, 50.0%, 90.91%, and 54.5%, respectively. There was a significant difference in the performance of RDT and film microscopy methods ( P ≤ 0.05). Conclusion: Microscopy performed better and is more reliable than first response (RDT) in areas with low parasite density among patients ≥6 years of age. Rapid diagnostic tests could be useful in aareas with high parasite density as an alternative to smear microscopy
TL;DR: Students with newly diagnosed SpLD have greater odds of being "clinically anxious" relative to their regular peers, and screening for anxiety in children with SpLD immediately after diagnosis is recommended so that their optimum rehabilitation can be facilitated.
Abstract: Background and Objectives: School students with specific learning disabilities (SpLDs) experience chronic academic underachievement and resultant stress. The present study aimed to determine if school students with newly diagnosed SpLD were more likely to have anxiety than their regular peers. Materials and Methods: The study cases (aged 8-15 years) were recruited from our institute's learning disability clinic. The matched controls were recruited from four schools in Mumbai, Maharashtra, India. Anxiety was measured using the Spence Children's Anxiety Scale (SCAS)-child self-report version questionnaire. Median SCAS scores and the proportion of students with an SCAS score in the clinical anxiety range were compared between the groups. Results: SCAS scores were significantly higher in 8-11-year-old learning-disabled male and female students (P < 0.0001 for both groups) and 12-15-year-old female students (P = 0.004), as compared with matched controls. A significantly higher number of learning-disabled students were found to have clinical anxiety [24.64% vs 4.35%, crude odds ratio (OR) = 7.19, 95% confidence interval (CI) 2.91-17.78, P = 0.0001], as compared with the controls regardless of gender, age group, presence of comorbid attention-deficit/hyperactivity disorder (ADHD), or associated medical conditions. A significantly higher proportion of 8-11-year-old learning-disabled students, especially males, were found to have clinical anxiety as compared with 12-15-year-old learning-disabled students (crude OR = 4.38, 95% CI 1.94-9.92, P = 0.0004). Gender, presence of comorbid ADHD or associated medical conditions, and type of school attended or curriculum did not impact the prevalence of clinical anxiety in learning-disabled students. Interpretation and Conclusions: Students with newly diagnosed SpLD have greater odds of being clinically anxious relative to their regular peers. We recommend screening for anxiety in children with SpLD immediately after diagnosis so that their optimum rehabilitation can be facilitated.
TL;DR: The landmark results of genome-wide association studies (GWAS) with respect to major complex diseases - Coronary artery disease, type 2 diabetes mellitus (T2DM), and predominant cancers are outlined and the list of the most significant SNPs identified through GWAS was made, which may be useful for designing studies in functional validation.
Abstract: The Human Genome Project (HGP) has identified millions of single nucleotide polymorphisms (SNPs) and their association with several diseases, apart from successfully characterizing the Mendelian/monogenic diseases. However, the dissection of precise etiology of complex genetic disorders still poses a challenge for human geneticists. This review outlines the landmark results of genome-wide association studies (GWAS) with respect to major complex diseases - Coronary artery disease (CAD), type 2 diabetes mellitus (T2DM), and predominant cancers. A brief account on the current Indian scenario is also given. All the relevant publications till mid-2015 were accessed through web databases such as PubMed and Google. Several databases providing genetic information related to these diseases were tabulated and in particular, the list of the most significant SNPs identified through GWAS was made, which may be useful for designing studies in functional validation. Post-GWAS implications and emerging concepts such as epigenomics and pharmacogenomics were also discussed.
TL;DR: An in-depth understanding of the emotions - Their root cause, coping strategies, and spiritual and cultural orientations of the cancer survivor - Is essential to develop any effective intervention program in India.
