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Left ventricular hypertrophy (LVH), the most common structural cardiac complication, is the single most important cause for sudden cardiac death. There are no published data from India looking at the changes in left ventricular mass and cardiac dysfunction after kidney transplantation. We aimed to determine the changes in the left ventricular mass and other cardiovascular risk factors in kidney transplant recipients. This was a prospective observational study. All patients who underwent kidney transplantation at Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, during the study period were included in the study. Measurement of clinical and biochemical parameters and echocardiography were done before, six months, and one year after transplantation. There was significant reduction in LV mass index (124.8 ± 39 vs. 102.2 ± 24.4 g/m2, P

BACKGROUND Hand transplantation and advances in the field of prostheses have opened new frontiers in the restoration of hand function among bilateral hand amputees (BHA). There is only scarce literature evaluating the health utility (HU) and quality adjusted life years (QALY) gained by bilateral hand composite tissue allotransplantation (CTA) or prosthesis over amputation. The study was focused on BHA restored with prosthesis or CTA. METHODS The HU of three different health states (HS) namely, BHA, using prosthesis or with CTA and net QALYs gained by hand transplantation or prosthesis over amputation were computed by time trade-off (TTO) method among 236 study participants. RESULTS Among 236 study participants, medical professional (120), general public (89), BHA (23), and bilateral hand transplant recipients (4) were included. The mean HU by TTO method among the study participants (n = 232) as BHA, using prosthesis or CTA was 0.34 (±0.24), 0.50 (±0.26) and 0.69 (±0.26) respectively. Bilateral hand CTA imparted an expected gain of 12.57 (±11.43) mean QALYs over amputation among the study participants. The subgroup analysis displayed higher mean HU in hand CTA recipient HS along with maximum QALY gained by CTA over amputation. CONCLUSIONS Bilateral hand CTA HS stands above the other 2 HSs, namely BHA and prosthesis, in terms of the health utility. As demonstrated by QALY gain of 12.57, participants' valuation of health utility is notably higher for CTA with acceptance of lifelong immunosuppressant rather than for a state of uncompromised physical health with a bilateral hand amputation.

Objectives/hypothesis In adults, fibreoptic endoscopic evaluation of swallowing (FEES) has established its place in the assessment of dysphagia and aspiration vis-a-vis the current gold standard, videofluoroscopic swallow study (VFSS), almost at parity. However, in children with quite a different set of factors in play, its role is not certain. The primary objective was to measure the accuracy of FEES in young children with dysphagia, compared to VFSS. The secondary objective was to correlate other endoscopic findings with aspiration in videofluoroscopy. Study design Prospective, observational. Methodology Sixty-five children, aged 0.4–36 months with suspected oropharyngeal dysphagia and aspiration underwent FEES and VFSS. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and diagnostic agreement of FEES were calculated using VFSS as the gold standard. To test the statistical significance of the difference in two measurements, Mc Nemar's Chi-square test was used and to test the agreement between FEES and VFSS, Kappa value was calculated. To test the statistical significance of the association of endoscopic findings with VFSS findings, Chi-square test was used.Results: FEES performed in young children was found to be less sensitive (50%) but more specific of aspiration (82%) with an accuracy of 77% in comparison with VFSS. The reverse was true of penetration (81%, 44% and 59% respectively). The agreement between FEES and VFSS in young children, on all parameters were low (k = 0.061–0.302). Endoscopic findings such as glottic secretions (P = 0.02), weak or diminished laryngeal adductor reflex (LAR) (P = 0.001) and penetration (P = 0.01) were significantly associated with aspiration in VFSS. Excessive secretions in the hypopharynx had a stronger correlation with oesophageal dysmotility (P = 0.02) than pharyngeal dysphagia (P = 0.05). Conclusion FEES in young children appears to have a low agreement with VFSS unlike in adults. Aspiration observed in FEES is likely to be significant since specificity is high. FEES negative for aspiration may be interpreted taking into account, the aspiration risk of the subject and/or other endoscopic risk factors (penetration, weak/absent LAR & glottic secretions), if VFSS is not a viable alternative.

