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Background The caregiver burden in psychiatric illness is profound. However, the burden on spouses of patients with ADS remains a quest for medical research. The present study was done to assess the caregiver (wives) burden in a group of patients suffering from ADS as compared with that of schizophrenia. Materials and Methods This cross-sectional hospital-based study was conducted in the psychiatric ward. A detailed comparative assessment was done between the caregiver burden and quality of life of wives whose spouses were diagnosed with schizophrenia and alcohol dependence syndrome. Result The average burden perceived by spouses in schizophrenia was 77.69% ±1.51 across all domains as compared with spouses of an alcohol group (78.39 ± 1.69). Factors related to high burden and low quality of life among wives of the alcoholic group were found to be residing in rural areas, living in nuclear families, critical in-laws and noncooperative family members, severely abused, and having two or more children. Discussion The caregiver burden in the spouse of a male ADS is comparable with the burden of the spouse of schizophrenia. Spouses (wives) of addicts need more appreciation and support from the other family members mostly in-laws.

Background Obstructive sleep apnea (OSA) is a common sleep disorder associated with cardiovascular risks. This study aimed to assess the prevalence of probable OSA and its relationship with cardiovascular risks and diseases focusing on age‐stratified young adults (20–40 years) and older (>40 years). Methods and Results The study used a cross‐sectional design, analyzing data from the National Health and Nutrition Examination Survey conducted between 2013 and 2018, comprising 9887 community‐dwelling adults aged ≥20 years. Probable OSA was determined on the basis of self‐report of OSA‐related symptoms (eg, snoring, gasping/breath cessation while sleeping). Cardiovascular risk factors, including hypertension, diabetes, hyperlipidemia, and metabolic syndrome, were evaluated according to established guidelines. Cardiovascular diseases (CVDs) included self‐reported heart conditions, including congestive heart failure, coronary heart disease, angina, heart attacks, and strokes. Individuals with probable OSA showed a significantly higher prevalence of health conditions, including hypertension (adjusted prevalence ratio [aPR], 1.19; P

Patients admitted to the hospital ward from the emergency department (ED) occasionally decompensate and require transfer to the intensive care unit (ICU). An emergency medicine (EM) curriculum focused on review of these ICU upgrade cases could improve resident knowledge related to patient acuity, critical illness, and appropriate disposition. Furthermore, initial identification of critical pathology in the ED and earlier admission to the ICU could reduce delays in care and improve patient outcomes. We performed a retrospective analysis to determine the effectiveness of a resident quality improvement curriculum evaluating cases where patients require transfer from the inpatient floor to the ICU within 12 hours of admission from the ED. We compared postgraduate year 2 (PGY-2) EM residents who participated in the ICU upgrades curriculum during their first year to PGY-2 EM residents who did not participate in the curriculum. Analysis of the 242 qualifying ICU upgrade cases from July 2019–October 2021 showed post-curriculum residents were responsible for an average of 1.0 upgrades per resident compared to an average of 1.54 upgrades per resident (P = 0.12) for pre-curriculum residents. Although there was no statistically significant difference in ICU upgrades between the groups, there was a trend toward decreased ICU upgrade cases for residents who participated in the curriculum. Common reasons for ICU upgrade included worsening respiratory distress requiring higher level of respiratory support, recurrent hypotension after initial intravenous fluid resuscitation requiring vasopressor support, and declining mental status. This retrospective study showed no significant difference in the number of ICU upgrades for residents who completed the ICU upgrades curriculum compared to residents who were not enrolled in the course. However, the study was likely underpowered to detect a significant difference in the groups, and there was a trend toward reduced ICU upgrades for residents who completed the curriculum. ICU upgrade cases were frequently associated with worsening respiratory status, hypotension, and mental status. These findings highlight the importance of reassessment of vital signs and mental status prior to determining disposition from the ED. Additional, larger studies are needed to better determine the curriculum’s impact on resident proficiency in recognizing critical illness and reducing ICU upgrades.

