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Objective  The primary objective of this study was to assess the diagnostic performance of multiplex polymerase chain reaction (mPCR) for the detection of Mycobacterium tuberculosis complex (MTBC) in presumptive pulmonary TB patients, in the setting of a tertiary level teaching hospital in central India, in comparison to liquid culture using BACTEC mycobacteria growth indicator tubes (MGIT) 960 TB system as the gold standard. The secondary objective was to assess the performance of mPCR for Ziehl Neelsen smear negative samples and ascertain the utility of this assay in smear negative samples. Materials and Methods  Sputum or bronchoalveolar lavage samples were collected from patients who were adults, aged 18 years or older, presenting with presumptive pulmonary TB, and subjected to three microbiological investigations, that is, Ziehl Neelsen staining, mycobacterial culture using mycobacterial growth indicator tubes in the BD BACTEC MGIT 960 instrument, and the mPCR. Statistical Analysis  For statistical analysis, 2 × 2 contingency tables were prepared and analyzed separately for all samples and for smear-negative samples using GraphPad and MedCalc tools. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of mPCR were calculated by taking MGIT culture as the reference standard. Results  For all samples ( n  = 114), sensitivity of mPCR for the detection of (MTBC) was 93.48% (95% confidence interval [CI]: 82.10-98.63%), specificity was 95.59% (95% CI: 87.64-99.08%), positive predictive value (PPV) was 93.48% (95% CI: 82.54-97.75%), and NPV was 95.59% (95% CI: 87.87-98.48%). For smear negative samples ( n  = 80), sensitivity was 80.00% (95% CI: 51.91-95.67%), specificity was 98.46% (95% CI: 91.72-99.96%), PPV was 92.31% (95% CI: 62.80-98.84%), and NPV was 95.52% (95% CI: 88.57-98.33%). Conclusion  In this study, we were able to demonstrate the good performance characteristics of the mPCR for the detection of MTBC from clinical samples of patients with presumptive pulmonary tuberculosis, with MGIT liquid culture as the reference standard. It may be concluded that mPCR can be considered equivalent to MGIT culture in terms of clinical decision making and yield of positivity, owing to the good sensitivity and specificity for the detection of MTBC., Competing Interests: Conflict of Interest None., (The Indian Association of Laboratory Physicians. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Context: Diabetic peripheral neuropathy (DPN) if detected early can reduce the burden on the health system and prevent the development of diabetic foot ulcers and amputation., Aim: To study the effectiveness of Semmes Weinstein 10 gm monofilament in detecting DPN taking nerve conduction studies (NCS) and autonomic function testing (AFT) as reference tests., Settings and Design: Observational and comparative cross-sectional study conducted in the Physiology department AIIMS, Bhopal in collaboration with the Medicine department of the institute., Methods and Material: A total of 72 diagnosed type-2 diabetes mellitus patients were examined using Semmes Weinstein 10 gm monofilament, DPN was confirmed using NCS (Nihon Kohden Neuropack XI machine) and autonomic neuropathy was confirmed using AFT (Ewing's battery and Power lab) with heart rate variability (HRV). Diagnostic value of Semmes Weinstein 10 gm monofilament taking NCS and AFT as reference test was calculated., Statistical Analysis Used: Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were calculated using the standard formula., Results: Sensitivity, specificity, PPV, and NPV using monofilament are 69.23%, 20%, 69.23% and 20% respectively taking NCS as reference test and 70.59%, 0, 92.30%, and 0 respectively taking AFT as reference test., Conclusions: Semmes Weinstein 10 gm monofilament is not the ideal screening test for the diagnosis of DPN. Sole clinical use of monofilament should be discouraged., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Objective: Participation in cardiac rehabilitation (CR) is associated with reduced morbidity and mortality. However, most programs rely on self-report measures when assessing the critical risk factor of smoking. This study examined smoking status using self-report versus objective measurement using expired carbon monoxide (CO) and compared patient characteristics by CO level., Method: Patients were screened for smoking status when entering CR by self-report and by objectively measured CO. Measures of aerobic fitness, educational attainment, depressive symptoms, and self-reported physical function were also collected. The discrepancy between smoking status based on self-report and objective measurement was examined and patient characteristics by CO measurement were compared., Results: Of the 853 patients screened, 62 self-reported current smoking and 112 had a CO of ≥ 4 ppm. Using a cut-off of ≥ 4 ppm encompassed almost all self-reported smokers (specificity: 98.5%) and identified 61 patients (not reporting current smoking) needing further screening. Further questioning yielded an additional 21 patients with combusted use (tobacco/cannabis), six nonsmoking patients with environmental CO exposure, and 34 where the reason for elevated CO was unknown. CO ≥ 4 ppm patients were younger (62.2 vs. 67.7, p < .01), had higher depression scores (5.6 vs. 3.7, Patient Health Questionairre-9, p < .01), had lower educational attainment (59.0% ≤ high school vs. 31.3%, p < .01), had lower levels of fitness (after controlling for clinical characteristics, p < .01), and completed fewer CR sessions (18 vs. 22, p < .01)., Conclusions: A substantial number of patients who are actively smoking may be misclassified by relying on patient report alone. CO monitoring provides a simple and objective method of systematically screening patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Background: The outcomes in critical illness depend on disease severity, practice protocols, workload, and access to care. This study investigates the factors affecting outcomes in mechanically ventilated coronavirus disease-2019 acute respiratory distress syndrome (COVID-19 ARDS) patients admitted in a tertiary teaching hospital intensive care unit (ICU) in Central India with reference to different time periods in pandemic. This is one of the largest series of mechanically ventilated COVID-19 ARDS patients, globally., Methods: This retrospective cohort study classified the entire data into four time periods (Period 1: April 2020 to June 2020; Period 2: July 2020 to September 2020; Period 3: October 2020 to December 2020; and Period 4: January 2021 to April 2021). We performed a multivariable-adjusted analysis to evaluate predictors of mortality, adjusted for baseline-severity, sequential organ failure assessment (SOFA score) and time period. We applied mixed-effect binomial logistic regression to model fixed-effect variables with incremental complexity., Results: Among the 56 survivors (19.4%) out of 288 mechanically ventilated patients, there was an up-gradient of survival proportion (0, 18.2, 17.4, and 28.6%) in four time periods. Symptom-intubation interval (OR 1.16; 95% CI 1.03-1.31) and driving pressures (DPs) (OR 1.17; 95% CI 1.07-1.28) were significant predictors of mortality in the model having minimal AIC and BIC values. Patients aged above 60 years also had a larger effect, but statistically insignificant effect favoring mortality (OR 1.99; 95% CI 0.92-4.27). The most complex but less parsimonious model (with higher AIC/BIC) indicated the protective odds of high steroid on mortality (OR 0.59; 95% CI 0.59-0.82)., Conclusion: The outcomes in mechanically ventilated COVID-19 ARDS patients are heterogeneous across time windows and may be affected by the complex interaction of baseline risk and critical care parameters., How to Cite This Article: Saigal S, Joshi A, Panda R, Goyal A, Kodamanchili S, Anand A, et al . Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India. Indian J Crit Care Med 2022;26(9):1022-1030., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; The Author(s).)