Background: Acute kidney injury (AKI) after cardiac surgery (CS) is not uncommon and has serious effects on mortality and morbidity. A majority of patients suffer mild forms of AKI. There is a paucity of Indian data regarding this important complication after CS. Aims and Objectives: The primary objective was to study the incidence of AKI associated with CS in an Indian study population. Secondary objectives were to describe the risk factors associated with AKI-CS in our population and to generate outcome data in patients who suffer this complication. Methods: Serial patients (n = 400) presenting for adult CS (emergency/elective) at a tertiary referral care hospital in South India from August 2016 to November 2017 were included as the study individuals. The incidence of AKI-CS AKI network (AKIN criteria), risk factors associated with this condition and the outcomes following AKI-CS are described. Results: Out of 400, 37 (9.25%) patients developed AKI after CS. AKI associated with CS was associated with a mortality of 13.5% (no AKI group mortality 2.8%, P = 0.001 [P < 0.05]). When AKI was severe enough to need renal replacement therapy, the mortality increased to 75%. Patients with AKI had a mean hospital stay 16.92 ± 12.75 days which was comparatively longer than patients without AKI (14 ± 7.98 days). Recent acute coronary syndrome, postoperative atrial fibrillation, and systemic hypertension significantly predicted the onset of AKI-CS in our population. Conclusions: The overall incidence of AKI-CS was 9.25%. The incidence of AKI-CS requiring dialysis (Stage 3 AKIN) AKI-CS was lower (2%). However, mortality risks were disproportionately high in patients with AKIN Stage 3 AKI-CS (75%). There is a need for quality improvement in the care of patients with AKI-CS in its most severe forms since mortality risks posed by the development of Stage 3 AKIN AKI is higher than reported in other index populations from high resource settings.

Aims: Available literature on the prevalence of Charcot arthropathy (CA) represents mainly Western population. No study has been reported from India so far. Hence we attempted to study the prevalence of CA in patients with type 2 diabetes mellitus and severe peripheral neuropathy (T2DMPN), belonging to Indian population amongst whom type 2 diabetes is on the rise in alarming proportions. Materials and Methods: Medical records of 3387 patients who performed an objective vibration perception threshold test during the year 2015 were screened for T2DMPN. Out of these, 1475 T2DMPN patients above 50 years were selected and analyzed in detail for CA. CA was diagnosed based on clinical features and/or radiological investigations. The anatomical localization of the disease distribution of the affected foot was done according to Brodsky's classification. Results: The prevalence of CA in T2DMPN patients was found to be 9.8%. The mean age of patients diagnosed with CA was 63 ± 8.36 years, and mean duration of DM for CA to develop was 18.01 ± 8.23 years. About 62.5% of the patients were male and 37.5% female. Bilateral presentation of CA was observed in 20.8% of patients. Multiple sites of the foot were affected in 48.6% of patients and belonged to type 4 classification of Brodsky. Conclusions: A high prevalence of CA (9.8%) was observed in the present study conducted on T2DMPN patients who presented to the endocrinology department of a tertiary care South Indian hospital. In the majority of patients, the area of foot affected belonged to type 4 classification of Brodsky.