Background The purpose of this study is to compare the prevalence of self‐reported cardiovascular conditions among individuals with moderate to severe traumatic brain injury (TBI) to a propensity‐matched control cohort. Methods and Results A cross‐sectional study described self‐reported cardiovascular conditions (hypertension, congestive heart failure [CHF], myocardial infarction [MI], and stroke) from participants who completed interviews between January 2015 and March 2020 in 2 harmonized large cohort studies, the TBI Model Systems and the National Health and Nutrition Examination Survey. Mixed‐effect logistic regression models were used to compare the prevalence of cardiovascular conditions after 1:1 propensity‐score matching based on age, sex, race, ethnicity, body mass index, education level, and smoking status. The final sample was 4690 matched pairs. Individuals with TBI were more likely to report hypertension (odds ratio [OR], 1.18 [95% CI, 1.08–1.28]) and stroke (OR, 1.70 [95% CI, 1.56–1.98]) but less likely to report CHF (OR, 0.81 [95% CI, 0.67–0.99]) or MI (OR, 0.66 [95% CI, 0.55–0.79]). There was no difference in rate of CHF or MI for those ≤50 years old; however, rates of CHF and MI were lower in the TBI group for individuals >50 years old. Over 65% of individuals who died before the first follow‐up interview at 1 year post‐TBI were >50 years old, and those >50 years old were more likely to die of heart disease than those ≤50 years old (17.6% versus 8.6%). Conclusions Individuals with moderate to severe TBI had an increased rate of self‐reported hypertension and stroke but lower rate of MI and CHF than uninjured adults, which may be due to survival bias.

Post-Concussion Syndrome (PCS) refers to the persistence of physical, cognitive, and emotional symptoms following mild traumatic brain injury (mTBI)/concussion, occurring in roughly 15–30% of individuals. Hyperbaric oxygen therapy (HBOT) has been suggested as a potential treatment for PCS; however, the evidence to date is mixed due to inconsistencies in the treatment protocol and focus on veterans with combat-related injuries, which may not be generalizable to the general population. The goal of Hyperbaric Oxygen Therapy for Post-Concussion Syndrome (HOT-POCS) is to assess the efficacy and safety of HBOT for the treatment of PCS in the civilian population. This randomized, controlled pilot study will be using a standardized HBOT protocol (20 sessions of 100% O2 at 2.0 atm absolute [ATA]) compared with a true placebo gas system that mimics the oxygen composition at room air (20 sessions of 10.5% O2 and 89.5% nitrogen at 2.0 ATA) in a cohort of 100 adults with persistent post-concussive symptoms 3–12 months following injury. Change in symptoms on the Rivermead Post-concussion Questionnaire (RPQ) will be the primary outcome of interest. Secondary outcomes include the rate of adverse events, change in the quality of life, and change in cognitive function. Exploratory outcome measures will include changes in physical function and changes in cerebral brain perfusion and oxygen metabolism on MRI brain imaging. Overall, the HOT-POCS study will compare the efficacy of a standardized HBOT treatment protocol against a true placebo gas for the treatment of PCS within 12 months after injury.

The aim of this systematic review and meta-analysis was to summarize and compare the available evidence on the level of vitamin D and antioxidant trace elements between the keratoconus (KC) patients and healthy controls. Seven case–control studies with 830 subjects were found eligible with a systematic search using PubMed, SCOPUS, Web of Science, and EMBASE till November 21, 2021. Data were synthesized with a DerSimonian and Laird random-effects method of meta-analysis. The mean serum vitamin D level was significantly lower in the patients with KC [standardized mean difference (SMD): −0.71; P < 0.001] as compared with the control group. The mean serum vitamin D level decreased more in the progressive patients (SMD: −0.80; P = 0.016) than in the stable patients (SMD: −0.66; P < 0.001) when compared with the control group. The mean serum zinc level was found significantly lower in the patients with KC compared with the control group (SMD: −1.98; P = 0.005). Pooled analysis based on the two studies showed significantly lower mean selenium levels in the KC patients (SMD: −0.34; P = 0.003). Regular evaluation of serum vitamin D, zinc, and selenium levels among the patients with KC at disease onset and future follow-ups could be promising in predicting the progressive disease and disease severity.