Abstract: Background and Rationale: Patients suffering with head and neck cancers are observed to have a relatively high risk of developing emotional disturbances after diagnosis and treatment. These emotional concerns can be best understood and explored through the method of content analysis or qualitative data. Though a number of qualitative studies have been conducted in the last few years in the field of psychosocial oncology, none have looked at the emotions experienced and the coping by head and neck cancer patients. Materials and Methods: Seventy-five new cases of postsurgery patients of head and neck cancers were qualitatively interviewed regarding the emotions experienced and coping strategies after diagnosis. Results: Qualitative content analysis of the in-depth interviews brought out that patients experienced varied emotions on realizing that they were suffering from cancer, the cause of which could be mainly attributed to three themes: 1) knowledge of their illness; 2) duration of untreated illness; and 3) object of blame. They coped with their emotions by either: 1) inculcating a positive attitude and faith in the doctor/treatment, 2) ventilating their emotions with family and friends, or 3) indulging in activities to divert attention. Conclusion: The results brought out a conceptual framework, which showed that an in-depth understanding of the emotions - Their root cause, coping strategies, and spiritual and cultural orientations of the cancer survivor - Is essential to develop any effective intervention program in India.
TL;DR: Assessing if the NLR and other leukocyte counts and indices were deranged in treatment-naïve patients with primary brain tumors when compared with an age-matched healthy control group found significant changes in the neutrophil, monocyte, and platelet counts.
Abstract: Background: Elevation of the neutrophil to lymphocyte ratio (NLR) has been shown to be an indicator of poor prognosis in many malignancies including recurrent glioblastoma multiforme. Objectives: This study was aimed at assessing if the NLR and other leukocyte counts and indices were deranged in treatment-naive patients with primary brain tumors when compared with an age-matched healthy control group. Materials and Methods: This was a prospective comparative clinical observational study by design. A healthy control population was compared with treatment-naive patients diagnosed with intra- and extraaxial brain tumors. Leukocyte counts (neutrophil, lymphocyte, monocyte, eosinophil, and basophil counts) as well as leukocyte ratios such as the NLR and the monocyte to lymphocyte ratio (MLR) were calculated. We also evaluated if the counts and indices were related to the tumor volume. Results: In all patients with tumors, the platelet and neutrophil counts were elevated when compared to the controls. In contrast, monocyte counts and the MLR were found to be decreased in patients with tumors when compared to the controls. The subset of patients with glioblastoma showed a significant increase in NLR when compared to the controls. Conclusions: Significant changes in the neutrophil, monocyte, and platelet counts as well as NLR and MLR were observed. Prospective longitudinal studies are required to determine the prognostic and therapeutic implications of these findings.
TL;DR: Inappropriate utilization of FOBT in the inpatient setting is common, even when the indication does not support its use, and quality improvement initiatives are needed to educate clinicians on the appropriate use.
Abstract: Background: Despite lack of evidence supporting the use of fecal occult blood test (FOBT) in the acute hospital setting, FOBT is commonly used in the inpatient setting for reasons other than colorectal cancer (CRC) screening. Aims: To evaluate practice trends in utilizing FOBT on inpatients and its impact on affecting clinical management and outcomes. Materials and Methods: A cross-sectional study of consecutive adult patients undergoing FOBT from January 1, 2011 to December 31, 2011 during an acute medical admission at a large urban safety net hospital was performed. Indications for FOBT, and the impact of FOBT results on endoscopic procedures performed and clinical outcomes were assessed. The number of inpatient endoscopic procedures before and after discontinuing inpatient FOBT was also assessed. Results: A total of 207 inpatient FOBTs were performed in 2011. The most common reason cited for FOBT was anemia (36%, n = 74) followed by gastrointestinal (GI) bleeding (27%, n = 55). Interestingly, 23% (n = 47) of the patients undergoing inpatient FOBT had overt GI bleeding. As expected, patients with positive FOBT were significantly more likely to undergo endoscopic examinations (P < 0.01). After discontinuing the availability of inpatient FOBT, patients were less likely to undergo endoscopic examinations [odds ratio (OR) 0.80, 95% confidence interval (CI) 0.75-0.85]. Conclusion: Inappropriate utilization of FOBT in the inpatient setting is common, even when the indication does not support its use. Setting limitations on inpatient FOBT may reduce the inappropriate utilization of inpatient FOBT. Quality improvement initiatives are needed to educate clinicians on the appropriate use of FOBT, which is primarily for average risk CRC screening.