Background: There has been no previous study that has investigated the effect of a low glycemic index (LGI) diet with local recipes of South Indian cuisine on the body fat composition using dual-energy X-ray absorptiometry (DXA). Truncal obesity has been associated with the risk of metabolic disorders and cardiovascular diseases. Aim: The aim of this study was to examine the effect of a low GI diet on glycemic control and body composition in people with type 2 diabetes in South India. Method: This was a prospective and randomized controlled study that was conducted over a period of 24 weeks. A total of 40 participants were recruited from the Department of Endocrinology and Diabetes Outpatient in Kerala, South India. All the patients had type 2 diabetes and were randomly assigned and given advice and instructions to follow either a low GI diet plan (n = 18) or their usual diet, which served as control (n = 18). The advice was reinforced throughout the study period. Dietary compliance was evaluated based on a 24 h dietary recall at weeks 3, 11, 12, 18, 23, and 24. The age of the subjects ranged from 35 to 65 years. Anthropometric, body composition, and cardio-metabolic parameters were measured according to standard procedures. T-tests were conducted to compare differences between intervention and control groups and the Pearson correlation coefficient was used to evaluate associations between the variables. Results: There were significant reductions (p &lt, 0.05) in the low GI diet compared to the control group with respect to weight, body mass index (BMI), and triceps skinfold thickness. Similarly, significant reductions were observed in the low GI diet group with respect to region, total fat, android, and gynoid fat mass and the differences between the groups were significant at p &lt, 0.05. There was also a positive correlation between BMI and android fat mass (r = 0.745), total fat mass (r = 0.661), total truncal mass (r = 0.821), and truncal fat (r = 0.707). There was a significant reduction in glycated hemoglobin in the low GI diet group compared to the control group at p &lt, 0.05. Conclusion: This study has demonstrated that there was a significant reduction (p &lt, 0.05) of truncal obesity and glycated hemoglobin in patients with type 2 diabetes on a local diet of South Indian cuisine with low GI compared with the control.

BACKGROUND Microsatellite instability (MSI) accounts for 15-20% of colorectal cancer (CRC) and is considered to have favorable stage-adjusted prognosis compared to Microsatellite stable (MSS) CRCs. Determination of MSI in stage II CRC is important for management decisions regarding adjuvant chemotherapy administration. The aim of this study was to determine the prognostic and predictive significance of MSI in stage 2 CRC in the Indian scenario. MATERIALS AND METHODS A total of 195 patients who underwent curative surgery for stage II CRC from 2010 to 2017 were included. MSI testing by immunohistochemistry (DNA MisMatch Repair proteins) was performed in all. Various clinicopathological factors and disease-free survival and overall survival were assessed between MSI and MSS groups. The effect of treatment in terms of survival benefits with adjuvant therapy in the MSI group was also assessed. RESULTS 27.1% of the CRCs' showed MSI. Younger age (

To assess the efficacy of hyperbaric oxygen therapy (HBOT) in patients with hypoxic ischemic encephalopathy (HIE).Non-randomized case-control observational study.Tertiary level neurorehabilitation unit.Twenty-five patients with HIE seen between 1 to 12 months after the injury and having a coma recovery scale-revised (CRS-R) score less than 7 at entry were recruited.Out of the patients who received HBOT, 20 received 20 sessions of HBOT at two absolute atmosphere pressure (ATA), and two received 60 sessions at 2 ATA over three different treatment intervals. We compared the outcomes between cases (who received HBOT) and controls (who did not receive HBOT).Cases and controls were allocated to three groups based on the time interval after injury following which they were recruited to the study: 1-3 months (9 cases and 16 controls), 4-8 months (9 cases and 9 controls) and 9-12 months (8 cases and 3 controls).CRS-R, Karnofsky performance scale, and change in disorder of consciousness (DOC) at admission and discharge were assessed.We observed a significant difference in CRS-R favoring the HBOT group at time intervals of 1-3 and 4-8 months. More patients in the HBOT group improved in DOC than the control group.HBOT given in the first nine months post-HIE can result in a better recovery and functional outcome.

To determine the correlation between our questionnaire scores and two standard Parkinson's disease (PD) disability scores [Unified Parkinsons' Disease Rating Scale (UPDRS) and Hoehn and Yahr (H and Y)], and to study the correlation between the various subgroups of our dysphagia screening questionnaire.This study was conducted at a movement disorder clinic in a tertiary care hospital in Kochi, Kerala. This was a cross-sectional observational study.A questionnaire was developed comprising 11 items, keeping in mind the most relevant swallowing issues in PD patients. The questions were subdivided into four groups representing the different stages of swallowing. Reliability and validity studies were conducted for the questionnaire. Corresponding UPDRS and H and Y scores were documented on the same day.Mean and standard deviation (SD) values of the scores in each group and the correlation between scores (Pearson correlation coefficient) were done.Responses were obtained from 106 PD patients (67 males, 39 females), with a mean age of 66.9 years (SD, 8.62). Our questionnaire score showed a high coefficient of variation (145%) compared to the UPDRS and H and Y scores. There was also moderate correlation between our questionnaire score and the two standard scores with a significant P value. Finally, the highest mean scores were for questions from group A and the least for questions from group D.The association between worsening motor symptoms and swallowing difficulties has been documented in this study. The oral stage of swallowing remains the most affected in PD, which can be recognized early using our questionnaire.