Abstract Background: Peri-diagnostic vaccination contemporaneous with SARS-CoV-2 infection might boost antiviral immunity and improve patient outcomes. We investigated, among previously unvaccinated patients, whether vaccination (with the Pfizer, Moderna, or J&J vaccines) during the week before or after a positive COVID-19 test was associated with altered 30-day patient outcomes. Methods: Using a deidentified longitudinal EHR repository, we selected all previously unvaccinated adults who initially tested positive for SARS-CoV-2 between December 11, 2020 (the date of vaccine emergency use approval) and December 19, 2021. We assessed whether vaccination between days –7 and +7 of a positive test affected outcomes. The primary measure was progression to a more severe disease outcome within 30 days of diagnosis using the following hierarchy: hospitalization, intensive care, or death. Results: Among 60,031 hospitalized patients, 543 (0.91%) were initially vaccinated at the time of diagnosis and 59,488 (99.09%) remained unvaccinated during the period of interest. Among 316,337 nonhospitalized patients, 2,844 (0.90%) were initially vaccinated and 313,493 (99.1%) remained unvaccinated. In both analyses, individuals receiving vaccines were older, more often located in the northeast, more commonly insured by Medicare, and more burdened by comorbidities. Among previously unvaccinated patients, there was no association between receiving an initial vaccine dose between days −7 and +7 of diagnosis and progression to more severe disease within 30 days compared to patients who did not receive vaccines. Conclusions: Immunization during acute SARS-CoV-2 infection does not appear associated with clinical progression during the acute infectious period.

Abstract There is emerging evidence demonstrating an association between maternal polycystic ovary syndrome (PCOS) and autism spectrum disorder (ASD) in children, however, the cumulative effect of maternal PCOS on the development of ASD or other neuropsychiatry disorders (NPD) in children and separately for males and females has not been examined. We sought to systematically evaluate the influence of maternal PCOS on a wide range of NPD including ASD, attention deficit hyperactivity disorder (ADHD), chronic tic disorder (CDT), other behavior disorders, anxiety, depression, bipolar disorder, schizophrenia in children as well as in women of reproductive age only. We queried electronic databases including PubMed, EMBASE, and Google Scholar, until March 2021. We used DerSimonian and Laird (D-L) random effects method to compute pooled effect size in terms of odds ratio (OR). Nineteen studies (1667851 mothers, 2260622 children) were included in this study. Mothers with PCOS had an increased odds of children diagnosed with ASD (OR = 1.40, p

Abstract Several comorbidities have been shown to be associated with coronavirus disease 2019 (COVID-19) related severity and mortality. However, considerable variation in the prevalence estimates of comorbidities and their effects on COVID-19 morbidity and mortality have been observed in prior studies. This systematic review and meta-analysis aimed to determine geographical, age, and gender related differences in the prevalence of comorbidities and associated severity and mortality rates among COVID-19 patients. We conducted a search using PubMed, Scopus, and EMBASE to include all COVID-19 studies published between January 1st, 2020 to July 24th, 2020 reporting comorbidities with severity or mortality. We included studies reporting the confirmed diagnosis of COVID-19 on human patients that also provided information on comorbidities or disease outcomes. We used DerSimonian and Laird random effects method for calculating estimates. Of 120 studies with 125,446 patients, the most prevalent comorbidity was hypertension (32%), obesity (25%), diabetes (18%), and cardiovascular disease (16%) while chronic kidney or other renal diseases (51%, 44%), cerebrovascular accident (43%, 44%), and cardiovascular disease (44%, 40%) patients had more COVID-19 severity and mortality respectively. Considerable variation in the prevalence of comorbidities and associated disease severity and mortality in different geographic regions was observed. The highest mortality was observed in studies with Latin American and European patients with any medical condition, mostly older adults (≥ 65 years), and predominantly male patients. Although the US studies observed the highest prevalence of comorbidities in COVID-19 patients, the severity of COVID-19 among each comorbid condition was highest in Asian studies whereas the mortality was highest in the European and Latin American countries. Risk stratification and effective control strategies for the COVID-19 should be done according to comorbidities, age, and gender differences specific to geographical location.

