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Background A secondary care hospital in rural India serving a highly tuberculosis (TB) and malnutrition endemic region. Objective In this study conducted on patients with chronic protein energy malnutrition (PEM) and TB, we sought to compare nurse-estimated vs. smartphone photograph analytic methods for assessing caloric intake and determine the incidence of refeeding hypophosphatemia (RH) and refeeding syndrome (RFS) in patients with TB. Methods Inpatients were prospectively enrolled. Baseline demographic, comorbidity and preadmission caloric data were collected. Nurse estimated caloric intake was compared with digital “before and after” meal images. Serum phosphorus was measured on days 1, 3 and 7 post admission. Patients with RH underwent further evaluation for RFS-associated findings. Results 27 patients were enrolled. 85% were at risk of RFS by National Institute for Health and Care Excellence (NICE) criteria. Significant discrepancy (>700 calories) was noted between nurse-estimated caloric intake compared to digital images. RH was found in 37% (10/27). None developed clinical RFS. Conclusions Our study suggests more standardized methods of caloric intake are needed in resource-limited settings with high co-prevalence of PEM and TB. We noted that despite RH being common in inpatients with PEM+TB given high caloric diets, RFS was not detected.

Critically ill adults are frequently administered continuous sedative and/or opioid infusions, based on clinicians’ intentions of optimising comfort, facilitating mechanical ventilation and promoting safety.1 Deep sedation, more prevalent during the current SARS-CoV-2 pandemic,2 is associated with coma, delirium and muscle weakness, with associated impairments in survival and physical, cognitive and mental health.1 The 2013 Pain, Agitation and Delirium (PAD) guidelines made an ungraded statement that using a sedation protocol (SP) to target light levels of sedation or instituting Spontaneous Awakening Trials (SAT) will improve short-term outcomes (eg, duration of mechanical ventilation or ICU stay).3 The 2018 PAD, Immobility and Sleep (PADIS) guidelines make a graded conditional recommendation that light (vs deep) sedation, should be used, regardless of sedative choice, in critically ill, mechanically ventilated adults.1 The PADIS panel relied on evidence from eight randomised controlled trials (RCTs), published prior to October 2015, where light versus deep sedation was defined a priori and evaluated ≥4 times daily.1 Studies solely evaluating an SAT were excluded as this approach often results in light sedation at only a single time point during the 24-hour day.1 Results from RCTs were prioritised over cohort studies. Four RCTs compared a light (vs deep) sedation approach using the same sedative regimen. The other four RCTs compared a light (vs deep) approach where the light group either received a no (or ‘as needed’) sedation approach (n=2) or dexmedetomidine (n=2). Two RCTs implemented light sedation intervention for …

PURPOSE: B-lines on lung ultrasound (US) are the hallmark of pulmonary edema. It is unknown if ultrasound machine settings or probe type matter. METHODS: We created an in-vitro gelatin model. Using lung presets as baseline, five blinded investigators assessed the impact of 32 distinct settings on B-line visibility based on a Likert-Scale (LS) from 0–10 (5 better) separately for two probes. The experiment was then repeated in-vivo in a patient with known pulmonary edema. RESULTS: Based on a multivariable regression LS-ratings were similar when comparing the in-vitro vs. in-vivo experiment (P=0.16; partial R(2)=0.2%) and when using the curvilinear vs. linear probe (P=0.69; partial R(2)=0.02%) but significantly different across machine settings (P