Purpose: Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR., Methods: This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ 2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate., Results: Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables., Conclusions: Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Aeromonas salmonicida is a well-known pathogen in salmonid fishes. It was believed to be non-pathogenic to humans because of inability to grow at 37°C. Here we present a case of a woman in her 20s who was diagnosed with abdominal tuberculosis 6 months previously but had not been compliant with the treatment. She presented with occasional febrile episodes, whitish vaginal discharge, burning micturition, anal ulcer, whitish discharge from mouth and recent onset breathlessness. Patient tested serologically positive for HIV-1, and A. salmonicida was isolated from urine sample. Patient was treated with antituberculosis therapy, antiretroviral therapy and antimicrobials. She showed marked improvement over the next few weeks. This case highlights the importance of recognition of rare organisms, especially in immunocompromised patients. The identification and subsequent treatment of such pathogens have improved since the advent of automated identification systems., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction The management of septic shock and refractory septic shock is essential in preventing sepsis-related death. The handheld vital microscope is a new modality of investigation for sepsis for microcirculatory assessment. This study aimed to identify predictors of inotrope requirements among patients with early sepsis and impending septic shock with particular reference to sublingual microcirculation assessment parameters. Methodology We conducted an observational cross-sectional hospital-based study in central India. The formal sample size was calculated to be 52 patients using a convenient sampling technique. The study was initiated with ethics approval (IHEC-LOP/2019/ MD0090) with consent from the patients. We used the MicroScan (MicroVision Medical, Netherlands) Video Microscope System (No.16A00102) to obtain sidestream dark-field imaging along with the AVA 4.3C software (MicroVision Medical). Results Of 51 cases, 60.8% were women, and 39.2% were men, and the study population had a mean age of 41.0 ± 14.9 years. Patients were recruited from medical wards (64.7%) and emergency departments (35.3%). The most common site of infection was gastrointestinal (33.3%), followed by respiratory infections (25.5%) and genitourinary infections (11.8%). The quick sequential organ failure assessment score was 2.0 ± 0.1. Eight patients required inotropes, and six patients died. High respiratory rates and lactate levels were important predictors of inotrope requirements in patients with early sepsis. Sublingual microcirculatory parameters at baseline did not significantly affect the requirement of inotropes consequently. Conclusions Sublingual microscopy is a suggested tool for the management of sepsis. However, without clearly defined cut-off values, handheld vital microscopy could not predict fluid responsiveness among patients with early sepsis. Also, it would be difficult to incorporate this technology into regular practice without equipment upgrades and image acquisition software., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Bose et al.)

Current smoking is the strongest predictor of future morbidity and mortality in those with cardiovascular disease, yet clinically, smoking status is usually ascertained through self-report. We objectively measured smoking status, using exhaled carbon monoxide (CO), for 1122 consecutive patients entering cardiac rehabilitation. Within those with elevated CO levels (≥4 ppm), females had CO levels almost twice that of males (20.4 vs. 11.6), suggesting higher amounts of smoking., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Purpose: Depression affects cardiac health and is important to track within cardiac rehabilitation (CR). Using two depression screeners within one sample, we calculated prevalence of baseline depressive symptomology, improvements during CR, and predictors of both., Methods: Data were drawn from the University of Vermont Medical Center CR program prospectively collected database. A total of 1781 patients who attended between January 2011 and July 2019 were included. Two depression screeners (Geriatric Depression Scale-Short Form [GDS-SF] and Patient Health Questionnaire-9 [PHQ-9]) were compared on proportion of the sample categorized with ≥ mild or moderate levels of depressive symptoms (PHQ-9 ≥5, ≥10; GDS-SF ≥6, ≥10). Changes in depressive symptoms by screener were examined within patients who had completed ≥9 sessions of CR. Patient characteristics associated with depressive symptoms at entry, and changes in symptoms were identified., Results: Within those who completed ≥9 sessions of CR with exit scores on both screeners (n = 1201), entrance prevalence of ≥ mild and ≥ moderate depressive symptoms differed by screener (32% and 9% PHQ-9; 12% and 3% GDS-SF; both P< .001). Patients who were younger, female, with lower cardiorespiratory fitness (CRF) scores were more likely to have ≥ mild depressive symptoms at entry. Most patients with ≥ mild symptoms decreased severity by ≥1 category by exit (PHQ-9 = 73%; GDS-SF = 77%). Nonsurgical diagnosis and lower CRF were associated with less improvement in symptoms on the PHQ-9 (both P< .05)., Conclusion: Our results provide initial benchmarks of depressive symptoms in CR. They identify younger patients, women, patients with lower CRF, and those with nonsurgical diagnosis as higher risk groups for having depressive symptoms or lack of improvement in symptoms., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: There is very limited data on the usefulness of pulmonary rehabilitation in patients with coronavirus pneumonia who have survived intensive care unit care. The primary aim was to explore the feasibility of conducting a pulmonary rehabilitation program in patients with coronavirus disease-19 pneumonia surviving intensive care. The secondary aim was to study the impact of a hospital-based 6-week pulmonary rehabilitation program on exercise capacity, quality of life, and psychological parameters in these patients. This study was conducted at the Center for Pulmonary Rehabilitation, Department of Pulmonary Medicine of the institute., Material and Methods: A total of 27 patients were enrolled. Among them, 14 patients who completed the desired 12 sessions over 6 weeks constituted the pulmonary rehabilitation group and 13 patients who either did not consent or defaulted within the first 2 weeks were considered as controls. Both groups had assessments at 0 and 6 weeks that included a 6-Minute Walk Test, Incremental Shuttle Walk Test, mMRC Dyspnea Scale, Baseline Dyspnea Index, and Transitional Dyspnea Index, Saint George's Respiratory Questionnaire score, and Depression, Anxiety, Stress Scale-21 score., Results: Significant improvement in dyspnea by mMRC (P = .01) and exercise capacity as measured by 6-Minute Walk Test (P <.001) and Incremental Shuttle Walk Test (P = .025) was seen in the pulmonary rehabilitation group as compared to the control group. There was no significant improvement in quality of life and psychological parameters (Depression, Anxiety, Stress Scale 21 score) after 6 weeks of pulmonary rehabilitation program as measured in our study., Conclusion: Pulmonary rehabilitation is feasible and appears promising in coronavirus disease acute respiratory distress syndrome survivors. However, data from other centers and a larger number of patients are required to imbibe conclusive results.