Abstract Background Coronavirus disease (COVID-19) has been associated with adverse pregnancy outcomes. Due to the lack of effective treatments for COVID-19, it becomes imperative to assess the geographical differences and trends in the current clinical care and outcomes of COVID-19 in pregnant women. Methods A PubMed search was performed to screen articles reporting therapeutics and outcomes of confirmed COVID-19 in pregnant women prior to August 27, 2020. We performed searches, quality assessments of eligible studies, extracted and reported data according to PRISMA guidelines. Meta-analyses and cumulative meta-analyses of proportions were performed for estimating each outcome and their pattern over time respectively. Results One thousand two hundred thirty nine pregnant women with COVID-19 from 66 studies were analyzed. In case series analysis reflecting average-risk patients, the proportion of oxygen support, antibiotics, antivirals, and plasma therapy administration except for hydroxychloroquine was substantially higher in Asian studies (55, 78, 80, 6, and 0%) compared to the US (7, 1, 12, 0, and 7%) or European (33, 12, 14, 1, and 26%) studies, respectively. The highest preterm birth and the average length of hospital stay (35%, 11.9 days) were estimated in Asian studies compared to the US studies (13%, 9.4 days) and European studies (29%, 7.3 days), respectively. Even in case reports reflecting severe cases, the use of antivirals and antibiotics was higher in Asian studies compared to the US, Latin American, and European studies. A significant decline in the use of most therapeutics along with adverse outcomes of COVID-19 in pregnant women was observed. Conclusions Geographical differences in therapeutic practice of COVID-19 were observed with differential rates of maternal and clinical outcomes. Minimizing the use of some therapeutics particularly antibiotics, antivirals, oxygen therapy, immunosuppressants, and hydroxychloroquine by risk stratification and careful consideration may further improve maternal and clinical outcomes.

Aim: Present systematic review and meta-analysis examined the burden of psychological reactions predominantly anxiety, depression, stress, and insomnia during the novel COVID-19 pandemic phase among the frontline healthcare, nonfrontline healthcare, and general population. Material and Methods: PubMed, EMBASE, and SCOPUS were searched for studies between January 1, 2020, and May 25, 2020. Brief protocol of the systematic review was registered with the PROSPERO database, (CRD42020186229). Any study that reported the burden of at least one of psychological reactions including anxiety or depression or stress or insomnia was eligible. Heterogeneity was assessed using I2 statistic and results were synthesized using random-effect meta-analysis. Results: Out of 49 eligible studies, 41 databases from 37 studies reported anxiety, 39 databases (35 studies) reported depression, 20 studies reported stress and 12 databases from 11 studies reported insomnia. The overall prevalence for anxiety, depression, stress, and insomnia was 26.3%, 25.9%, 26.2%, and 31.3%, respectively. Prevalence of anxiety, depression, stress, and insomnia were found highest among the frontline healthcare as compared to general healthcare workers and the general population. Conclusion: Anxiety, depression, stress, and insomnia were more prevalent among frontline health-care workers compared to general. Such increased prevalence is prompting toward the global mental health emergency. Therefore, a call of urgent attention and pan-region effective mental-health intervention are required to mitigate these psychological reactions.

Abstract Background Inflammation has been implicated in the initiation and perpetuation of non‐valvular atrial fibrillation (AF). However, there is a lack of similar data on AF in rheumatic heart disease (RHD). The objective of this study was to analyze the association of inflammation as measured by serum inflammatory biomarkers with AF in rheumatic mitral stenosis (Rh‐MS). Methods A comparative cross‐sectional analytical study was conducted on 181 Rh‐MS patients in normal sinus rhythm (NSR; n = 69), subclinical transient AF (SCAF; detected by 24‐hours Holter monitoring; n = 30) and chronic AF (n = 82). Serum hs‐CRP, IL‐6, and sCD‐40L were assessed using ELISA immunoassay and compared in all groups of Rh‐MS with or without AF. Results We found significantly higher serum hs‐CRP and sCD‐40L levels in the overall AF (Chronic AF + SCAF) group (hs‐CRP: 4.5 ± 3.4 vs 2.3 ± 2.9 mg/L, P