BackgroundUnderstanding the factors associated with disease severity and mortality in Coronavirus disease (COVID-19) is imperative to effectively triage patients. We performed a systematic review to determine the demographic, clinical, laboratory and radiological factors associated with severity and mortality in COVID-19.MethodsWe searched PubMed, Embase and WHO database for English language articles from inception until May 8, 2020. We included Observational studies with direct comparison of clinical characteristics between a) patients who died and those who survived or b) patients with severe disease and those without severe disease. Data extraction and quality assessment were performed by two authors independently.ResultsAmong 15680 articles from the literature search, 109 articles were included in the analysis. The risk of mortality was higher in patients with increasing age, male gender (RR 1.45, 95%CI 1.23–1.71), dyspnea (RR 2.55, 95%CI 1.88–2.46), diabetes (RR 1.59, 95%CI 1.41–1.78), hypertension (RR 1.90, 95%CI 1.69–2.15). Congestive heart failure (OR 4.76, 95%CI 1.34–16.97), hilar lymphadenopathy (OR 8.34, 95%CI 2.57–27.08), bilateral lung involvement (OR 4.86, 95%CI 3.19–7.39) and reticular pattern (OR 5.54, 95%CI 1.24–24.67) were associated with severe disease. Clinically relevant cut-offs for leukocytosis(>10.0 ×109/L), lymphopenia(< 1.1 ×109/L), elevated C-reactive protein(>100mg/L), LDH(>250U/L) and D-dimer(>1mg/L) had higher odds of severe disease and greater risk of mortality.ConclusionKnowledge of the factors associated of disease severity and mortality identified in our study may assist in clinical decision-making and critical-care resource allocation for patients with COVID-19.Primary Funding SourceNone.

Background The prevalence of hypertension in low‐ and middle‐income countries is rapidly increasing, with most cases undiagnosed and many poorly controlled among those diagnosed. Medication reconciliation studies from high‐income countries have demonstrated a high occurrence of antihypertensive medication errors and a strong association between medication errors and inadequate blood pressure control, but data from low‐ and middle‐income countries are lacking. Methods and Results We conducted a cross‐sectional study from April to October 2018 of adult patients on pharmacologic management for known hypertension at 7 public health facilities in Kweneng East District, Botswana. Our aims included to evaluate the frequency of uncontrolled hypertension, the frequency and type of medication errors causing discrepancies between patient‐reported and prescribed antihypertensive medications, and the association between medication errors and uncontrolled hypertension. Descriptive analyses and multivariable logistic regression were used. The prevalence of uncontrolled hypertension was 55% among 280 enrolled adult patients, and 95 (34%) had ≥1 medication error. The most common errors included patients taking medications incorrectly (11.1%; 31/280), patients omitting medications (7.9%; 22/280), and unfilled prescriptions caused by pharmacy stock outs (7.5%%; 21/280). Uncontrolled hypertension was significantly associated with having ≥1 medication error compared with no errors (adjusted odds ratio, 3.26; 95% CI, 1.75–6.06; P Conclusions Medication errors are strongly associated with poor blood pressure control in this setting. Further research is warranted to assess whether medication reconciliation and other low‐cost interventions addressing root causes of medication errors can improve the control of hypertension and other chronic conditions in low‐ and middle‐income countries.

Background Understanding the factors associated with disease severity and mortality in Coronavirus disease (COVID-19) is imperative to effectively triage patients. We performed a systematic review to determine the demographic, clinical, laboratory and radiological factors associated with severity and mortality in COVID-19. Methods We searched PubMed, Embase and WHO database for English language articles from inception until May 8, 2020. We included Observational studies with direct comparison of clinical characteristics between a) patients who died and those who survived or b) patients with severe disease and those without severe disease. Data extraction and quality assessment were performed by two authors independently. Results Among 15680 articles from the literature search, 109 articles were included in the analysis. The risk of mortality was higher in patients with increasing age, male gender (RR 1.45, 95%CI 1.23–1.71), dyspnea (RR 2.55, 95%CI 1.88–2.46), diabetes (RR 1.59, 95%CI 1.41–1.78), hypertension (RR 1.90, 95%CI 1.69–2.15). Congestive heart failure (OR 4.76, 95%CI 1.34–16.97), hilar lymphadenopathy (OR 8.34, 95%CI 2.57–27.08), bilateral lung involvement (OR 4.86, 95%CI 3.19–7.39) and reticular pattern (OR 5.54, 95%CI 1.24–24.67) were associated with severe disease. Clinically relevant cut-offs for leukocytosis(>10.0 x109/L), lymphopenia(< 1.1 x109/L), elevated C-reactive protein(>100mg/L), LDH(>250U/L) and D-dimer(>1mg/L) had higher odds of severe disease and greater risk of mortality. Conclusion Knowledge of the factors associated of disease severity and mortality identified in our study may assist in clinical decision-making and critical-care resource allocation for patients with COVID-19.