Importance: Despite lower baseline fitness levels, women in cardiac rehabilitation (CR) do not typically improve peak aerobic exercise capacity (defined as peak oxygen uptake [peak Vo2]) compared with men in CR., Objective: To evaluate the effect of high-intensity interval training (HIIT) and intensive lower extremity resistance training (RT) compared with standard moderate intensity continuous training (MCT) on peak Vo2 among women in CR., Design, Setting, and Participants: This randomized clinical trial conducted from July 2017 to February 2020 included women from a community-based cardiac rehabilitation program affiliated with a university hospital in Vermont. A total of 56 women (mean [SD] age, 65 [11] years; range 43-98 years) participating in CR enrolled in the study., Interventions: MCT (70% to 85% of peak heart rate [HR]) with moderate intensive RT or HIIT (90% to 95% of peak HR) along with higher-intensity lower extremity RT 3 times per week over 12 weeks., Main Outcomes and Measures: The primary outcome was the between-group difference in change in peak Vo2 (L/min) from baseline to 12 weeks., Results: Peak Vo2 increased to a greater degree in the HIIT group (+23%) than in the control group (+7%) (mean [SD] increase, 0.3 [0.2] L/min vs 0.1 [0.2] L/min; P = .03). Similarly, the change in leg strength was greater in the HIIT-RT group compared with the control group (mean [SD] increase, 15.3 [0.3] kg vs 6.4 [1.1] kg; P = .004)., Conclusions and Relevance: An exercise protocol combining HIIT and intensive lower extremity RT enhanced exercise training response for women in CR compared with standard CR exercise training. Women randomized to HIIT experienced significantly greater improvements in both peak Vo2 and leg strength during CR., Trial Registration: ClinicalTrials.gov Identifier: NCT03438968.

Background: Cirrhosis progression varies greatly from patient to patient due to a variety of factors, including hepatic reserve, cirrhosis etiology, and the presence of hepatocellular cancer. As a result, determining a prognosis in a patient with cirrhosis remains a difficult task. For nearly three decades, the Child-Pugh score (CPS) has been the gold standard for determining the prognosis of cirrhosis. In the last two decades, many prognostic models and scores like a model for end-stage liver disease (MELD), chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score, peripheral blood lymphocyte to monocyte ratio (LMR) have been presented to predict prognosis in patients with cirrhosis and to choose the best therapy option. The aim of our study is to determine which score is more effective in predicting three-month mortality and whether these scores are equally effective in predicting short-term outcomes., Materials & Methods: In this hospital-based longitudinal study, we analyzed 140 patients with cirrhosis of liver visiting All India Institute of Medical Sciences Bhopal between July 2019 and July 2020. All the 140 patients were followed up for three months to establish short-term outcomes. The blood investigations were done at the time of presentation from all the patients and after three months in the survivors. Various scores were calculated., Results: The majority of patients (47%) were in Child-Pugh class C. Mean MELD score was 13.54, LMR score was 1.96 and CLIF-SOFA score was 5. The total bilirubin, serum creatinine, international normalized ratio (INR), total leukocyte count, absolute monocyte count, CPS, MELD, CLIF-SOFA were significantly higher in a non-surviving group as compared to the surviving group, whereas the albumin and LMR significantly decreased in the non-surviving group. On performing multivariate regression, LMR and CLIF-SOFA were significant independent risk factors of mortality after adjusting for confounding factors. All the parameters had significant discriminatory power to predict mortality. Discriminatory power of CLIF-SOFA (AUC 0.808; 95% CI: 0.733 to 0.870) was excellent and discriminatory power of CPS (AUC 0.792; 95% CI: 0.716 to 0.856), MELD score (AUC 0.765; 95% CI: 0.685 to 0.832) and LMR (AUC 0.75; 95% CI: 0.669 to 0.819) was acceptable. Among all the parameters, CLIF-SOFA was the best predictor of mortality at a cut-off point of >5 with 80.80% chances of correctly predicting mortality., Conclusion: The significant morbidity and mortality indicators are high total bilirubin, high creatinine, high INR, high TLC, low platelet count, and low albumin. Among the various scores, CLIF-SOFA is a better predictor of mortality and morbidity. Low LMR and high CLIF-SOFA are significant independent risk factors of mortality at three months., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Mallik et al.)