Background: Atypical antipsychotics, widely used in many psychiatric diseases, are known to cause metabolic syndrome (MetS). But, there is sparse of prospective study to see the effect of atypical antipsychotics causing MetS in drug naïve or drug free patients among the Indian population. This study aimed to determine the incidence of MetS and change in individual risk factor for MetS in schizophrenia and mood disorder patients after three months of receiving atypical antipsychotics. Method: Sixty patients of schizophrenia (n=40) and mood disorders (n=20) were screened at the baseline and all of them were prospectively followed up for the occurrence of MetS after three months. Results: By applying the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP/ATP III) modified criteria for Asian, the incidence of MetS was found to be 11.66%. When analysing the individual risk factor for MetS, the mean value from baseline to follow-up was weight (in kg) 58.55±10.03 to 59.80±10.24 (p

Summary: Background: Given the projected trends in population ageing and population growth, the number of people with dementia is expected to increase. In addition, strong evidence has emerged supporting the importance of potentially modifiable risk factors for dementia. Characterising the distribution and magnitude of anticipated growth is crucial for public health planning and resource prioritisation. This study aimed to improve on previous forecasts of dementia prevalence by producing country-level estimates and incorporating information on selected risk factors. Methods: We forecasted the prevalence of dementia attributable to the three dementia risk factors included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 (high body-mass index, high fasting plasma glucose, and smoking) from 2019 to 2050, using relative risks and forecasted risk factor prevalence to predict GBD risk-attributable prevalence in 2050 globally and by world region and country. Using linear regression models with education included as an additional predictor, we then forecasted the prevalence of dementia not attributable to GBD risks. To assess the relative contribution of future trends in GBD risk factors, education, population growth, and population ageing, we did a decomposition analysis. Findings: We estimated that the number of people with dementia would increase from 57·4 (95% uncertainty interval 50·4–65·1) million cases globally in 2019 to 152·8 (130·8–175·9) million cases in 2050. Despite large increases in the projected number of people living with dementia, age-standardised both-sex prevalence remained stable between 2019 and 2050 (global percentage change of 0·1% [–7·5 to 10·8]). We estimated that there were more women with dementia than men with dementia globally in 2019 (female-to-male ratio of 1·69 [1·64–1·73]), and we expect this pattern to continue to 2050 (female-to-male ratio of 1·67 [1·52–1·85]). There was geographical heterogeneity in the projected increases across countries and regions, with the smallest percentage changes in the number of projected dementia cases in high-income Asia Pacific (53% [41–67]) and western Europe (74% [58–90]), and the largest in north Africa and the Middle East (367% [329–403]) and eastern sub-Saharan Africa (357% [323–395]). Projected increases in cases could largely be attributed to population growth and population ageing, although their relative importance varied by world region, with population growth contributing most to the increases in sub-Saharan Africa and population ageing contributing most to the increases in east Asia. Interpretation: Growth in the number of individuals living with dementia underscores the need for public health planning efforts and policy to address the needs of this group. Country-level estimates can be used to inform national planning efforts and decisions. Multifaceted approaches, including scaling up interventions to address modifiable risk factors and investing in research on biological mechanisms, will be key in addressing the expected increases in the number of individuals affected by dementia. Funding: Bill & Melinda Gates Foundation and Gates Ventures.

Background: Legionnaires' disease (LD) is a potentially fatal pneumonia predominantly caused by infection due to Legionella pneumophila although more than 50 other Legionella species are described. Water systems contaminated with Legionella spp. are the implicated sources of Legionnaires' disease. In this study, we aimed to assess Legionella contamination in the water sources of a tertiary care hospital and to determine the virulence properties and molecular characteristics of L. pneumophila environmental isolates.Methods: During May 2015 through August 2018, a total of 201 hospital water samples were tested for L. pneumophila by standardized culture procedures; environmental isolates were examined for the presence of two virulence genes: Legionella vir homolog (lvh) and repeats in structural toxin (rtxA) by PCR. The genotyping of isolates was performed by sequence-based typing (SBT) according to the protocol of the European Study Group for Legionella Infections (ESGLI).Results:L. pneumophila was isolated from 38/201 (18.9%) water samples; among the 46 isolates, the lvh locus was present in 45 (97.8%), the rtxA locus was found in 45 (97.8%), and both loci were found in 44 (95.7%) isolates. A total of 23 sequence types (STs) were identified among the 44 isolates (index of discrimination [IOD] of 0.929), and 11/23 (47.8%) STs were new to the ESGLI database.Conclusions: The study results showed genetic diversity in L. pneumophila isolates from the hospital environment along with a high percentage of pathogenicity loci. Besides, certain STs may have an increased ability to cause legionellosis, thus requires specific infection control and prevention strategies whenever identified.