Background: The optimal dose of tranexamic acid in minimizing perioperative bleeding is uncertain. We compared efficacy of two different doses of tranexamic acid in reducing post-operative blood loss and its side effects in patients with congenital cyanotic heart disease undergoing cardiac surgery. Settings and Design: Prospective observational study at a pediatric cardiac center in South India. Methods: Consecutive cyanotic patients undergoing cardiac surgery were divided into groups I and II to receive either 10 mg/kg or 25 mg/kg of tranexamic acid administered as triple dose regime after induction, during cardiopulmonary bypass, and after protamine. Post-operative blood loss at 24 hours, blood component utilization, incidence of renal dysfunction and seizures were compared. Results: Totally, 124 patients were recruited, 62 in each group. The pre-operative variables and cardiopulmonary bypass time were comparable. Patients receiving 25 mg/kg had lower post-operative blood loss compared to patients in lower dose group (8.04 ± 8.89 vs 12.41 ± 19.23 ml/kg/24 hours, P = 0.03). There was no difference in the transfused volume of packed red cells (9.21 ± 7.13 ml/kg vs 12.41 ± 9.23 ml/kg, P = 0.712), fresh frozen plasma (13.91 ± 13.38 ml/kg vs 11.02 ± 8.04 ml/kg, P = 0.19), platelets (9.03 ± 6.76 ml/kg vs 10.90 ± 6.9 ml/kg, P = 0.14) or cryoprecipitate (0.66 ± 0.59 ml/kg vs 0.53 ± 0.54 ml/kg, P = 0.5) in group II and I, respectively. Two patients developed renal dysfunction secondary to low cardiac output in lower dose group. There were no seizures. Conclusions: Tranexamic acid administered at a dose of 25 mg/kg as triple dose regime is associated with lower post-operative blood loss compared to a lower dose of 10 mg/kg in cyanotic patients undergoing cardiac surgery without causing major adverse effects.

Background and rationale Coronary artery disease (CAD) and its pathological atherosclerotic process are closely related to lipids. Lipids levels are in turn influenced by dietary oils and fats. Saturated fatty acids increase the risk for atherosclerosis by increasing the cholesterol level. This study was conducted to investigate the impact of cooking oil media (coconut oil and sunflower oil) on lipid profile, antioxidant mechanism, and endothelial function in patients with established CAD. Design and methods In a single center randomized study in India, patients with stable CAD on standard medical care were assigned to receive coconut oil (Group I) or sunflower oil (Group II) as cooking media for 2 years. Anthropometric measurements, serum, lipids, Lipoprotein a, apo B/A-1 ratio, antioxidants, flow-mediated vasodilation, and cardiovascular events were assessed at 3 months, 6 months, 1 year, and 2 years. Results Hundred patients in each arm completed 2 years with 98% follow-up. There was no statistically significant difference in the anthropometric, biochemical, vascular function, and in cardiovascular events after 2 years. Conclusion Coconut oil even though rich in saturated fatty acids in comparison to sunflower oil when used as cooking oil media over a period of 2 years did not change the lipid-related cardiovascular risk factors and events in those receiving standard medical care.