Interstitial lung disease (ILD) confers a high mortality and symptom burden, substantially impacting quality of life. Studies evaluating palliative care in ILD are rapidly expanding. Uniform outcome measures are crucial to assessing the impact of palliative care in ILD. This scoping review evaluates existing outcome measures in general health-related quality of life (HRQoL), physical health, mental health, social health and advance care planning (ACP) domains in patients with ILD. Articles in English with quantitative assessment of at least one measure of general HRQoL, physical health, mental health, social health or ACP in patients with ILD were included. Searches across three databases yielded 3488 non-duplicate articles. 23 met eligibility criteria and included three randomised controlled trials (RCTs) or secondary analysis of an RCT (13%), three cross-sectional studies or secondary analysis of cross-sectional study (13%), one prospective study (4%) and 16 retrospective studies (70%). Among eligible articles, 25 distinct instruments were identified. Six studies assessed general HRQoL (26%), 16 assessed physical health (70%), 11 assessed mental health (48%), six assessed social health (26%) and 16 assessed ACP (70%). The ability to compare results across studies remains challenging given the heterogeneity in outcome measures. Future work is needed to develop core palliative care outcome measures in ILD.

Influenza A (H1N1) caused significant mortality and morbidity globally. We identified the hotspots for H1N1 influenza in India using cases and deaths reported in the Integrated Disease Surveillance Program between 2010 and 2017. A total of 114,667 cases and 8543 deaths were reported from across India, at an overall case fatality rate of 7.5%. While Maharashtra accounted for 21% of cases and 31% of deaths, Delhi and Gujarat were ranked the highest based on the population-adjusted ranks for morbidity and mortality, respectively. The current analysis identified states and union territories in western India (Delhi, Punjab, Rajasthan, Gujarat and Maharashtra) to be especially vulnerable.

Rationale: Hospitalization is an opportunity to engage smokers who may not seek tobacco treatment. Our safety-net hospital developed and implemented an inpatient intervention consisting of an "opt-out" electronic health record-based Best Practice Alert (BPA)+order-set, designed to trigger referral to the Tobacco Treatment Consult (TTC) service (a team staffed by tobacco treatment specialists) for all hospitalized smokers, regardless of motivation to quit.Objectives: We performed a sequential explanatory mixed-methods study to evaluate the feasibility, acceptability, and adoption of the TTC service.Methods: Among all admissions of adult "current smokers" between July 2016 and June 2017, we calculated the percentage of patients whose clinicians accepted the order-set (through a simple "order" click), thus generating the TTC referral. We then determined the extent of clinician follow-through of TTC recommendations for prescribing nicotine replacement therapy among 1,651 consecutive smokers seen by the TTC service. Finally, we conducted qualitative interviews with inpatient clinicians (n = 25) to understand their rationale for adoption or nonuse of the TTC intervention, including perceived usefulness, barriers to adoption, and strategies to improve the utility of the service.Results: Clinicians accepted the TTC order-set for 4,100 out of 6,598 "current smokers" (62.1%) for whom the BPA fired, typically after initially deferring the BPA. Rates of acceptance significantly differed across clinical services (range: 8% [obstetrics-gynecology] to 82.2% [cardiology]; P < 0.00001). A chart review showed that 43.5% (719/1,651) of the patients seen by the TTC service desired outpatient nicotine replacement therapy, but only half of these patients (48.8%; 351/719) received a discharge prescription from the inpatient team. Clinicians expressed that they valued the TTC service, but that BPA fatigue, time constraints, competing priorities, and poor communication with the TTC service were barriers to using the service and following recommendations. Clinicians suggested strategies to address barriers to the use of tobacco treatment interventions during hospitalization and after discharge.Conclusions: Implementing a large-scale "opt-out" tobacco treatment service for hospitalized smokers at a safety-net hospital is feasible and acceptable, but suffers from inconsistent adoption due to a variety of clinician barriers. System-level changes are needed to increase uptake and sustain inpatient tobacco treatment interventions to promote smoking cessation.