Background: Population aging is inevitable. Old age is marked with health problems because of aging process, long-term chronic illnesses, also associated with social and mental problems. Objectives: To determine the pattern of physical morbidities in geriatric population and to study the utilization of health services among them. Methods: A cross-sectional study was undertaken from April to September 2017, among 270 consenting elderly people, residing in urban slums under field practice area of a medical college, using a structured interview schedule. Results: Among the 270 elderly, 36.30% were males, 80% belonged to nuclear families. A total of 262 reported of some morbidity, 61.85% had hypertension, 45.19% had diabetes, 37.78% had acid peptic disease, and 51.08% reported to have 1--3 morbidities. Majority (41.85%) of them had visited a physician on an average of 4--6 times in the preceding year. A total of 84.81% went to the urban health center, whereas 24.81% to a government hospital for treatment. Reasons cited for preference of health facility were “free consultation” and “nearby location” (85.19%). A total of 90.74% received allopathic medicines. Conclusion: Prevalence of morbidity was found to be high, which can be attributed to their compromised living conditions. Health-seeking behavior was found to be good.

Introduction and aim. Patients with acute on chronic liver failure (ACLF) have abnormal conventional coagulation tests- platelet count and international normalized ratio (INR). Thromboelastography (TEG) is a rapid, point-of-care assay, more comprehensive than platelet count and INR as it assesses for platelet adequacy(number and function), coagulation factors and clot retraction. The aim of the study was to evaluate the TEG parameters in patients with ACLF, chronic liver disease having acute decompensation (AD) and healthy subjects (HC).Material and methods. TEG parameters were assessed in patients with ACLF and AD within 24 h of admission. Consecutive patients were included in the study over 12 months. Healthy subjects were recruited as controls.Results. 179 patients were included- 68 ACLF, 53 AD and 58 HC. The mean values of INR in ACLF, AD and HC groups were 2.9 ± 1.4, 1.6 ± 0.4 and 1.1 ± 0.2; P < 0.001. Among TEG parameters - maximum amplitude (MA) was low in ACLF and AD patients as compared with HC (53.8 ± 15, 58.3 ± 13.9 mm and 67.2 ± 12.1 mm, respectively; P < 0.001). Lysis at 30 min (LY30) was high in ACLF patients, as compared to AD and HC (8.6 ± 14.1%, 5.0 ± 9.5% and 4.9 ± 9.8%, respectively; P = 0.060). There were no differences in r time, k time, and alpha angle between groups; normal in >90% patients. There was no difference in TEG parameters between different ACLF grades, whereas CCTs were more deranged with increasing grades of ACLF.Conclusion. Despite abnormal conventional coagulation tests, TEG parameters in ACLF patients are essentially normal, except reduced maximum amplitude. Future studies are needed to explore the utility of TEG in clinical management of ACLF patients.

Abstract Background Neoadjuvant chemotherapy (NACT), a standard of care for locally advanced breast cancer patients, is widely used for early breast cancer patients also. The varying role of regimens used as NACT needs to be investigated. Despite availability of some randomized controlled trials (RCTs), it is unclear which treatment regimen suits best. Further, there is no study comparing all the three regimens. Accordingly, present study will compare the efficacy of anthracyclines, taxanes, and targeted therapy administered in neoadjuvant setting on the basis of oncological outcomes and functional outcomes. Method/design Online databases PubMed and Cochrane Register of Controlled Trials will be searched to acquire eligible studies. Further, content of relevant journals, references of relevant articles, and proceedings of major related conference will also be searched. The RCTs comparing any of abovementioned regimen as NACT on breast cancer patients will be eligible. Two reviewers independently and in duplicate will screen the records on the basis of title and abstract and complete full-text review to determine eligibility. Similarly, data extraction and risk of bias assessment will be done by two independent reviewers. The pair-wise meta-analysis as well as network meta-analysis will be conducted to assess the relative efficacy of anthracyclines, taxanes, and targeted therapy regimens. Discussion The present systematic review will improve the understanding of the relative efficacies of the three treatment regimens and possibly guide the clinical practices by providing the current best evidence on the efficacy of various regimens of NACT in the management of breast cancer patients. Systematic review registration PROSPERO (CRD42016027236).