Introduction Swallowing problems have significant subjective component. Their evaluation necessitates the use of questionnaires to know both extent of symptoms and effect on quality of life. These should be designed to get maximum information with minimum trouble to the patient. Parkinson's disease (PD) involves swallowing disorder as a symptom, often unreported. Hence, this needs to be assessed separately. Aim To develop a questionnaire, in the vernacular, to check for the presence of swallowing problems in PD patients and to study its reliability and validity. Materials and methods We developed an 11-item questionnaire in English, modeled on the Tel Aviv swallowing disturbance questionnaire (SDQ), chosen for its brevity. This was translated into the vernacular (Malayalam, native tongue of the state of Kerala in India) and administered to patients (n = 106) attending the weekly PD clinic of a tertiary care center, in consultation with the attending n in charge of movement disorder patients. The same questionnaire was also administered to age-matched controls (patients without any swallowing disorders) (n = 63) attending the ear, nose, and throat (ENT); neurology; and geriatric clinics. The scores were documented and statistical analysis done, to check for internal reliability and validity. Results Comparison of mean total scores between cases (2.89) and controls (1.51) showed a statistically significant difference, indicating statistical validity (p = 0.009). Guttman's split-half correlation showed fairly good reliability for both cases (0.812) and controls (0.851). Conclusion The present questionnaire to assess dysphagia in PD patients has been found to be reliable and valid for use. We recommend it as a screening tool in the neurology outpatient department (OPD). How to cite this article Menon U, Radhakrishnan SK, Sundaram KR. Reliability and Validity of a Questionnaire to Assess Swallowing Disorders in Parkinson's Disease Cases. Int J Phonosurg Laryngol 2016;6(2):78-82.

Background: Inflammation is considered as a predictor of cardiovascular diseases in type 2 diabetes mellitus. No previous studies have investigated the effect of low glycemic index (LGI) recipes of South Indian cuisine on the risk factors of cardiovascular disease in patients with diabetes. Aim: The aim of this randomized controlled trial was to evaluate the improvement in cardiovascular risk factors and blood glucose control, in patients with type 2 diabetes, after intervention with recipes of Kerala cuisine, from locally available whole grain cereals, low in glycemic index. Method: This was a prospective and randomized controlled study that was conducted over a period of 24 weeks. A total of 80 participants were recruited from the Department of Endocrinology and Diabetes Outpatient in Kerala, South India. All 80 patients had type 2 diabetes, and were aged between 35 and 65 years. Participants were randomly assigned and advised to follow either a LGI diet plan (n = 40) or their usual diet, which served as a control group (n = 40). The advice was reinforced throughout the study period. Anthropometric, biochemical parameters which included glycemic and cardio-metabolic parameters were measured according to standard procedures. T-tests were conducted to compare the differences between intervention and control groups, and the Pearson correlation coefficient was used to evaluate associations between the variables. Results: There were significant differences (p &lt, 0.05) between the intervention and control groups with respect to weight, HbA1c, insulin, triglycerides, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), high sensitivity C-reactive protein (hs-CRP) and apolipoprotein B (ApoB). There was also a positive correlation between weight and blood glucose variables. ApoB was positively correlated with lipid profile and insulin levels. Conclusions: The long-term implementation of LGI diet of Kerala cuisine has been found to promote weight loss, enhance insulin sensitivity and reduce the cardiovascular risk.

The aggressiveness of brain tumors is attributed to the expression of multiple oncogenes involved in proliferation, metabolism and therapeutic resistance whose potential correlation with tumor progression has not been well-studied. In this study, we aimed to investigate the relationship of oncotargets involved in pathogenesis with respect to glioma grades. Gliomas ( n =40) were analyzed by reverse transcription-polymerase chain reaction (RT-PCR) and sequencing for the detection of epidermal growth factor receptor ( EGFR ) mutants. Expressions levels of EGFR , EGFR variant III ( EGFRvIII ), Lck/Yes novel tyrosine kinase ( LYN ), Spleen tyrosine kinase ( SYK ), insulin receptor substrate 1 ( IRS1 ), phosphatidylinositol 3-kinase ( PI3K ), Src homology 2 domain-containing inositol 5-phosphatase 1 ( SHIP1 ) and glucose transporter 3 ( GLUT3 ) were studied using real-time PCR and compared against glioma grades via statistical methods. Protein expressions were analyzed using immunohistochemistry and western blotting. EGFRvIII was detected in 53% and exon 4 deletion ( de4 EGFR ) in 20% of gliomas. Importantly, the expressions levels of candidate oncogenes were significantly upregulated ( P