TL;DR: Chest radiography should be included as part of basic evaluation at presentation in patients with scrub typhus, especially in those with breathlessness, eschar, jaundice, and severe thrombocytopenia.
Abstract: Background and Rationale: Respiratory system involvement in scrub typhus is seen in 20–72% of patients. In endemic areas, good understanding and familiarity with the various radiologic findings of scrub typhus are essential in identifying pulmonary complications. Materials and Methods: Patients admitted to a tertiary care center with scrub typhus between October 2012 and September 2013 and had a chest X ray done were included in the analysis. Details and radiographic findings were noted and factors associated with abnormal X-rays were analyzed. Results: The study cohort contained 398 patients. Common presenting complaints included fever (100%), generalized myalgia (83%), headache (65%), dyspnea (54%), cough (24.3%), and altered sensorium (14%). Almost half of the patients (49.4%) had normal chest radiographs. Common radiological pulmonary abnormalities included pleural effusion (14.6%), acute respiratory distress syndrome (14%), airspace opacity (10.5%), reticulonodular opacities (10.3%), peribronchial thickening (5.8%), and pulmonary edema (2%). Cardiomegaly was noted in 3.5% of patients. Breathlessness, presence of an eschar, platelet counts of 2 mg/dL had the highest odds of having an abnormal chest radiograph. Patients with an abnormal chest X-ray had a higher requirement of noninvasive ventilation (odds ratio [OR]: 13.98; 95% confidence interval CI: 5.89–33.16), invasive ventilation (OR: 18.07; 95% CI: 6.42–50.88), inotropes (OR: 8.76; 95% CI: 4.35–17.62), higher involvement of other organ systems, longer duration of hospital stay (3.18 ± 3 vs. 7.27 ± 5.58 days; P< 0.001), and higher mortality (OR: 4.63; 95% CI: 1.54–13.85). Conclusion: Almost half of the patients with scrub typhus have abnormal chest radiographs. Chest radiography should be included as part of basic evaluation at presentation in patients with scrub typhus, especially in those with breathlessness, eschar, jaundice, and severe thrombocytopenia.
TL;DR: A considerable high prevalence of smoking is revealed among male and female adolescents and addressing the beliefs and knowledge about smoking during childhood is crucial in any antismoking program.
Abstract: Background: Adolescent smoking relates to numerous risk factors, of which beliefs and attitudes toward smoking may play a role. The study aimed to investigate the association between beliefs and attitudes and the risk of adolescent smoking. Materials and Methods: In a school-based cross-sectional study, 3,400 students were recruited from 34 intermediate and secondary schools in Madinah City, Al Madinah Region, Saudi Arabia. Data about sociodemographics, smoking-related factors, and beliefs and attitudes toward smoking were collected using a valid and reliable self-administered questionnaire. Prevalence of smoking was estimated and the studied beliefs and attitudes were compared by smoking status and sex using appropriate statistical analyses including multivariate logistic regression. Results: Of the 3,322 respondents, 33.02% (38.9% males and 26.4% females) were current smokers. Beliefs and attitudes toward smoking significantly differed between smokers and nonsmokers in the studied male and female students. The adjusted risk of smoking was significantly increased among female adolescents who believed that male smokers were more attractive [odds ratio (OR) = 2.2; 95% confidence interval (CI) = 1.6-2.9] and among male smokers who believed that female smokers are more attractive (OR = 1.7; 95% CI = 1.2-2.2). The risk was also increased among all adolescents who believed that smoking lent comfort in social gatherings. Belief that smoking is harmful, however, was negatively associated with the risk of smoking, particularly among females (OR = 0.55; 95% CI = 0.35-0.91). Conclusions: The study revealed a considerable high prevalence of smoking among male and female adolescents. Addressing the beliefs and knowledge about smoking during childhood is crucial in any antismoking program.
