Pondicherry Institute of Medical Sciences

AIM: To describe the diverse clinical and laboratory manifestations of scrub typhus diagnosed in Pondicherry Institute of Medical Sciences, Pondicherry. MATERIALS AND METHODS: All cases of febrile illness diagnosed as scrub typhus over a period of 2 years were analysed. Diagnosis was based on the presence of the eschar and/or positive Weil Felix test with a titre of > 1:80. RESULTS: Fifty cases of scrub typhus were seen over a period of 2 years (April 2006 and April 2008). Common symptoms were high grade fever of 7-14 days duration, nausea, vomiting, headache, myalgia, cough and breathlessness. Eschar was seen in 23 cases (46%) and the common sites were axilla, breast and groin. Weil Felix test was positive in 39 cases (78%). Liver enzymes were elevated in nearly all cases (95.9%). Multiple Organ Dysfunction Syndrome (MODS) was present in one third of our patients (17 out of 50, 34%). Hypotension (8 patients, 16%), renal impairment (6 patients, 12%), ARDS (4 patients, 8%) and meningitis (7 patients, 14%) were some of the important complications. There was a dramatic response to doxycycline in nearly all the patients. CONCLUSION: Scrub typhus has emerged as an important cause of febrile illness in Pondicherry. Empirical treatment with doxycycline is justified in endemic areas.

BACKGROUND: Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. METHODS: GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. FINDINGS: The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. INTERPRETATION: We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. FUNDING: Gates Foundation.

ispd guidelines

Sir Internet-based surveys have steadily gained popularity with researchers because of their myriad advantages such as ability to reach a larger pool of potential participants within a shorter period of time (vis-a-vis face-to-face surveys), study subjects who maybe geographically dispersed or otherwise difficult to access and efficiency of data management and collation.1 2 This is in addition to obvious reasons such as convenience, relative inexpensiveness and user-friendly features such as comfortable pace and enhanced sense of participant control. With the advent of the COVID-19 pandemic and dwindling opportunities for face-to-face data collection, internet-based tools offer a powerful alternative to rapidly collect data. Moreover, they could be useful tools from a public health perspective to track public perceptions, myths and misconceptions3 in times of disaster. Many methodological issues confront a prospective researcher while designing online questionnaires/surveys. A few of them and some corresponding suggestions for troubleshooting are outlined below: 1. Web or mailed questionnaire?—A meta-analysis of 39 studies4 concluded that response rates to mail surveys are, in general, higher than web surveys. Interestingly, two important factors underlying this variation were the type of respondents and medium of follow-up reminders. While college students were more responsive to web surveys, physicians and laypersons were found to be more receptive to mail surveys. Further, follow-up reminders were more effective when given by mail, probably owing to greater personalisation, than the web. Recently, a hybrid method called web-push surveys, wherein, initial and subsequent follow-up contacts are made by mail to request a response by web was found to be a parsimonious method to elicit responses.5 However, results …

In many developing countries in the South Asian region, screening for chronic diseases in the community has shown a widely varying prevalence. However, certain geographical regions have shown a high prevalence of chronic kidney disease (CKD) of unknown etiology. This predominantly affects the young and middle-aged population with a lower socioeconomic status. Here, we describe the hotspots of CKD of undiagnosed etiology in South Asian countries including the North, Central and Eastern provinces of Sri Lanka and the coastal region of the state of Andhra Pradesh in India. Screening of these populations has revealed cases of CKD in various stages. Race has also been shown to be a factor, with a much lower prevalence of CKD in whites compared to Asians, which could be related to the known influence of ethnicity on CKD development as well as environmental factors. The difference between developed and developing nations is most stark in the realm of healthcare, which translates into CKD hotspots in many regions of South Asian countries. Additionally, the burden of CKD stage G5 remains unknown due to the lack of registry reports, poor access to healthcare and lack of an organized chronic disease management program. The population receiving various forms of renal replacement therapy has dramatically increased in the last decade due to better access to point of care, despite the disproportionate increase in nephrology manpower. In this article we will discuss the nephrology care provided in various countries in South Asia, including India, Bangladesh, Pakistan, Nepal, Bhutan, Sri Lanka and Afghanistan.