Introduction Multimodal therapy is the current recommended treatment of choice for rectal cancer. The effects of the neoadjuvant therapy/tumour regression can be assessed histologically in the resection specimen. Methods This is a 5 year retrospective study at a tertiary centre in South India to assess the prognostic significance of the pathological grading of tumour regression in rectal cancer pre-treated with long course neoadjuvant therapy. 137 patients with rectal adenocarcarcinoma who recieved long course neoadjuvant chemoradiation followed by surgery were analysed and categorised based on the Tumour Regression Grade(TRG) into 2 groups- Group 1(Good response, TRG 0,1) and Group 2 (Poor response, TRG 2,3). Other factors (clinical and pathological features like lymphovascular/perineural invasion, discontinuous extramural tumour deposits, resection margin status and pTNM stage of tumour) were also evaluated and all variables along with TRG were correlated with disease progression and 5 year survival. Statistical analysis used: IBM SPSS version 20.0 software. Categorical variables expressed using frequency and percentage and the continuous variables presented using mean and standard deviation. The chi-square test was used for finding prognostic factors. Univariate analyses of survival were carried out by Kaplan-Meier method and the evaluations of differences were performed with Log Rank test. Results Group 1 showed reduced risk for disease progression (p 0.01) and better mean disease free period and overall survival. Poor tumour regression was associated with lymphovascular and perineural invasion and regional lymph node metastases (p Conclusions Pathological assessment of tumour regression serves as a good predictor for disease outcome and should be assessed in all neoadjuvant treated rectal resection specimens.

The role of electroconvulsive therapy in schizophrenic patients is controversial. We assessed its use in Indian patients who generally present to hospital at a late stage in their disease.We studied 48 schizophrenic patients, 30 of whom had chronic disease. Twenty-three patients were given drugs and 25, who were unsuitable for drug therapy alone, were also treated with electroconvulsive therapy. The global assessment scale score for overall individual functioning was used to assess the response.The global assessment scores at admission for the drugs alone, and drugs and electroconvulsive therapy groups were 27±9.4 and 19±8.4. At discharge there was a significant improvement to 57±16 and 62±14.3.Electroconvulsivetherapy may be an effective adjunctive treatment in Indian patients with schizophrenia who are unsuitable for drug therapy alone.

Coconut is a popular food ingredient in many parts of the world and the water it contains is believed to be the purest form of natural drink available. The water is rich in potassium, sodium, chloride and many vitamins, and hence is considered the beverage of choice. In medical practice, coconut water is recommended as the preferred oral rehydration fluid in cases of severe dehydration due to diarrhoea. Chronic heavy metal poisoning has been shown to occur from plant products. However there is scanty research work relating to coconuts and heavy metal contamination. Among the various metals, lead is said to be the commonest metal involved. Arsenic is only second to lead in the incidence of chronic toxicity. When plants are exposed to heavy metals, mostly through contaminated water (irrigation), or contaminated soil, they accumulate in edible parts such as the fruits. This study was undertaken to detect the presence of two of the commonest heavy metals - arsenic and lead – in coconut water present in coconuts sold in different parts of Ernakulam district of Kerala state, and to quantitatively assess their levels. It was also decided to detect the differences in the levels of the metals between tender and mature coconut water, and also to detect inter-zonal variations within Ernakulam district in the levels of the two heavy metals, in tender and mature coconut water.