Background: Social and demographic changes in Botswana are resulting in an increased prevalence of cardiovascular disease (CVD). Providers, mostly nurses, in this setting have limited training in managing CVD risk and few opportunities for continued medical education. We aimed to evaluate providers' perceived confidence in managing CVD risk factors and describe management of patients with hypertension at public-sector clinics in a rural district of Botswana. Methods: In this cross-sectional study, we invited public-sector health-care providers in 11 ambulatory clinics in the Kweneng East district of Botswana to complete an anonymous questionnaire survey. We used descriptive statistics to evaluate providers' confidence in managing CVD risk (a Likert scale from 1 [low confidence] to 5 [high confidence]). We used t tests to compare confidence levels between groups of providers and specific risk factors. Additionally, we interviewed patients and did chart reviews to assess how CVD risk factors were managed in 275 hypertensive patients at seven of the 11 sites surveyed. Uncontrolled hypertension was defined as ≥140/90 mm Hg (or ≥130/80 mm Hg in patients with diabetes) for an average of two blood pressure readings and CVD risk was defined using WHO guidelines. Findings: Of 88 health care providers invited to participate, 44 registered nurses (80%), four family nurse practitioners (7%), and seven doctors (13%) completed the survey. Providers reported feeling significantly more comfortable managing hypertension than they did diabetes (3·73 vs 3·15; p

The neutrophil-to-lymphocyte (ANC/ALC) ratio is associated with worse prognosis in patients with NSCLC on immunotherapies, but the role of ALC remains unclear. The previous radiation therapy causes lymphopenia, and given approaches of combining radiation with immunotherapies, it is critical to better understand the impact of peripheral lymphocytes. We evaluated retrospectively 22 patients with advanced NSCLC treated with nivolumab at Boston Medical Center from January 2014 to September 2016 and correlated the peripheral blood counts with the overall survival (OS) and overall time on treatment. We assessed the effect of the previous radiation on peripheral blood counts and clinical outcomes. Baseline ALC and ANC/ALC ratios are positively and negatively correlated, respectively, with the OS on nivolumab. The ALC and ALC/WBC ratios at 6 weeks on treatment are positively associated with the OS. Kaplan–Meier analysis at baseline and at 6 weeks showed significantly increased OS in the group of patients with the highest ALC. The previous radiation therapy was positively correlated with the ANC and negatively correlated with the ALC/WBC ratio at 8 weeks after the initiation of nivolumab. Our finding that ALC at baseline and at 6 weeks on treatment is positively correlated with the OS provides an easily obtained predictive marker. Our result that the previous radiation is associated with higher ANC and lower ALC during treatment supports that the combination of radiation therapy with immunotherapy should be carefully applied and potentially peripheral blood counts can be utilized to stratify patients for this approach.