PURPOSE: To study the qualitative and quantitative methods for the investigation of biofilm formation and to examine the correlation between biofilm and antibiotic resistance among the clinical isolates of Acinetobacter baumannii . We also verified the association between biofilm and presence of extended spectrum beta-lactamases, particularly, bla PER-1 . METHODS: A total of 55 isolates were subjected to susceptibility testing by disc diffusion method for 13 clinically relevant antibiotics. Screening for biofilm production was done by both qualitative and quantitative methods through tube and microtitre plate assay respectively. The presence of bla PER-1 was checked by PCR. RESULTS: A. baumannii isolates showed very high resistance (>75%) to imipenem, cephotaxime, amikacin and ciprofloxacin. Only cefoperazone, netillin and norfloxacin were found to be effective agents. Results of microtitre and tube methods were concordant with 34 isolates (62%) showing biofilm formation. Resistance to four antibiotics such as amikacin (82% vs. 17.6%, P < 0.001), cephotaxime (88% vs. 11%, P P < 0.001), ciprofloxacin (70% vs. 29%, P =0.005) and aztreonam (38% vs. 11%, P =0.039) was comparatively higher among biofilm producers than non-biofilm producers. Microtitre assay additionally detected 14 weakly adherent isolates. Only 11 isolates had bla PER-1 gene and among these two were strong biofilm producers, while remaining were weakly adherent isolates. CONCLUSION: Microtitre plate method was found to be a more sensitive method for biofilm detection. This study demonstrates a high propensity among the clinical isolates of A. baumannii to form biofilm and a significant association of biofilms with multiple drug resistance. Presence of bla PER-1 appears to be more critical for cell adherence than for biofilm formation.

Background: Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports Methods: A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness-a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits.