Participation in cardiac rehabilitation (CR) significantly decreases morbidity and mortality and improves quality of life following a wide variety of cardiac diagnoses and interventions. However, participation rates and adherence with CR are still suboptimal and certain populations, such as women, minorities, and those of lower socio-economic status, are particularly unlikely to engage in and complete CR. In this paper we review the current status of CR participation rates and interventions that have been used successfully to improve CR participation. In addition, we review populations known to be less likely to engage in CR, and interventions that have been used to improve participation specifically in these underrepresented populations. Finally, we will explore how CR programs may need to expand or change to serve a greater proportion of CR-eligible populations. The best studied interventions that have successfully increased CR participation include automated referral to CR and utilization of a CR liaison person to coordinate the sometimes awkward transition from inpatient status to outpatient CR participation. Furthermore, it appears likely that maximizing secondary prevention in these at-risk populations will require a combination of increasing attendance at traditional center-based CR programs among underrepresented populations, improving and expanding upon tele- or community-based programs, and alternative strategies for improving secondary prevention in those who do not participate in CR., (Copyright © 2022. Published by Elsevier Inc.)

Competing Interests: Conflict of Interest None declared.

Introduction Antimicrobial resistance (AMR) has become a global pandemic. In order to identify this menace, World Health Organisation (WHO) has developed the Global Action Plan on AMR (GAP AMR). Antimicrobial stewardship programs (AMSP) have been identified as a decisive tool for combating AMR. One of the most efficient measures of these programs has been the implementation of point prevalence surveys (PPS) of antibiotic usage and subsequent audit feedback. The present study was undertaken to identify the impact of AMSP on curtailing of empirical usage of antibiotics and the augmentation of targeted therapy.  Methods It is an observational, cross-sectional study comprising 1396 patients. The microbiology culture details and anti-microbial-sensitivity results were recorded. Antibiotic prescriptions were recorded in each patient during their hospital stay. Result Out of 1396 patients treated over four quarters (Q1-Q4), 711 (50.9%) patients were on antibiotics, and among them, only 415 patients were subjected to any microbiological cultures with an overall bacterial culture rate (BCR) of 58.3%, and 296 patients (41.6%) were treated with antibiotics empirically without sending any samples for bacterial culture. There was a statistically significant rise in BCR from 47.3% in the first quarter to 77.6% in the fourth quarter. Sending specimens for blood culture increased significantly from 29.2% in Q1 to 37.6% in Q4. After receiving culture reports, 72.3% of cases continued with the same antibiotic, the antibiotic was changed in 19.9% of cases, and the antibiotic was stopped in 7.8% of cases. Conclusion There was a strong positive impact of AMSP in curtailment of empirical usage of antibiotics and augmenting targeted therapy as evidenced by the significant rise in BCR over Q1-Q4 PPS as well as a significant rise in ordering for blood culture over the same time period., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Garg et al.)

Objectives This study was performed to estimate diagnostic accuracy of the two commercially available point-of-care tests to identify poor glycemic control defined by HbA1c levels, with high-performance liquid chromatography (HPLC) as a reference. Settings The study was carried at two locations, general medical outpatient department of a teaching medical college in Bhopal (urban), and a primary health care centre in a rural area in the state of Madhya Pradesh, India. Participants All individuals with diabetes mellitus who presented to the health care facility for assessment of glycemic control. We compared HbA1c estimated from two index tests (Hemocue Hb 501, Sweden; SD Biosensor, South Korea) from capillary blood samples with HPLC performed from venous blood, as a reference standard. Primary and secondary outcome measures Diagnostic properties of index tests such as sensitivity, specificity, positive and negative predictive value and diagnostic accuracy for identifying poor glycemic control were primary outcome measures. Lin's concordance correlation coefficient (CCC) was secondary outcome measure. Results Out of 114 patients, all received reference standard - 103 patients received Hemocue A1C test and 110 patients received SD Biosensor test. Overall both the index tests had similar diagnostic accuracy estimates. The area under the Receiver Operating Curve for SDA1c device was 0.935 (95% CI 0.886-0.983), and for Hemocue device was 0.938 (95% CI 0.893-0.984). The Hemocue device HbA1c value of above 7.0 (positive) correctly predicted poor glycemic control 92% times (81.58% for SD device). There were 4 vs. 11 device failures and 14 vs. 12 failures with SD and Hemocue, respectively. Ambient air temperatures were no different for the device test failures. Conclusions Commercially available point-of-care tests evaluated in this study are comparable and an acceptable alternative to HPLC-based measurements for the assessment of glycemic control. Tests and device failure rates of both the index tests are similar., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Khadanga et al.)