Objective To evaluate the treatment and survival pattern of patients with advanced epithelial ovarian cancer. Methods and results Retrospective study of all advanced epithelial ovarian cancer patients treated in the department of gynaecologic oncology from an academic centre, in a four year period from 1 January 2008-31 December 2011. Selection criteria All patients with advanced epithelial ovarian cancer (stage III and IV) who underwent surgery from 2008-2011and had a follow-up of at least three months after completion of treatment were included. The decision on whether primary surgery or neoadjuvant chemotherapy (NACT) in advanced ovarian cancer was based on age, performance status, clinical and imaging findings. Results A total of 178 cases of epithelial ovarian cancer were operated on during this four year period. Among them 28 patients were recurrent cases, 22 had early stages of ovarian cancer, and the rest 128 had stage III and IV ovarian cancer. In these 128 patients, 50(39.1%) underwent primary surgery and 78(60.9%) had NACT followed by surgery. In the primary surgery group 36(72.0%) patients had optimal debulking while in the NACT group 59(75.6%) patient had optimal debulking. With a median follow-up of 34 months, the median overall survival (OS) and progression free survival (PFS) was 53 and 49 months respectively. Patients who underwent primary surgery had better median PFS than patients who had NACT (56 months versus 39 months, p = 0.002). In stage III C the difference median PFS was significant for those treated with primary surgery when compared with NACT (55 months versus 39 months, p = 0.012). In patients who had optimal debulking to no residual disease (n = 90), primary surgery gave a significant improved PFS (59 months versus 38 months, p = 0.001) when compared with NACT. In univariate analysis, NACT was associated with increased risk of death (HR: 0.350; CI: 0.177-0.693). Conclusion In advanced epithelial ovarian cancer, primary surgery seems to have a definite survival advantage over NACT in patients who can be optimally debulked to no residual disease.

Objectives. To study the impact of modular training and implementation of infection control practices on all health-careassociated infections (HAIs) in a cardiac surgery (CVTS) program of a tertiary care hospital. Design. Baseline data were compared with post-intervention (with modular training) data. Settings. This study was conducted in a cardiovascular surgical unit. Participants. In total, 2838 patients were admitted in cardiovascular surgical service. Interventions. Two training modules and online continuous education were delivered to all health-care workers in CVTS unit. Main Outcome Measures. All four HAIs, such as surgical site infections (SSI), central line-associated blood stream infection (CLABSI), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CA-UTI), were studied. Additional outcome measures included average length of stay cost of avoidance mortality and readmission rates. Results. The SSI rate had decreased in the post-intervention phase from 46 to 3.27% per 100 surgeries (P , 0.0001), CLABSI had decreased from 44 to 3.10% per 1000 catheter days (P , 0.009), VAP was reduced from 65 to 4.8% per 1000 ventilator days (P , 0.0001) and CA-UTI had reduced from 37 to 3.48% per 1000 urinary catheter days (P , 1.0). For every $1 spent on training, the return on investment was $236 as cost of avoidance of healthcare associated infections (HAIs). Conclusions. Standardization of infection control training and practices is the most cost-effective way to reduce HCAIs and related adverse outcomes.

Rejection sensitivity (RS) is the disposition to defensively expect, perceive and over-react to perceived rejection by others. RS has been theorized to originate from early attachment. However, this hypothesized link remains untested. This study aims to examine the relationship between attachment security and rejection sensitivity in early adolescence. Eight-graders (N = 406) completed self-report measures of attachment security and rejection sensitivity. Attachment security to father and mother were found to be associated. Attachment dimensions-trust and alienation from mother were significant predictors of RS in the adolescents. Alienation from mother mediated the link between alienation from father and RS in the adolescents. The two forms of RS- anxious RS and angry RS were predicted by different dimensions of attachment to mother.