Introduction CKD, with its high prevalence, morbidity and mortality, is an important public health problem. With <3% of land mass, India hosts 17% of the Earth’s population. Large numbers of patients below the poverty line, low gross domestic product, and low monetary allocations for health care have led to suboptimal outcomes. Moreover, CKD and other noncommunicable diseases have often been ignored in the face of persistent challenges from and competition for resources for communicable diseases and high infant and maternal mortality (1). CKD Several issues contribute to high prevalence of CKD in India. United Nations Children’s Emergency Fund data show that 28% of children are <2.5 kg at birth. Hypovitaminosis A and other nutritional issues during pregnancy may cause smaller kidney volume at birth and a lower eGFR (2). Consanguinity and genetic inbreeding increase risk of congenital anomalies of the kidney and urinary tract and obstructive or reflux nephropathy. Poverty, poor sanitation, pollutants, water contamination, overcrowding, and known and unknown nephrotoxins (including heavy metals and plant toxins in indigenous remedies) may lead to glomerular and interstitial kidney diseases. Added to these exposures are the growing burden of hypertension and diabetes mellitus. By 2030, India is expected to have the world’s largest population of patients with diabetes. Because of challenges in access to care, over 50% of patients with advanced CKD are first seen when the eGFR is <15 ml/min per 1.73 m2 (3). This sobering number highlights the need for robust screening programs for those at risk for CKD. The reported prevalence of CKD in different regions ranges from <1% to 13%, and recently, data from the International Society of Nephrology’s Kidney Disease Data Center Study reported a prevalence of 17% (4). The etiology of CKD varies considerably throughout India. Parts of the states of Andhra Pradesh, Odisha, and Goa have high levels of CKD of unknown etiology (CKDu), which is a chronic interstitial nephropathy with insidious onset and slow progression (5). Compounding these issues is the sobering fact that 1.3 billion people are served by 1850 nephrologists who are unequally distributed but mostly concentrated in urban centers. Nephrology training positions are inadequate to grow the workforce, and the situation is worsened by “brain drain” to developed countries. ESKD The true burden of ESKD in India is not known, with few dedicated centers for care, lack of universal access to RRT, and absence of a registry. Even today, over 90% of patients requiring RRT in India die because of inability to afford care, and even in those who do start RRT, 60% stop for financial reasons. Among patients who undergo kidney transplantation, unexpected complications have the potential to impose serious financial hardships. Hemodialysis (HD) was introduced in India in 1962, transplantation was introduced in 1971, and peritoneal dialysis (PD) was introduced in 1991. As of 2017, RRT is predominantly a private health care–driven initiative. There are over 130,000 patients receiving dialysis, and the number is increasing by about 232 per million population, a reflection of increasing longevity in general. Early immunization against hepatitis B is implemented in less than one quarter of patients with advanced CKD (3), and only a few have adequate titers of protective hepatitis B surface antibodies (6). Patients referred late are often anemic, have lower likelihood of hepatitis B immunization, start dialysis without an arteriovenous fistula, and have poorer prognosis and higher mortality at dialysis initiation. Protein energy wasting is present in 68%–93% of patients on dialysis from middle and lower socioeconomic strata (7). HD is the most common modality followed by transplantation, and PD is a distant third. India is estimated to have about 120,000 patients on HD. The recurring cost of a session of HD is approximately $9–$45 (without costs for allotted space and machines), but expenses incurred by the patient vary greatly. The urban locations of HD units make PD attractive for the majority of rural patients, but lack of health insurance coverage and prohibitively expensive recurring costs (approximately $350–$400 monthly) are deterrents (8). Despite these barriers, PD utilization is increasing. India is estimated to have over 8500 patients on PD. Timely supply of PD fluid to remote regions across mountainous terrains and villages without adequate road access and hospital access for evaluation and treatment of PD-related infections are important challenges. The problems of unhygienic living conditions and nonavailability of a separate clean room for PD (especially for those living in mud huts) are being addressed. In areas where clean running water is unavailable for hand washing before doing a PD exchange, patients are taught to use water with dilute potassium permanganate solution instead. Transplantation practices are dependent on state welfare funding, brain death declaration practice, personal religious beliefs, and availability of technical expertise and expensive immunosuppressive medication. Living donor kidney transplantation far exceeds deceased donor transplantation. However, despite its cost-effectiveness, high initial costs and limited availability of living related donors are barriers. The imbalance between availability of organs and the need for transplantation has led to the regrettable unregulated practice of illegal living donor transplants in several south Asian countries, including India. Furthermore, infections are an important cause of mortality in transplant recipients. Ongoing Efforts and Future Solutions The challenge of patient care seems daunting. Education regarding diet and smoking avoidance, improved antenatal care, and community-level screening for noncommunicable diseases, like diabetes and hypertension, at the primary health care level must be universally implemented. Awareness regarding CKD must increase. CKD prevention and delaying progression by timely interventions are important public health objectives. Success necessitates the united effort of the government, nongovernmental organizations, philanthropists, and community members. The World Health Organization Package of Essential Noncommunicable Disease Interventions promises hope for CKD prevention. Early diagnosis of CKD made by screening those with diabetes, hypertension, autoimmune diseases, or family history of CKD must become a priority. The Indian Society of Nephrology has made education modules for community physicians with helpful algorithms regarding CKD management and timely nephrology referral. It is hoped that this translates into most patients with CKD being managed appropriately by primary care and family physicians, with appropriate referral to nephrologists when needed. Subsequent follow-up of these patients should continue to be under their primary care physician, with only periodic visits to the nephrologist until advanced stages of CKD are reached and advanced care, like RRT, becomes necessary. The International Society of Nephrology has funded screening programs. The CKDu core group conducts research into its etiology, and this should translate into reducing incidence. To study risk factors and rate of CKD progression as well as development of cardiovascular disease, the Indian Chronic Kidney Disease Study cohort is presently recruiting about 5000 patients (9). Some patients are able to afford access to RRT by government health insurance schemes (where available) that provide chronic twice weekly HD, PD, or transplantation for the underprivileged. This is a boon for the beneficiaries. The Indian Government, in its Healthcare Union Budget 2016, announced the plan for stand-alone HD centers for patients with ESKD, and the National Dialysis Services Program proposes that each district hospital offer HD services in a Public Private Partnership model. Training of patients on PD and caregivers in transmitting photographs of PD fluid bags and exit sites to the physician is enabling early diagnosis and treatment of infections. Implementation of the Transplantation of Human Organs Act (THOA) and bad publicity in the press and social media have considerably curtailed commercial transplantation. The unequivocal and universal implementation of the United Nations Trafficking Protocol may eliminate this bane from society. The THOA has led to organ sharing partnerships between private and government hospitals in some states, and this has revolutionized deceased donor transplantation. The Tamil Nadu Cadaver Transplant Program is an example, having done 5092 organ transplants, including 1655 kidney transplants, in under a decade. This is a direct result of education and promoting awareness in the community. Increasing numbers of deceased donor transplantation (although clearly insufficient) may gradually narrow the gap between donor requirement and availability, and they have also dented commercial transplantation (10). Conclusion Like other developing countries, India has unique situations and challenges that influence early diagnosis and management of CKD. Facilities and expertise available in different parts of the country are unequally distributed. Prevention and early detection of CKD mandate involvement of physicians at all levels. Most patients with CKD can be managed by their primary physicians with timely nephrology referrals. The Indian Society of Nephrology modules should increase competence and lead to uniformity of delivered care. Welcome initiatives, such as governmental provision of affordable and easily accessible RRT (where available), drastic reduction in commercial transplantation, and increasing deceased donor transplants, are improving care of patients with ESKD. Disclosures None.