TL;DR: Low bone mass is extremely common in endocrinopathies, warranting routine screening and intervention and Calcium and vitamin D supplementations may improve bone health in this setting.
Abstract: Background: Data are scant on bone health in endocrinopathies from India. This study evaluated bone mineral density (BMD) loss in endocrinopathies [Graves' disease (GD), type 1 diabetes mellitus (T1DM), hypogonadotrophic hypogonadism (HypoH), hypergonadotropic hypogonadism (HyperH), hypopituitarism, primary hyperparathyroidism (PHPT)] as compared to age-related BMD loss [postmenopausal osteoporosis (PMO), andropause]. Materials and Methods: Retrospective audit of records of patients >30 years age attending a bone clinic from August 2014 to January 2016 was done. Results: Five-hundred and seven records were screened, out of which 420 (females:male = 294:126) were analyzed. A significantly higher occurrence of vitamin D deficiency and insufficiency was noted in T1DM (89.09%), HyperH (85%), and HypoH (79.59%) compared to age-related BMD loss (60.02%; P < 0.001). The occurrence of osteoporosis among females and males was 55.41% and 53.97%, respectively, and of osteopenia among females and males was 28.91% and 32.54%, respectively. In females, osteoporosis was significantly higher in T1DM (92%), HyperH (85%), and HypoH (59.26%) compared to PMO (49.34%; P < 0.001). Z score at LS, TF, NOF, and greater trochanter (GT) was consistently lowest in T1DM women. Among men, osteoporosis was significantly higher in T1DM (76.67%) and HypoH (54.55%) compared to andropause (45.45%; P = 0.001). Z score at LS, TF, NOF, GT, and TR was consistently lowest in T1DM men. In GD, the burden of osteoporosis was similar to PMO and andropause. BMD difference among the study groups was not significantly different after adjusting for body mass index (BMI) and vitamin D. Conclusion: Low bone mass is extremely common in endocrinopathies, warranting routine screening and intervention. Concomitant vitamin D deficiency compounds the problem. Calcium and vitamin D supplementations may improve bone health in this setting.
TL;DR: Although the commonly established factors appear to be associated with leptospirosis, the role of host factors seems to play a more important role in determining susceptibility to leptosphereirosis in exposed individuals.
Abstract: Background: The current study was planned to identify the epidemiological factors associated with leptospirosis in South Gujarat region using neighborhood controls. Methods: A total of 100 cases of leptospirosis occurred in South Gujarat region during the year 2012 were selected using simple random sampling. Three neighbors of the selected cases formed the controls ( n = 300). A pretested structured questionnaire was used for data collection and data were analyzed using Epi Info 2007. Results: There was significant association of illiteracy (odds ratio [OR] =1.82, 95% confidence interval [CI] =1.14–2.89), working in waterlogged fields during the reference season (OR = 4.6, 95% CI = 1.6–17.9), swimming/bathing in canals, open air defecation practices, storage of cow dung in or surrounding house, residence in the house made up of cow dung walls, households with access of food to rodents, injuries over hands/foot during the endemic season (OR = 3, 95% CI = 1.8–4.8), and history of skin disease during the endemic season (OR = 4.2, 95% CI = 2–8.5), with leptospirosis. Only 10% of individuals had gumboots for protection. A total of 83 (83%) cases and 240 (80%) controls had taken oral doxycycline chemoprophylaxis ( P > 0.05). Cases had taken chemoprophylaxis for a median 4 weeks (range: 1–8) while controls had taken the same for median 8 weeks (range = 1–8) ( P Conclusions: Although the commonly established factors appear to be associated with leptospirosis, the role of host factors seems to play a more important role in determining susceptibility to leptospirosis in exposed individuals.
TL;DR: The serological cross-reactivity with other Flavivirus, particularly with DENV makes laboratory confirmation challenging and will place additional burden on health systems to establish molecular diagnostic facilities, as ZIKV disease continues to mystify us with several unanswered questions.