Introduction and aim. Multiple prognostic scores are available for acute liver failure (ALF). Our objective was to compare the dynamicity of model for end stage liver disease (MELD), MELD-sodium, acute liver failure early dynamic model (ALFED), chronic liver failure (CLIF)-consortium ACLF score and King’s College Hospital Criteria (KCH) for predicting outcome in ALF.Materials and methods. All consecutive patients with ALF at a tertiary care centre in India were included. MELD, MELD-Na, ALFED, CLIF-C ACLF scores and KCH criteria were calculated at admission and day 3 of admission. Area under receiver operator characteristic curves (AUROC) were compared with DeLong method. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) and diagnostic accuracy (DA) were reported.Results. Of the 115 patients included in the study, 73 (63.5%) died. The discrimination of mortality with baseline values of prognostic scores (MELD, MELD-Na, ALFED, CLIF-C ACLF and KCH) was modest (AUROC: 0.65-0.77). The AUROC increased on day 3 for all scores, except KCH criteria. On day 3 of admission, ALFED score had the highest AUROC 0.95, followed by CLIF-C ACLF 0.88, MELD 0.81, MELD-Na 0.77 and KCH 0.52. The AUROC for ALFED was significantly higher than MELD, MELD-Na and KCH (P < 0.001 for all) and CLIF-C ACLF (P = 0.05). ALFED score > 4 on day 3 had the best sensitivity (87.1%), specificity (89.5%), PPV (93.8%), NPV (79.1%), LR positive (8.3) and DA (87.9%) for predicting mortality.Conclusions. Dynamic assessment of prognostic scores better predicts outcome. ALFED model performs better than MELD, MELD, MELD-Na, CLIF-C ACLF scores and KCH criteria for predicting outcome in viral hepatitis-related ALF.

Background: Gallbladder carcinoma (GBC) exhibits poor prognosis due to its detection at an advanced stage. Upregulation of lysosomal cysteine proteases cathepsin L (CTSL) and cathepsin B (CTSB) has been implicated in several tumorigenic processes. However, no such information in GBC was available. Therefore, the present study was planned to investigate the expression and clinical significance of these cathepsins in GBC.Methods: Activities of CTSL and CTSB were assayed in the gallbladder (GB) tissues obtained from GBC patients (n = 43) and control subjects (n = 69). Protein and mRNA levels were quantified using immunohistochemistry and real-time PCR (qPCR), respectively. Finally, serum levels of CTSL and CTSB were estimated by ELISA. Receiver operating characteristic (ROC) curve analysis was used for the assessment of sensitivity, specificity, and diagnostic accuracy of these cysteine cathepsins in GBC. The association of combined CTSL and CTSB activity with overall survival was assessed using Kaplan Meier survival analysis.Results: The expression and activity of both CTSL and CTSB were significantly increased (p < 0.050) in tumors of GBC patients as compared to controls. Enzymatic activity of CTSL+B and CTSB exhibited a strong positive association with tumor stage and lymph node involvement in GBC (p < 0.050). Interestingly, the elevated activity of combined CTSL+B was also associated with increased mortality in these patients. Furthermore, significantly enhanced levels of serum CTSL and CTSB were also observed in GBC (p < 0.050) as compared to controls. ROC analysis revealed high diagnostic significance of serum CTSB and CTSL for distinguishing GBC patients from controls with an area under the curve (AUC) of 82 and 77%, respectively.Conclusion: This study, for the first time, demonstrates the clinical significance of CTSL and CTSB overexpression in GBC. Our findings may help improve the clinical management of this carcinoma.