Minimally invasive and non-invasive methods of estimation of cardiac output (CO) were developed to overcome the limitations of invasive nature of pulmonary artery catheterization (PAC) and direct Fick method used for the measurement of stroke volume (SV). The important minimally invasive techniques available are: oesophageal Doppler monitoring (ODM), the derivative Fick method (using partial carbon dioxide (CO2 ) breathing), transpulmonary thermodilution, lithium indicator dilution, pulse contour and pulse power analysis. Impedance cardiography is probably the only non-invasive technique in true sense. It provides information about haemodynamic status without the risk, cost and skill associated with the other invasive or minimally invasive techniques. It is important to understand what is really being measured and what assumptions and calculations have been incorporated with respect to a monitoring device. Understanding the basic principles of the above techniques as well as their advantages and limitations may be useful. In addition, the clinical validation of new techniques is necessary to convince that these new tools provide reliable measurements. In this review the physics behind the working of ODM, partial CO2 breathing, transpulmonary thermodilution and lithium dilution techniques are dealt with. The physical and the physiological aspects underlying the pulse contour and pulse power analyses, various pulse contour techniques, their development, advantages and limitations are also covered. The principle of thoracic bioimpedance along with computation of CO from changes in thoracic impedance is explained. The purpose of the review is to help us minimize the dogmatic nature of practice favouring one technique or the other.

Since their introduction in clinical practice in the 1950's, Sulfonylureas (SUs) have remained the main-stay of pharmacotherapy in the management of type 2 diabetes. Despite their well-established benefits, their place in therapy is inappropriately being overshadowed by newer therapies. Many of the clinical issues associated with the use of SUs are agent-specific, and do not pertain to the class as such. Modern SUs (glimepiride, gliclazide MR) are backed by a large body of evidence, experience, and most importantly, outcome data, which supports their role in managing patients with diabetes. Person-centred care, i.e., careful choice of SU, appropriate dosage, timing of administration, and adequate patient counseling, will ensure that deserving patients are not deprived of the advantages of this well-established class of anti-diabetic agents. Considering their efficacy, safety, pleiotropic benefits, and low cost of therapy, SUs should be considered as recommended therapy for the treatment of diabetes in South Asia. This initiative by SAFES aims to encourage rational, safe and smart prescription of SUs, and includes appropriate medication counseling.