Abstract: Until now, known as the demure cousin of dengue virus (DENV) inhabiting Africa, Zika virus (ZIKV) has reinvented itself to cause explosive epidemics captivating the Western hemisphere. The outbreak causing potential for ZIKV was realized when it made its way from Africa to Yap Island Micronesia in 2007, and in French Polynesia in 2013. From there, it moved on to Brazil in 2015. Now ZIKV has infected people in more than 33 countries in Central and South America and the Caribbean. Moreover the epidemiological and subsequent virological association with microcephaly cases in Brazil has prompted the World Health Organization to declare a public health emergency of International Concern. ZIKV shares not only its vector Aedes aegypti with dengue and chikungunya but also the geographic distribution and clinical features, which makes the laboratory confirmation mandatory for definitive diagnosis. The serological cross-reactivity with other Flavivirus, particularly with DENV makes laboratory confirmation challenging and will place additional burden on health systems to establish molecular diagnostic facilities. The evidence of additional nonvector modes of transmission, such as perinatal, sexual as well as transfusion has made preventative strategies more difficult. As ZIKV disease continues to mystify us with several unanswered questions, it calls for coordinated effort of global scientific community to address the ever growing arboviral threat to mankind.
TL;DR: The findings are important for policy makers to allocate healthcare resources and develop strategies to prevent SJS/TEN which could decrease length of stay and cost of care.
Abstract: Background: Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are life-threatening dermatologic conditions. Although, the incidence of SJS/TEN in Thailand is high, information on cost of care for SJS/TEN is limited. This study aims to estimate healthcare resource utilization and cost of SJS/TEN in Thailand, using hospital perspective. Methods: A retrospective study using an electronic health database from a university-affiliated hospital in Thailand was undertaken. Patients admitted with SJS/TEN from 2002 to 2007 were included. Direct medical cost was estimated by the cost-to-charge ratio. Cost was converted to 2013 value by consumer price index, and converted to $US using 31 Baht/ 1 $US. The healthcare resource utilization was also estimated. Results: A total of 157 patients were included with average age of 45.3±23.0 years. About 146 patients (93.0%) were diagnosed as SJS and the remaining (7.0%) were diagnosed as TEN. Most of the patients (83.4%) were treated with systemic corticosteroids. Overall, mortality rate was 8.3%, while the average length of stay (LOS) was 10.1±13.2 days. The average cost of managing SJS/TEN for all patients was $1,064±$2,558. The average cost for SJS patients was $1,019±$2,601 while that for TEN patients was $1,660±$1,887. Conclusions: Healthcare resource utilization and cost of care for SJS/TEN in Thailand were tremendous. The findings are important for policy makers to allocate healthcare resources and develop strategies to prevent SJS/TEN which could decrease length of stay and cost of care.
TL;DR: Although warfarin use did not independently predict mortality, preinjury warfarIn use was associated with greater mortality and HLOS in the subset of patients with sTBI, and safety initiatives directed at better initiation and management of warfarins are needed.