Purpose: Participation in cardiac rehabilitation (CR) is low despite proven benefits. The aim of this study was to assess medical, psychosocial, and behavioral predictors of participation in a phase 2 CR., Methods: This was a prospective observational study. Participants hospitalized for an acute cardiac event and eligible for CR completed in-hospital assessments, and the primary outcome was CR participation over a 4-mo follow-up. Measures included age, sex, educational attainment, smoking status, medical diagnosis, ejection fraction, and electronic referral to CR. Data included General Anxiety Disorder, Patient Health Questionnaire, Medical Outcomes Study Short Form-36, Behavioral Rating Inventory of Executive Function, and Duke Social Support Index. Logistic regression and Classification and Regression Tree analysis were performed., Results: Of 378 hospitalized patients approached, 294 (31% females) enrolled in the study and 175 participated in CR. The presence of electronic referral, surgical diagnosis, non/former smoker, and strength of physician recommendation (all Ps < .02) were independent predictors for CR participation. No differences were seen in participation by measures of anxiety, depression, or executive function. Males with a profile of electronic referral to CR, high school or higher education, ejection fraction >50%, and strong physician recommendation were the most likely cohort to participate in CR (89%). Patients not referred to CR were the least likely to attend (20%)., Conclusions: Lack of CR referral, lower educational attainment, nonsurgical diagnosis, current smoking, and reduced ejection fraction can predict patients at a highest risk of CR nonparticipation. Specific interventions such as electronic referral and a strong in-person recommendation from a medical provider may enhance CR participation rates., Competing Interests: Conflicts of Interest: None., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Context  Dyslipidemia is a multifactorial disease in which lipoproteins play an important role as one of the early markers for coronary heart disease (CHD). Mixed dyslipidemia is common in people with diabetes mellitus, but nondiabetic dyslipidemics (NDD) remain unidentified for the risk of developing dyslipidemia and eventually CHD. Objectives  This pilot study attempts to analyze the genetic basis of lipid metabolism alterations, emphasizing the association between fatty acid-binding protein-2 (FABP2-Ala54Thr) and apolipoprotein-C3 (APOC3-rs5128) genetic polymorphism, as a risk for developing dyslipidemia and CHD in NDD. Methods and Design  Total 90 subjects-30 DD, 30 NDD, and 30 apparently healthy subjects representing Central India-were included. Biochemical analysis and DNA genotyping were done by polymerase chain reaction restriction fragment length polymorphism. Statistical Analysis  The biochemical parameters were reported as means ± standard deviation. One-way analysis of variance test was used to compare biochemical parameters of three groups. Chi-squared test was done to compare genotype distributions. The strength of association was assessed by odds ratios (ORs) with 95% confidence intervals (CIs). All statistical analysis was done using SPSS-PC software and Graph Pad. Results  In NDD, maximum polymorphism was observed followed by DD and least polymorphism was observed in controls. There was a significant association of APOC3 G allele with occurrence of hypertriglyceridemia ( p  < 0.05); however, no such association was found for FABP2 A allele ( p > 0.05). Logistic regression analysis revealed APOC3 polymorphism to be significantly associated with dyslipidemia (OR = 2.6667, 95% CI = 1.0510-6.7663, p  = 0.0341); no such association was found for FABP2 polymorphism (OR = 0.4643, 95% CI = 0.1641-1.3136, p  = 0.1347). The triglyceride and cholesterol values in individuals with homozygous genotype indicate that genetic study is comparable to the biochemical findings in carriers of polymorphic allele than noncarriers, especially in NDD patients. Conclusions  Pilot study indicates that the presence of APOC3 gene polymorphism is associated with pro-atherogenic dyslipidemia in nondiabetic patients and may raise risk of CHD. This information could be used for preventive strategies in NDD group that may otherwise go unnoticed., Competing Interests: Conflict of interest Authors declare no conflicts of interest., (The Indian Association of Laboratory Physicians. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Purpose: Despite the known benefits of cardiac rehabilitation (CR), it remains underutilized particularly among women. The aim of this review was to provide an overview regarding women in CR, addressing barriers that may affect enrollment and attendance as well as to discuss the training response and methods to optimize exercise-related benefits of CR., Review Methods: The review examines original studies and meta-analyses regarding women in CR., Summary: Women are less likely to engage in CR compared with men, and this may be attributed to lack of referral or psychosocial barriers on the part of the patient. Furthermore, despite having lower levels of fitness, women do not improve their fitness as much as men in CR. This review summarizes the current literature and provides recommendations for providers regarding participation and adherence as well as optimal methods for exercise training for women in CR., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The disease severity, ranging from being asymptomatic to having acute illness, and associated inflammatory responses has suggested that alterations in the gut microbiota may play a crucial role in the development of chronic disorders due to COVID-19 infection. This study describes gut microbiota dysbiosis in COVID-19 patients and its implications relating to the disease., Design: A cross sectional prospective study was performed on thirty RT-PCR-confirmed COVID-19 patients admitted to the All India Institute of Medical Sciences, Bhopal, India, between September 10 and 20, 2020. Ten healthy volunteers were recruited as the control group. IFN, TNF, and IL-21 profiling was conducted using plasma samples, and gut bacterial analysis was performed after obtaining the metagenomics data of stool samples., Results: Patients with a variable COVID-19 severity showed distinct gut microflora and peripheral interleukin-21 levels. A low Firmicute/Bacteroidetes ratio, caused by the depletion of the fibre-utilizing bacteria, F. prausnitzii , B. Plebius , and Prevotella , and an increase in Bacteroidetes has associated gut microbiota dysbiosis with COVID-19 disease severity., Conclusions: The loss of the functional attributes of signature commensals in the gut, due to dysbiosis, is a predisposing factor of COVID-19 pathophysiology.

Background: Malaria has been an important public health all over the globe. Although conventional light microscopy is the gold standard of diagnosis, light microscopes are heavy, fragile, costly, and electricity dependent. Rapid diagnostic tests (RDTs) have become more popular but perform badly in temperate climate. This is because the RDT kits require maintenance of cold chain for its optimal use. In this regard, there is a recent interest in handheld malaria microscopy at the point of care in the field setting. Foldscopes are cheap, handy, nonfragile, and use mobile camera for illumination. The purpose of the study was to find whether foldscope can be used in the national vector borne disease control program (NVBDCP) in India., Methods: Ten laboratory technicians were trained in identifying malaria parasites using foldscope and their mobiles. Later, they were provided with unassembled foldscope to document their test results for the preidentified malaria slides. The blood smears were stained as per the protocol of NVBDCP. The report of the index test (foldscope microscopy) was compared with the reference test (conventional microscopy)., Results: The sensitivity and specificity of the index test was found to be 13.3% (6.257-26.18), specificity of 97.78% (88.43-99.61), positive predictive value 85.71% (48.69-97.43), and negative predictive value 53.01% (42.38-63.38). The devise failure rate and test failure rate were 20% and 11.7%. The kappa agreement between the index and reference microscopy was only 11% and the McNemar P < 0.01., Conclusion: The ×400 foldscope at its present magnification and illumination cannot be utilized in the field under NVBDCP., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Microscopy and Ultrastructure.)