For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.

In spite of a knowledge explosion in cariology science, dental caries still remains a misunderstood phenomenon by the clinicians. In order to effectively use the wide range of preventive and management strategies, it is imperative to look beyond those black and white spots that manifest on the tooth surfaces. This paper focuses on the revised versions of the etiopathogenesis and definition of dental caries disease in the present century.

INTRODUCTION: To evaluate the hepatoprotective activity of active phytochemicals, picroliv, curcumin, and ellagic acid in comparison to silymarin in the mice model of carbon tetrachloride (CCl(4)) induced liver toxicity. In addition, attempts were made to elucidate their possible mechanism(s) of action. MATERIALS AND METHODS: Oxidative stress was induced in Swiss albino mice by a single injection (s.c.) of CCl(4), 1 ml/kg body weight, diluted with arachis oil at a 1:1 ratio. The phytochemicals were administered once a day for 7& days (p.o.) as pretreatment at two dose levels (50 and 100 mg/kg/day). RESULTS: CCl(4)-induced hepatotoxicity was manifested by an increase in the activities of liver enzymes (alanine transaminase, P < 0.001, aspartate transaminase, P < 0.001 and alkaline phosphatase, P < 0.001), malondialdehyde (MDA, P < 0.001)) levels and a decrease in activity of reduced glutathione (P < 0.001) and catalase in liver tissues. The histopathological examination of liver sections revealed centrizonal necrosis, fatty changes, and inflammatory reactions. The pretreatment with picroliv, curcumin, and ellagic acid normalized serum aminotransferase activities (P < 0.001), decreased levels of MDA (P < 0.001), improved the antioxidant status, and normalized the hepatic histo-architecture. The restoration of phenobarbitone-induced sleeping time also suggested the normalization of liver cytochrome P450 enzymes. CONCLUSION: This study supports the use of these active phytochemicals against toxic liver injury, which may act by preventing lipid peroxidation, augmenting the antioxidant defense system or by regenerating the hepatocytes.

CONTEXT: Non-communicable diseases, no longer a disease of the rich, impose a great threat in the developing nations due to demographic and epidemiological transition. This increasing burden of non-communicable diseases and their risk factors is worrisome. Adherence to hypertension (HT) medication is very important for improving the quality of life and preventing complications of HT. AIM: To study the factors determining adherence to HT medication. SETTINGS AND DESIGN: A community-based cross-sectional study was conducted in a rural area of Kancheepuram district, Tamil Nadu, with a total population of around 16,005. MATERIALS AND METHODS: This study was carried out over a period of 6 months (February-July) using a pre-structured and validated questionnaire. All eligible participants were selected by house-to-house survey and individuals not available on three consecutive visits were excluded from the study. The questionnaire included information on demographic characteristics, lifestyle habits, adherence to HT medication, blood pressure, and body mass index (BMI). Caste was classified based on Tamil Nadu Public Service commission. STATISTICAL ANALYSIS: Data were entered in MS Excel and analyzed in SPSS version 16. P value <0.05 was considered statistically significant. Ethical Consideration: Informed verbal consent was obtained prior to data collection. The patient's adherence to HT medication was assessed using the Morisky 4-Item Self-Report Measure of Medication-taking Behavior [MMAS-4]. RESULTS: We studied 473 hypertensive patients of which 226 were males and 247 were females. The prevalence of adherence was 24.1% (n = 114) in the study population. Respondents with regular physical activity, non-smokers and non-alcoholics were more adherent to HT medication as compared with respondents with sedentary lifestyle, smoking and alcohol intake (P < 0.005). Based on health belief model, the respondents who perceived high susceptibility, severity, benefit had better adherence compared with moderate and low susceptibility, severity, benefit.