Abstract: Introduction: Warfarin continues to be widely prescribed for a variety of conditions. It has been shown that preinjury warfarin may worsen outcomes in trauma patients. We hypothesized that a substantial proportion of injured patients seen at our institution were receiving preinjury warfarin for inappropriate indications and that a significant number of such patients had subtherapeutic or supratherapeutic international normalized ratios as well as increased mortality. Materials and Methods: A retrospective review of registry data from a Level I trauma center was conducted for the period from January 2004 to July 2013. Included were patients aged ≥22 years (based on the youngest recorded patient on warfarin in this study). Abstracted variables included patient age, Injury Severity Score (ISS), Maximum Abbreviated Injury Score for Head (MAISH), mortality, hospital length of stay (HLOS), indication(s) for anticoagulant therapy, admission Glasgow Coma Scale (GCS), and admission international normalized ratio (INR). Suitability of warfarin indication(s) was determined using the most recent American College of Chest Physicians (ACCP) Guidelines. Inappropriate warfarin administration was defined as use inconsistent with these guidelines. For outcome comparisons, a case-control design with 1:1 ratio was used, matching patients taking preinjury warfarin to a random sample of trauma patients who were not taking warfarin. Severe traumatic brain injury (sTBI) was defined as MAISH ≥4. Results: A total of 700 out of 14,583 patients aged ≥22 years were receiving preinjury warfarin (4.8% incidence, WG). This group was age- and ISS-matched with 700 patients (4.8% total sample) who were not taking warfarin (NWG) in a total case-control sample of 1,400. The two groups were similar in age, gender, ISS, and initial GCS. According to the ACCP guidelines, 115/700 (16.4%) patients in the warfarin group were receiving anticoagulation for inappropriate indications. Nearly 65% of the patients were outside of their intended INR therapeutic window (43.4% subtherapeutic, 21.6% supratherapeutic). Overall, median HLOS was greater among patients taking preinjury warfarin (4 days vs 2 days, P < 0.010). Mortality was higher in the WG (7.4% or 52/700) than in the NWG (1.9% or 13/700, P < 0.010). Patients with sTBI in the WG had significantly greater mortality (12.8% or 34/266) than those with sTBI in the NWG (5.3% or 9/169, P < 0.013). Conclusion: A significant proportion of trauma patients admitted to our institution were noted to take warfarin for inappropriate indications. Moreover, many patients taking warfarin had either subtherapeutic or supratherapeutic INR. Although warfarin use did not independently predict mortality, preinjury warfarin use was associated with greater mortality and HLOS in the subset of patients with sTBI. Safety initiatives directed at better initiation and management of warfarin are needed.
TL;DR: Although BACTEC 9050 demonstrated a significantly higher recovery of microorganisms from blood, an appropriately performed conventional blood culture can facilitate the choice of therapy.
Abstract: Aims: Comparison of conventional blood culture with BACTEC 9050 for rate and time to detection of microorganisms. Settings and Design: A prospective study was carried out in a multispecialty tertiary care teaching hospital. Subjects and Methods: A total of 835 paired specimens (797 blood and 38 nonblood specimens) were collected and processed according to standard microbiological procedures by both conventional method as well as by BACTEC 9050 automated culture system. Clinical details of patients were recorded. Data were analyzed for time to detection and isolation rate by the two systems and compared. Results: Overall culture positivity for BACTEC 9050 and the conventional system was 32% and 19.88%, respectively. Eighty-five demonstrated concordant growth, 136 specimens were culture positive by BACTEC only, and 38 specimens were culture positive by conventional only. Twelve contaminants in BACTEC and nine contaminants in conventional system were detected. Using BACTEC 9050, higher isolation was observed for Acinetobacter spp., coagulase negative Staphylococcus spp., Streptococcus spp., and Candida spp. A total of 410 patients were on antimicrobial treatment and culture positivity was significantly higher with BACTEC 9050 (P < 0.0001). There was a significant difference in the mean time to detection with BACTEC 9050 recovering 86.8% of isolates within 48 h (P < 0.0001). Conclusions: Although BACTEC 9050 demonstrated a significantly higher recovery of microorganisms from blood, an appropriately performed conventional blood culture can facilitate the choice of therapy.
TL;DR: It is suggested that MLPA is a good substitute to traditional karyotype in diagnosing chromosomal abnormalities in first-trimester abortions.