Background: Antimicrobial resistance (AMR) is a global concern requiring immediate attention. Among many proven measures of decreasing AMR, practice of antimicrobial stewardship is the lowest hanging which can be adapted with negligible financial implications., Methods: This is a case record based extended cross-sectional type of observational operation research study conducted at an institute of national importance established by Government of India. Point prevalence of antibiotic usage among the patients admitted in the hospital, on four different days in four different quarters of a year was done to study the impact of antimicrobial stewardship program (AMSP)., Results: A cumulative 711 patients were exposed on antibiotics among 1396 study participants. There was a significant decrease in antibiotic consumption across the 1 st and 4 th quarter. The average antibiotic usage was 50.9% (61.75, 60%, 48.4%, and 39% respectively in the 1 st to 4 th quarter). Among the total number of patients, intravenous antibiotic usage was 47.9% (60.71%, 58.4%, 44.9%, and 34.2% respectively in 1 st to 4 th quarter). Among the newly admitted patients, the consumption of antibiotic usage decreased from 45.9% to 25.7%. Among the intravenous antibiotics, the top 10 consumed antibiotics were 3 rd generation cephalosporin (39.8%), aminoglycoside (14.8%), amoxicillin/amoxy-clav (12.5%), piperacillin-tazobactum (8.5%), carbapenams (6.6%), cefuroxime (6.4%), quinolones (4.3%), vancomycin/linezolid (4.1%), colistin (0.8%), and others (0.8%)., Conclusion: Government run hospitals can run low budget antimicrobial stewardship program with sustainable impact on antibiotic consumption. For a successful AMSP, it requires change in attitude, commitment, and administrative support rather than a huge financial support., Competing Interests: Dr. Sagar Khadanga received funds for the project from Indian Council of Medical Research., (Copyright: © 2021 Journal of Family Medicine and Primary Care.)

Background: Numerous studies have highlighted the burden of hypertension by estimating its prevalence. However, information regarding quantum and characteristics of persons whose blood pressure converts to hypertension range from their previous state of prehypertension or normal blood pressure is crucial for any public health programme. We aimed to estimate incidence rate of hypertension and to identify risk factors for the same, so that it is useful for programme implementation., Methods: We established a cohort of adults residing in urban slums of Bhopal, who were registered in a baseline cardiovascular risk assessment survey, which was performed between November 2017 and March 2018. Blood pressure assessment was done at least three times at baseline for diagnosis of hypertension, which was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on two occasions. Participants who did not have a diagnosis of hypertension were followed up during April-June 2019., Results: Of the 5673 participants assessed at baseline, 4185 did not have hypertension of which 3199 (76.4%) were followed up after a median on 1.25 years (IQR 1.08-1.60) and a total of 170 (5.31%) individuals were detected with incident hypertension. Overall incidence rate of hypertension was 4.1 (95% CI 3.54 to 4.75) per 100 person-years of follow-up. On multivariate analysis, age (relative risk/RR 1.98; 95% CI 1.19 to 3.3, for age >60 years), being in first and second wealth tertile (T-1 RR 1.85; 95% CI 1.17 to 2.91) and being illiterate (RR 1.94; 95% CI 1.31 to 2.86) were significant predictors of incident hypertension. Individuals who had prehypertension at baseline also had a significantly increased risk of developing hypertension (RR 2.72; 95% CI 1.83 to 4.03)., Conclusions: We found that incidence of hypertension in urban slums of central India is higher with increasing age and in men. Illiteracy, lower Wealth Index and prehypertension are other determinants. We also demonstrate feasibility of establishing a cohort within the public health delivery system, driven by efforts of community health workers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Continued smoking following myocardial infarction (MI) is strongly associated with increased morbidity and mortality. Patients who continue to smoke may also engage in other behaviors that exacerbate risk. This study sought to characterize the risk profile of a national sample of individuals with previous MI who currently smoke. Data were taken from the 2017 Behavioral Risk Factor Surveillance Survey (United States), with 4.2% of the sample reporting a past MI (N = 26,004). Participants were classified by smoking status (current/former/never) and compared on medical comorbidities and the clustering of modifiable behaviors relevant for secondary prevention (smoking, poor nutrition, problematic alcohol use, physical inactivity, medication adherence). Current smokers were more likely to report other comorbidities including stroke, chronic obstructive pulmonary disease, physical limitations, and poor mental health. Smokers were also less likely to report taking blood pressure and cholesterol medications, and less likely to attend cardiac rehabilitation (examined in a subset of the sample, N = 2181). Current smoking remained an independent predictor of other health-related behaviors even when controlling for age, sex, race, educational attainment, and other comorbidities. In the modifiable risk-factor behavior cluster analysis, the most common pattern among current smokers was having two risk factors, smoking plus one additional risk factor, whereas the most common pattern was zero risk factors among never or former-smokers. Physical inactivity was the most common additional risk factor across smoking statuses. Current smoking is associated with multiple comorbidities and should be considered a marker for a high-risk behavioral profile among patients with a history of MI., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Directly measured peak aerobic capacity or oxygen uptake is a powerful predictor of prognosis in individuals with cardiovascular disease. Women enter phase 2 cardiac rehabilitation (CR) with lower and their response to training, compared with men, is equivocal. We analyzed at entry and exit in patients participating in CR and improvements by diagnosis to assess training response. We also identified sex differences that may influence change in ., Methods: The cohort included consecutive patients enrolled in CR between January 1996 and December 2015 who performed entry exercise tolerance tests. Data collected included demographics, index diagnosis, , and exercise training response., Results: The cohort consisted of 3925 patients (24% female). There was a significant interaction between baseline and diagnosis (P < .001), with percutaneous coronary intervention and myocardial infarction greater than other diagnoses. Surgical patients demonstrated greater improvement in than nonsurgical diagnoses (n = 1789; P < .001). Women had lower than men for all diagnoses (P < .02) and demonstrated less improvement (13 vs 17%, P < .001). Percent improvement using estimated metabolic equivalents of task (METs) were similar for women and men (33 vs 31%, P = NS). Despite overall increases in , 18% of patients (24% women, 16% men) failed to demonstrate any improvement (exit ≤ entry )., Conclusions: While there were no differences in training effect estimated by METs, directly measured showed a significantly lower training response for women despite adjusting for covariates. In addition, 18% of patients did not see any improvement in . Alternatives to traditional CR exercise programming need to be considered.