Introduction: In Rheumatoid Arthritis (RA), extra-articular disease is single most important cause of morbidity and mortality. Although DAS-28 score is used for disease assessment in RA, extra-articular manifestations are not included in the same. Therefore an initial attempt was done for development of a composite Disease Assessment Score for Extra-Articular Manifestations (DAS-EAM) based on rheumatologists consensus. Aim: The study was an initial attempt to make a composite disease assessment score for EAMs in RA. Materials and Methods: A hospital based cross-sectional study done on 226 RA patients with various clinical parameters with waiting scores were included to develop the DAS-EAM score. This was compared with DAS-28 and Physician’s Global Assessment score and other demographic parameters and serology {RF, Anti-Cyclic Citrullinated Peptide (Anti-CCP)}. A Pearson’s correlation coefficient and Kappa agreement were calculated to find out the correlation as well as agreement between DAS-EAM score, Physician’s Global Assessment score and DAS-28 scores. Results: Patient’s age was significantly different among the DAS-EAM score (p=0.001). Other parameters such as gender, duration of disease and serology were not significantly associated with DAS-EAM score. There was no agreement between DAS-28 and DAS EAM score. Conclusion: Despite the major limitations such as single centered cross-sectional study design with small sample size, this is an initial attempt for development of a composite tool for extra-articular disease in RA.

Introduction: Evaluation of febrile infants and children without focus possess a great clinical concern. Although several biochemical indices indicate diagnosis towards bacterial agents, combining low cost and easily performed haematological parameters could reasonably predict the presence of Bacterial Infection (BI). Aim: To assess the value of C-reactive Protein (CRP) alone and in conjunction with total White Blood Cell (WBC) count and Absolute Neutrophil Count (ANC) in predicting bacterial infection in febrile children. Materials and Methods: A prospective study was conducted in the Department of Paediatrics of a tertiary care hospital among children aged 1 month to 14 years admitted with fever for >24 hours. Data were collected from 97 consecutive children in whom CRP and total blood count was advised at admission. These data were analysed to predict the presence of BI by investigating the diagnostic performance of CRP, WBC and ANC using standard statistical software Stata version 13.1. Results: BI was diagnosed in 41 children. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), Diagnostic Accuracy (DA) of CRP for BI among the febrile infants were 83%, 75.0%, 71%, 86% and 78% respectively. The sensitivity and specificity were 61% and 98% when all the three parameters CRP, WBC and ANC were positive and were 95% and 45% when any of these parameters was positive. Conclusion: A definitive cut-off value of 1.2 mg/L for CRP is a reasonably good predictor of BI among febrile children. However, addition of other laboratory parameters (total leukocyte count and ANC may enhance clinician’s ability to discriminate bacterial from non BIs.

There is a paucity of health policy relevant data for chronic liver disease from India, impeding formulation of an interventional strategy to address the issue. A prospective, multicentric study to delineate the etiology and clinical profile of chronic liver disease in India is reported here. A centrally coordinated and monitored web-based data repository was developed (Feb, 2010 to Jan, 2013) and analyzed. Eleven hospitals from different parts of India participated. Data were uploaded into a web based proforma and monitored by a single centre according to a standardized protocol. 1.28% (n = 266621) of all patients (n = 20701383) attending the eleven participating hospitals of India had liver disease. 65807 (24·68%) were diagnosed for the first time (new cases). Of these, 13014 (19·77%, median age 43 years, 73% males) cases of chronic liver disease were finally analyzed. 33.9% presented with decompensated cirrhosis. Alcoholism (34·3% of 4413) was the commonest cause of cirrhosis while Hepatitis B (33·3%) was predominant cause of chronic liver disease in general and non-cirrhotic chronic liver disease (40·8% out of 8163). There was significant interregional differences (hepatitis C in North, hepatitis B in East and South, alcohol in North-east, Non-alcoholic Fatty Liver Disease in West) in the predominant cause of chronic liver disease. Hepatitis B (46·8% of 438 cases) was the commonest cause of hepatocellular Cancer.11·7% had diabetes. Observations of our study will help guide a contextually relevant liver care policy for India and could serve as a framework for similar endeavor in other developing countries as well.