A 47-year-old woman with a self-reported 11-year history of diabetes mellitus presented with 2 days of nausea, vomiting, decreased oral intake, and back pain radiating to the neck. Her review of systems was remarkable for a “throbbing” headache of 1 day’s duration. Her medications included levothyroxine, subcutaneous long-acting insulin (glargine), topiramate, and canagliflozin, a selective sodium–glucose cotransporter 2 (SGLT2) inhibitor of the gloflozin class, which had been initiated 2 weeks earlier. Her medical history was remarkable for post-thyroidectomy Graves’ disease, cholecystectomy for multiple cholelithiasis, depression, fibromyalgia, and hyperlipidemia. She also had a history of spinal fusion surgery. In the emergency department, she appeared volume depleted. Her vital signs were temperature 98.9° F, blood pressure 118/76 mmHg, and a regular heart rate of 91 bpm. Her BMI was 27.45 kg/m2. Physical examination was remarkable for dry mucosal membranes, the absence of axillary sweat, and mild epigastric tenderness. Blood chemistry tests revealed a glucose of 152 mg/dL, sodium 138 mEq/L, potassium 4.4 mEq/L, chloride 105 mEq/L, and total carbon dioxide 16 mEq/L, with an anion gap of 17. Her serum blood urea nitrogen and creatinine were 16 mg/dL and 0.76 mg/dL, respectively. An arterial blood gas revealed a mixed acid-base disorder with both an anion gap and non–anion gap metabolic acidosis, as well as a primary respiratory acidosis with a pH of 7.18, partial pressure of carbon dioxide (PCO2) of 47.6 mmHg, and bicarbonate of 17 mEq/L. Urinalysis revealed a pH of 5 with 2+ ketones and 3+ glucose. Thyroid and liver function tests were unremarkable, and her serum lactic acid level was 1 mEq/L. Urine and serum drug screens were nondiagnostic. Initial management included withholding insulin, discontinuing canagliflozin, and initiating intravenous volume expansion with 5 L of 0.9% saline on a medical-surgical floor. Cultures, a spine MRI, and …

Background Patients suspected to have pulmonary tuberculosis (PTB) undergo serial sputum analysis under airborne infection isolation (AII). The US FDA approved the Cepheid GeneXpert-MTB-Rif® to support removing patients from AII. The FDA requires that “either one or two” separate sputum specimens be examined. To clarify this statement, the National Tuberculosis Controllers’ Association and the Association of Public Health Laboratories published guidelines that recommend that two sputum specimens be used and recommend that each institution examine their own data to determine whether one specimen is sufficient. Most patients in low prevalence settings do not have PTB yet are tested several times; an optimal testing strategy will reduce unnecessary isolation and related expenses. We sought to determine the diagnostic accuracy of a single vs. two sputum samples for Xpert MTB/RIF in discharging suspected PTB patients from AII. Methods Retrospective review of patients admitted between September 2016 to January 2018 was undertaken to identify sensitivity, specificity, positive and negative predictive values, for MTB gene Xpert in comparison to Mycobacterial culture as the gold standard. We further analyzed whether a larger number of such tests improved diagnostic yield for PTB. Results One hundred seventy-one patients, 17.5% of whom were HIV+, mostly of non-US origins (64%), provided 312 samples for Xpert MTB/RIF, of which 26 were Xpert-positive. These 26 samples came from 15 patients, 14 of whom were diagnosed using the first sample tested with Xpert MTB/RIF. Sensitivity and specificity of the first sample tested with Xpert MTB/RIF were more than those for the first two samples considered together or for all tested samples. Of these 15 positive cases, 13 were confirmed on sputum culture; 10 were positive from the first, one from the second, and two from the third sputum samples cultured. Conclusion Patients suspected to have PTB at our facility can be rapidly and accurately discharged from AII after testing a single sputum sample for MTB/RIF Xpert. Disclosures All authors: No reported disclosures.

Peer review is the traditional method for validating academic work and this process is not without complications. Debates about the way peer reviewing is accomplished, the hazy but sensational world of retractions and the costs of publishing for authors are taking center stage. In no other field do people conceive and build the work, pay for it, inspect it, distribute it and buy it back again for their continued survival. Still after all this investment they can struggle for rights of access. In order to stem the tide of discontent, incentives for peer reviewers were introduced. The authors investigate the many faceted approaches to incentivize the process of peer review and consider what value they add, if any. The authors explore other avenues to benefit the largely anonymous and uncredited work of peer reviewers who remain the sentinels of the world of published evidence.