Cardiac rehabilitation plays a key role in the care of older patients after a coronary event. Hospitalizations are prevented and quality of life, exercise capacity, and physical function are improved. Almost 50% of cardiac rehabilitation participants are older adults (>65 years), many of whom are frail or deconditioned. Resistance training, as a component of cardiac rehabilitation, improves muscle strength, endurance, and physical function. The purpose of this review is to describe the effects of resistance training in cardiac rehabilitation for older adults with a particular focus on physical function., (Copyright © 2019 Elsevier Inc. All rights reserved.)

India has witnessed a major shift in morbidity to non-communicable diseases (NCDs) in the last few decades. The service delivery for these long-term conditions has been physician-centred up till now. There is a recent move towards shared care, and nurses are being engaged in the delivery of NCD care. This study was performed in the context of a composite training initiative involving nurses and doctors. Our aim was to compare the performance of nurses with doctors to determine which skills need to be emphasised in future educational programmes. Baseline and end-training knowledge assessments were available from training records. In 2014, of a total of 387 participants from one state in India, 153 were followed up to assess long-term retention of knowledge in various NCD training domains. We found that despite a lower baseline, nurses had a similar attrition in knowledge after training compared to doctors. Results of our study emphasised that nurses can be trained for the primary care needs of NCDs and that both nurses and doctors have retraining needs.

Background: Variations in blood glucose levels over a given time interval is termed as glycemic variability (GV). Higher GV is associated with higher diabetes-related complications. The current study was done with the aim of detecting the sensitivity of various GV indices among individuals with type 2 diabetes mellitus of different glycemic control status., Methods: We performed a longitudinal study among individuals with type 2 diabetes mellitus (T2DM) who were participating in a two-week diabetes self-management education (DSME) program. Participants were categorized by their HbA1c as poor (≥8%), acceptable (7%⁻8%), and optimal control (<7%). Continuous glucose monitoring (CGM) sensors recorded interstitial glucose every 15 min from day 1. The evaluated GV measures include standard deviation (SD), coefficient of variation (CV), mean amplitude of glycemic excursion (MAGE), continuous overlapping net glycemic action (CONGA), mean of daily difference for inter-day variation (MODD), high blood glucose index (HBGI), and low blood glucose index (LBGI)., Results: A total of 41 study participants with 46347 CGM values were available for analysis. Of 41 participants, 20 (48.7%) were in the poor, 10 (24.3%) in the acceptable, and 11 (26.8%) in the optimal control group. The GV indices (SD; CV; MODD; MAGE; CONGA; HBGI) of poorly controlled (77.43; 38.02; 45.82; 216.63; 14.10; 16.62) were higher than acceptable (50.02; 39.32; 30.79; 138.01; 8.87; 5.56) and optimal (34.15; 29.46; 24.56; 126.15; 8.67; 3.13) control group. Glycemic variability was reduced in the poorly and acceptably controlled groups by the end of the 2-week period. There was a rise in LBGI in the optimally controlled group, indicating pitfalls of tight glycemic control., Conclusion: Indices of glycemic variability are useful complements, and changes in it can be demonstrated within short periods.

Background: Metabolic syndrome (MetS) is a constellation of high blood pressure, hyperglycemia, obesity, and dyslipidemia. Its presence makes the patient more prone for cardiovascular events. Its prevalence has been documented as 11%-41%. The present study was undertaken to find out the demographic profile of the MetS in Kanpur region of northern India., Materials and Methods: This is a hospital based, cross-sectional study with adequate sample size., Results: Out of the randomly selected 420 patients (232 males and 188 females), 172 cases (61 males and 111 females) were found to have MeTS adopting the National Cholesterol Education Program Adult Treatment Panel III criteria. The overall prevalence of MeTS was found to be 40.9% (26.2% of total males and 59% of total females). Among the 172 cases of MeTS, females were more than males (64.5% vs. 35.4%). Maximum numbers of MeTS cases were in the age range of 50-59 years (55/172 = 31.9%) followed by 40-49 years (50/172 = 29%), >60 years (35/172 = 20.3%), 30-39 years (30/172 = 17.4%), and <30 years (2/172 = 1.1%). In the total study population of 420 cases, hyperglycemia was the most common (29.2%) and hyperglycemia, obesity, and high triglyceride were significantly higher prevalence in females. Among the participants of 111 cases of MeTS, hyperglycemia was the most common (71.5%) and high blood pressure, and low high density lipoprotein was significantly higher among males., Conclusion: The prevalence of MetS was more than 40% and its prevalence in <40 years age group is rapidly increasing. Its high time to be more active physically, before fatal cardiovascular events., Competing Interests: There are no conflicts of interest.

Purpose: The goal of this study was to determine the prevalence of insulin resistance (IR) and type 2 diabetes mellitus (T2DM) in contemporary cardiac rehabilitation (CR) and to compare clinical responses in CR between these subsets of patients with coronary heart disease (CHD)., Methods: The study cohort included 818 patients enrolled in CR and separated into 3 groups: (1) individuals with normal hemoglobin A1c (HbA1c) (NoIR: HbA1c < 5.7%); (2) individuals with IR (IR: HbA1c ≥ 5.7 to <6.5%); (3) and individuals with T2DM (HbA1c ≥ 6.5%)., Results: The combined prevalence of IR (44%) and T2DM (23%) was 67%, which paralleled the prevalence of metabolic syndrome (MetSyn), present in 65% of patients. Women had a higher prevalence of IR and MetSyn than men (73% vs 64%, 72% vs. 63%, respectively) and a greater percentage with an elevated waist circumference (71% vs 60%) (all P < .05). All 3 groups experienced decreases in body weight (NoIR = -2.3 ± 4.0, IR = -1.7 ± 4.0, T2DM = -1.0 ± 4.2 kg) and increases in maximal metabolic equivalents (METs) at exercise testing (NoIR = +2.2 ± 2.5 vs IR = +2.1 ± 2.8 vs T2DM = +1.3 ± 2.3) (all P < .05). Individuals with NoIR achieved greater improvements in weight, body mass index, and METs than patients with T2DM (all P < .05). Selected individuals who participated in a 4-session behavioral weight-loss program lost more than twice the weight as nonparticipants., Conclusions: The combined prevalence of IR and T2DM in patients with CHD enrolled in CR was remarkably high (67%). To reverse the deleterious consequences of IR and T2DM, targeted interventions involving exercise and weight loss need to be a central focus of CR programming.