Abstract: Background and Introduction: Chromosomal abnormality is found in about half of first-trimester abortions. Karyotype is the gold standard to detect chromosomal abnormalities. Multiplex ligation-dependent probe amplification (MLPA) offers advantage over karyotype in terms of lower failure rate, faster turnaround time, and much higher resolution than conventional karyotyping and found to be 98% concordant with conventional karyotype. Aim: We performed this study to look for the utility of MLPA in diagnosing chromosomal abnormalities in first-trimester abortions. Materials and Methods: MLPA using subtelomeric SALSA probe sets (P036 and P070) was used to detect cytogenetic abnormalities in products of conception in missed/spontaneous abortions. Results: A total of ninety abortus samples were analyzed by MLPA. Successful results were provided in (67) 74.4% of the cases while no conclusion could be drawn in 25.6% (23) of the cases. Fifty-five (82.1%) cases were cytogenetically normal and 17.9% (12) had some abnormality. Aneuploidy was detected in 8 (66.7%) cases, 3 (25%) had double-segment imbalance, and one (8.3%) had partial aneuploidy. Conclusion: We suggest that MLPA is a good substitute to traditional karyotype.
TL;DR: A 70 year old lady presented to surgery emergency with small bowel obstruction and was found to have an obstructed obturator hernia, which is a rare pelvic hernia with an incidence of 0.07-1.4% of all intra-abdominal hernias.
Abstract: A 70 year old lady presented to surgery emergency with small bowel obstruction without any obvious etiology. On exploration she was found to have an obstructed obturator hernia, which is a rare pelvic hernia with an incidence of 0.07-1.4% of all intra-abdominal hernias. Diagnosis is often delayed until laparotomy for bowel obstruction. Strangulation is frequent and mortality remains high (25%). Early diagnosis and surgical treatment contributes greatly to reduce the mortality and morbidity rates. A variety of techniques have been described, however surgical repair has not been standardized. It is an important diagnosis to be considered in elderly patients with intestinal obstruction.
TL;DR: The qualitative summary showed that the perceived HIV stigma, inadequate health education, lack of awareness on available government services, psychological problems, alcohol use, asymptomatic conditions, and financial problems are major barriers to access care early for the late presenters.
Abstract: Background: Early diagnosis and treatment of human Immunodeficiency virus (HIV) is not only beneficial for the people living with HIV/acquired immunodeficiency syndrome (AIDS) (PLHA) but for the public and society as well. The study was aimed to identify the factors associated with late presentation to HIV/AIDS care. Materials and Methods: A facility-based unmatched case-control (1:1) study along with in-depth qualitative assessment was conducted at an ART Plus center at a district hospital, Udupi, southern India. A sample of 320 HIV patients (160 cases and 160 controls) was selected randomly between February and July 2014. Information regarding the patients were collected using an interviewer-administered semi-structured questionnaire. The qualitative component was assessed by in-depth interviews of 4 health professionals and 12 HIV-positive patients who were late for HIV care. The quantitative data were analyzed using Statistical Package for the Social Sciences (SPSS) version 15.0. The technique of thematic analysis was adopted for the analysis of qualitative data. Results: HIV-positive individuals who lived with families [odds ratio (OR) = 5.11], the patients having non-AIDS comorbidities [OR= 2.19, 95% confidence interval (CI): 1.09-4.40], the patients who perceived fear of losing family [OR = 5.00, 95% CI: 2.17-11.49], the patients who perceived fear that their status will be ruined in the community [OR= 2.00, 95% CI: 1.01-3.97], the patients who perceived fear of side effects of ART medications [OR = 4.3, 95% CI: 2.65-11.33], the patients who perceived fear of losing confidentiality [OR = 4.94, 95% CI: 2.54-9.59], the patients those who lack information available on government services [OR = 4.12, 95% CI: 2.127-8.005], and the patients who consumed alcohol [OR= 3.52, 95% CI: 1.83-6.77] were found to be independently associated with the late presentation to HIV/AIDS care after adjusting for all known confounders in a multivariable analysis. The qualitative summary showed that the perceived HIV stigma, inadequate health education, lack of awareness on available government services, psychological problems, alcohol use, asymptomatic conditions, and financial problems are major barriers to access care early for the late presenters. Conclusion: The identified factors can be utilized for the formulation of policies and interventions by promoting early diagnoses and addressing special concerns such as stigma, disclosure, health education, and awareness.