BACKGROUND: Metabolic syndrome (MetS), which confers a high risk for cardiovascular diseases, needs early diagnosis and treatment to reduce morbidity and mortality. Lipid accumulation product index has been reported to be an inexpensive marker of visceral fat and metabolic syndrome. This study aimed to evaluate lipid accumulation product index as a marker for metabolic syndrome in the Indian population where the prevalence of the condition is steadily increasing. METHODS: A hospital-based, case-control study was conducted with 72 diagnosed cases of metabolic syndrome and 79 control subjects. In all the participants, body mass index (BMI) and lipid accumulation product index were calculated. The difference between cases and controls in BMI, waist circumference (WC), and lipid accumulation product index was assessed by Mann-Whitney U test/unpaired t-test. Associations of BMI, WC, and lipid accumulation product index with metabolic syndrome were compared by multiple logistic regression analysis and receiver operating characteristic analysis. RESULTS: BMI, WC, and lipid accumulation product index were significantly higher in metabolic syndrome (P < 0.05). Although all were independently associated with metabolic syndrome, lipid accumulation product index had the highest prediction accuracy. The parameter also had a high area under curve of 0.901 (95% confidence interval 0.85-0.95) and a high sensitivity (76.4%), specificity (91.1%), positive predictive value (88.7%), and negative predictive value (80.9%) for detection of metabolic syndrome. CONCLUSION: In the Indian population, lipid accumulation product index is a better predictor of metabolic syndrome compared to BMI and WC and should be incorporated in laboratory reports as early, accurate, and inexpensive indicator of metabolic syndrome.

BACKGROUND: Hepatic diseases are common among chronic kidney disease patients and liver function tests particularly serum liver enzymes play an important role in diagnosing and monitoring these patients. Serum aminotransferase levels commonly fall near the lower end of the range of the normal values in patients of chronic kidney disease (CKD). High-levels of serum alkaline phosphatase (ALP) can occur in these patients due to renal osteodystrophy. Thus, the recognition of liver damage in these patients is challenging. AIM: To compare the levels of serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) and ALP among three groups - CKD patients without end stage renal disease (ESRD), patients with ESRD and healthy controls. MATERIALS AND METHODS: A retrospective, hospital-based study was carried out from 100 patients' records from each group and serum AST, ALT and ALP values were noted. RESULTS: Our study showed that serum AST and ALT levels were significantly lower in CKD patients both without and with ESRD compared to controls. Further, these two enzyme levels were also significantly lower in CKD patients with ESRD compared to CKD patients without the condition. Serum ALP levels were significantly higher in patients with and without ESRD as compared to the controls. However, the values did not differ significantly between patients with and without ESRD. CONCLUSION: Levels of serum aminotransferases were low in CKD with and without ESRD and the levels become lower as the severity of CKD increases. Thus, the study established the need for separate reference ranges of serum aminotransferase in different stages of CKD.

Hypertension (HTN) and prehypertension (pre-HTN) have been identified as independent risk factors for adverse cardiovascular events. Recently, increased psychosocial stress and work stress have contributed to the increased prevalence of HTN and pre-HTN, in addition to the contribution of obesity, diabetes, poor food habits and physical inactivity. Irrespective of the etiology, sympathetic overactivity has been recognized as the main pathophysiologic mechanism in the genesis of HTN and pre-HTN. Sympathovagal imbalance owing to sympathetic overactivity and vagal withdrawal is reported to be the basis of many clinical disorders. However, the role played by vagal withdrawal has been under-reported. In this review, we have analyzed the pathophysiologic involvement of sympathovagal imbalance in the development of HTN and pre-HTN, and the link of sympathovagal imbalance to cardiovascular dysfunctions. We have emphasized that adaptation to a healthier lifestyle will help improve sympathovagal homeostasis and prevent the occurrence of HTN and pre-HTN.