A middle-aged woman presented in shock with bleeding per rectum for 2 days without any significant past medical or surgical illness. Abdominal sonography, oesophagogastroduodenoscopy and sigmoidocolonoscopy were unremarkable. Despite 6 units of blood transfusion, 3000 mL of plasma expanders and ionotropes, the arterial pressure gradually decreased. We had no choice but to undergo life-threatening yet possibly life saving laparotomy. We found a 1×1 cm ileal bleeding mucosal polyp about 20 cm away from the ileocaecal junction. We resected and anastomosed end to end. Perioperatively, the patient was transfused with another 4 units of blood product. Immunohistopathology revealed a large number of CD34 positive spindle cells and eosinophils with extensive thick-walled capillaries compatible with inflammatory fibroid polyp. This case of Vanek's tumour is reported for its atypical site, which presented as massive obscure gastrointestinal haemorrhage without any prior warning signs., (2016 BMJ Publishing Group Ltd.)

Background: Change in health behaviors can occur among women newly diagnosed with ductal carcinoma in situ (DCIS). We sought to understand whether partnership status and socioeconomic status (SES) affected behavioral changes in body weight, physical activity, alcohol consumption, and smoking., Methods: The Wisconsin In Situ Cohort (WISC) study comprises 1,382 women diagnosed with DCIS with information on demographics, SES factors, and pre- and post-DCIS diagnosis health-related behaviors. Logistic regression models were used to determine the association between partnership status, education, and income with change in behavior variables., Results: Higher educational attainment was associated with lower likelihood of stopping physical activity [OR, 0.45; 95% confidence interval (CI), 0.32-0.63; college vs. high school degree], or starting to drink alcohol (OR, 0.34; 95% CI, 0.15-0.80). Results suggested that higher family income was associated with lower likelihood of gaining >5% body mass index (P = 0.07) or stopping physical activity (P = 0.09). Living with a partner was not strongly associated with behavior changes., Conclusion: Higher educational attainment and higher income, but not living with a partner, were associated with positive health behaviors after a DCIS diagnosis., Impact: The associations between higher educational attainment and, to a lesser extent, higher income with positive health behaviors underscore the importance of considering SES when identifying those at risk for negative behavioral change after DCIS diagnosis., (©2015 American Association for Cancer Research.)

Background: Vitamin D insufficiency is increasingly gaining prominence as an associated cardiovascular disease (CVD) risk factor, often thought to be an issue in colder climates and higher altitudes. The intent of this study was to ascertain vitamin D levels in the southern Alabama gulf-coast region that has a high number of sunny days along with an annual average elevated UV ray index., Methods: An observational retrospective study of 204 patients with established CVD treated at the University of South Alabama's Heart Center from January 2007 through January 2013 was undertaken. One-way ANOVA analyses were performed to determine any significant difference in the mean 25-hydroxyvitamin D (25(OH)D) serum based on gender and also based on race/ethnicity. Further, odds ratio (OR) was computed to ascertain if there was a relationship between vitamin D insufficiency and elevated body mass index (BMI)., Results: Out of 204 patients, 53.4% (n = 109) were found to have vitamin D insufficiency (25(OH)D = 20.1 ng/mL), while 46.6% (n = 95) were within the normal range (25(OH)D = 37.8 ng/mL). The mean 25(OH)D of the entire group was 28.3, indicating a general trend of vitamin D insufficiency for patients treated at the cardiology clinics., Conclusion: This study established the prevalence of vitamin D insufficiency in the hot and high UV ray index climate of the coastal south-eastern United States. Also, it revealed the relationship of increased BMI with low 25(OH)D serum level. More extensive studies should be conducted in similar climates to further assess vitamin D insufficiency.

There are very few and conflicting Indian data regarding the bacteriological etiology of community acquired pneumonia (CAP). Adding to this agony, there is no credible data from the eastern part of India. This is a cross-sectional study and descriptive in nature over a period of 1-year. Of the 464 cases of the study population, we could isolate aerobic bacteria in 149 patients (32.1%). Streptococcus pneumoniae has been identified as the most common organism causing CAP (68/149). Gram-negative bacilli (GNB) as a group exceeded marginally over S. pneumoniae (69/149). Among GNB, Pseudomonas aeruginosa was the most common organism (31/69), followed by Klebsiella pneumoniae (29/69). Staphylococcus aureus was identified in (12/149) cases. Co-amoxyclav is still the most sensitive drug for S. pneumoniae. P. aeruginosa was most sensitive to imipenam followed by piperacillin-tazobactam.

S. stercoralis infection is very common in South East Asian countries including India. Chronic infection is very common with symptoms of diarrhea, abdominal pain, nausea, vomiting, anemia, and cough. Hyperinfection and dissemination usually occur in immunocompromised patients with symptoms mimicking asthma, COPD, or aseptic meningitis. Very few cases of hyperinfection and dissemination have been documented in immunocompetent patients. We report this case for its rarity and future references.

Balantidium coli is the largest ciliated protozoa infecting humans by the feco-oral transmission from pigs. Large gut is the most common site of involvement. Symptomatology varies from asymptomatic carrier to invasive dysentery. Extra-intestinal infections can occur in liver, lung and urogenital tract. There are very few case reports of urinary balantidiasis. We present a case of urinary balantidiasis in an elderly farmer having diabetes and chronic kidney disease. This case is reported for its rarity and future references.