The rise in the world FDI inflows 1980 onwards has led to numerous research studies evaluating the factors that make a country an attractive FDI destination for investors. Although there is a lot of research work looking into the factors that affect FDI inflows, still very few studies have looked into the institutional environment of a country affecting FDI. Filling this research gap, this study aims to study the impact of World governance indicators on the FDI inflows of the country. The analysis leads us to conclude that out of six governance institutional indicators of WGI, only ‘better control of corruption’ and ‘better regulatory quality’ of a country leads to higher FDI inflows to the country.

The prevalent system of Undergraduate Medical Education in India by and large thrives on a system of didactic lectures or antiquated textbooks based teaching-learning rather than dynamic patient based interaction. Couple that with minimal motivation and future incentives for students pursuing undergraduate research as well as the lack of formal training, a graduate medical doctor is not equipped with the basic mandatory skill set of appraising available evidence for treating patients in his practice. doi : 10.5214/ans.0972.7531.200201

Hormones play an important role in the development and regulation of reproductive function and the menstrual cycle of women. Extremes of body weight tend to affect the homeostasis of the hypothalamo–pituitary–gonadal axis. This cross-sectional study was carried out in 113 women (57 with primary infertility and 56 with secondary infertility) in the age group 20–35 years, presenting for hormonal evaluation of infertility in a tertiary care hospital. After preliminary clinical evaluation, anthropometric indices (height, weight, BMI, waist circumference and waist hip ratio) were measured in all subjects. Fasting blood sample drawn on second/third day of menstrual cycle was analysed for serum luteinizing hormone, follicle stimulating hormone (FSH), prolactin and thyroid stimulating hormone (TSH). Serum FSH levels showed a significant positive correlation with indicators of central obesity (waist circumference and waist hip ratio in both the study groups). In primary infertility, significant positive correlation was also observed between serum FSH levels and other markers of obesity like body weight, hip circumference and BMI. In secondary infertility, serum prolactin and serum TSH levels demonstrated a significant positive correlation with body weight and BMI. Obesity is associated with hormonal derangements which are responsible for infertility. In overweight women with infertility, weight loss should be considered as a first line treatment.

Objective: The objective of the following study is to determine the effect of umbilical artery pH at birth on early neurobehavioral outcome of preterm infants as assessed by Neurobehavioral Assessment of Preterm Infants (NAPI) tool. Materials and Methods: Prospective cohort study conducted at the neonatal unit in a tertiary care center in North India. Preterm neonates < 34 weeks of gestation were enrolled at birth and divided into cases (umbilical artery pH < 7.2) and controls (umbilical artery pH > 7.2). At 34 weeks postconceptional age, the motor development and vigor (MDV) and alertness and orientation (AO) domains of neurobehavior were assessed by NAPI and compared among groups. Results: Hundred preterm neonates were enrolled in the study out of which 76 (30 cases and 46 controls) were finally analyzed. The groups were comparable in terms of gestational age, mode of delivery, birth weight and requirement of resuscitative measures at birth. There was no significant difference in incidence of meningitis, intraventricular hemorrhage, jaundice and hypoxic ischemic encephalopathy among the groups; however hypoglycemia was observed more commonly among cases. The MDV score (mean ± standard deviation [SD] [95% confidence interval]) was found to be significantly lower among cases compared to controls (37.0713 ± 13.616 [32.099-42.0431] vs. 47.506 ± 14.0692 [43.367-51.655]) (P = 0.002). Similarly, lower AO scores were observed among the cases. Conclusion: A low umbilical artery pH at birth is a predictor of poor early neurobehavioral outcome in preterm neonates.