Electronic cigarettes have grown in popularity due to natural curiosity, novel flavors, and advertising as both a means to aid smoking cessation and a "safe" smoking option. There is a substantial body of research on the harmful physical health effects of vaping, but there are relatively few studies on its mental health effects, particularly in adolescents 10-21 years of age. The purpose of this review is to examine the negative effects of vaping on mental health, in particular depression and suicidality. Using the databases PubMed, Scopus, Cochrane Library, and the search engine Google Scholar, we focused on observational studies looking into association between vaping, depression and suicidality. We found 7255 studies; after removing duplicates and other irrelevant articles, 106 articles were left. After reviewing the abstracts and titles, 99 citations were manually removed, 7 studies were included in the final review. Suicide attempts were significantly higher among e-cigarette users compared to non-users. E-cigarette use was associated with depression, suicidal ideation and suicide attempt. Suicide attempts were significantly higher among e-cigarette users compared to non-users. It is critical to raise awareness about the association between electronic cigarettes and adolescent mental health.

BACKGROUND: In India, a new care package consisting of (i) daily regimen with fixed-dose combination drugs, collected once-a-month and self-administered by the patient, (ii) 'one stop service' at antiretroviral treatment (ART) centre for both HIV and tuberculosis (TB) treatment and (iii) technology-enabled adherence support (99DOTS, which required patients to give a missed phone call after consuming drugs) was piloted for treatment of TB among HIV-infected TB patients. Conventional care included intermittent regimen (drugs consumed thrice-weekly) delivered under direct observation of treatment supporter and the patients needing to visit TB and HIV care facilities, separately for treatment. OBJECTIVE: To assess the effect of new care package on TB treatment outcomes among HIV-TB patients registered during January-December 2016, as compared to conventional care and explore the implementation challenges. METHODS: A mixed-methods study was conducted in four districts of Karnataka, India where new care package was piloted in few ART centres while the rest provided conventional care. Quantitative component involved a secondary cohort analysis of routine programme data. Adjusted relative risk(aRR) was calculated using Poisson regression to measure association between new care package and unsuccessful treatment outcome. We conducted in-depth interviews with healthcare providers and patients to understand the challenges. RESULTS: Unsuccessful TB treatment outcomes (death, loss to follow-up and failure) were higher in new care package (n = 871) compared to conventional care (n = 961) (30.5% vs 23.4%; P value<0.001) and aRR was 1.3(95% CI: 1.1-1.7). Key challenges included patients' inability to give missed call, increased work load for ART staff, reduced patient-provider interaction, deficiencies in training and lack of role clarity among providers and reduced involvement of TB program staff. CONCLUSION: With new care package, TB treatment outcomes did not improve as expected and conversely declined compared to conventional care. TB and HIV programs need to address the operational challenges to improve the outcomes.

Although not previously known to cause human infections, Kocuria species have now emerged as human pathogens, mostly in compromised hosts with severe underlying disease. Recently, there has been an increasing incidence of different types of Kocuria infections reported, most likely due to the adoption of better identification methods. Here, we report a case of peritonitis caused by Kocuria rosea in a diabetic nephropathy patient who was on continuous ambulatory peritoneal dialysis. Sepsis and peritonitis caused by K. rosea in our case yielded two identical Kocuria isolates from the peritoneal dialysate fluid within a period of three days. The infection was subsequently resolved by antibiotic treatment and catheter removal. In addition to reporting this case, we herein review the literature concerning the emergence of Kocuria as a significant human pathogen. The majority of cases were device-related, acquired in the hospital or endogenous, and different Kocuria species appear to share a common etiology of peritonitis. The overall disease burden associated with Kocuria appears to be high, and the treatment guidelines for diseases associated with Kocuria have not yet been clearly defined.