Chandrashekar J, Thankappan KR, Sundaram KR. Severe dental fluorosis and jowar consumption in Karnataka, India. Community Dent Oral Epidemiol 2010; 38: 559–567. © 2010 John Wiley & Sons A/S Abstract – Introduction: Dental fluorosis is a major public health problem in 17 states of India. Earlier studies have reported that Jowar (a type of millet) consumption interacts with fluoride (F) in the body and enhances fluorosis. We conducted this study to determine the association between jowar consumption and severity of dental fluorosis. Methods: A community based case control study was carried out in villages having different F levels (low, medium, and high) in drinking water in North Karnataka, India. 352 school Children (12–15 years, male 58%) with severe dental fluorosis classified by Thylstrup & Fejerskov Index (1988) were selected as cases. 428 school children (12–15 years, male 48.8%) with no dental fluorosis were selected randomly from the same area as controls. Exposure ascertainment of jowar consumption was done by 24-h diet recall and food frequency questionnaire. Ion selective electrode method was used to estimate the F level in spot urine samples of subjects and in drinking water. Multiple logistic regression analysis was done using SPSS V. 11.01 Results: Children who consumed jowar had 2.67 times more chance of getting severe dental fluorosis compared to those who did not [Odds Ratio (OR) 2.67, CI 1.98–3.62]. Children from high F level villages (OR 1.91, CI 1.27–2.85) had higher odds of severe dental fluorosis compared to children from medium and low F level villages. Daily jowar consumers (OR 2.14, CI 1.64–3.09) and weekly consumers (OR 1.68, CI 1.31–3.45) had higher risk for dental fluorosis compared to non jowar consumers. Children who started consuming jowar before 8 years of age had significantly higher proportion of severe dental fluorosis compared to their counterparts. Urinary F excretion among jowar consumers was significantly lower than non-jowar consumers. Conclusions: Jowar consumption was positively associated with severity of dental fluorosis in this population.

The article focuses on the profile of 102 couples referred from the family court for assessment and counseling. The majority of couples were married for 5 years or less, had a single child and many had been separated for at least 2 years. Behavior problems, especially maladaptive personality traits in the spouse were cited as the major reason for their marital problems. The scope of clinical psychologists in a family court is discussed.

To study the profile of alcoholic liver disease in India, 144 consecutive, histologically diagnosed patients were prospectively studied. The patients were divided into those having alcoholic fatty liver (AFL) (Gr. I, n = 32), alcoholic hepatitis (AH) (Gr. II, n = 42) and alcoholic cirrhosis (AC) (Gr. III, n = 70) on the basis of their histological findings. All the patients were males, those with fatty liver being younger than those with cirrhosis. The amount of alcohol consumed by patients with AFL, AH and AC was not significantly different. Similarly, the duration of alcohol consumption was not significantly different between the three groups of patients. The clinical features of the patients were quite similar to those reported from the West, except that AH was relatively milder in our patients. Intake of poor quality country liquor was quite common (60%), but its use was not found to be associated with more severe liver injury as compared with the use of good quality foreign varieties of liquor.

A case control study was conducted on 170 patients with oesophageal cancer. An equal number of healthy persons (attendants of patients) were included in the study as controls to identify nutritional risk factors for oesophageal cancer. The majority (55%) of the patients were of low socio-economic status and from Northern parts of India. They were predominantly male (66%). Increase in risk was associated with low consumption of green leafy vegetables, other vegetables and fresh fruits, milk and milk products. Heavy use of spices and use of very hot tea or food were also associated with increased risk. Differences in the past dietary consumption patterns of oesophageal cancer patients and controls suggest a role for nutritional factors in oesophageal cancer pathogenesis. At the same time substance abuse by cigarette or bidi smoking, alcohol consumption, paan and tobacco chewing also increased risk. After multivariate analysis, green leafy vegetables, other vegetables spices, bidi usage and fresh fruits provided protection against oesophageal cancer.

This article aims to describe the National Family Health Survey (NFHS) being carried out in India with its first round during 1992-93 (NFHS-I) and second round during 1998-99 (NFHS-II), with special reference to information available in relation to children. The survey was on lines of the existing systems of Demographic Surveys (DHS) in various developed as well as developing countries. Another important objective of the survey was to provide quality data to the researchers to carry out analytical work on various aspects. Further, the survey has paved the way to carry out comparative studies not only between states in India but also between countries. An attempt has also been made here to present salient features of comparative results under NFHS-I and NFHS-II.

For the first time, models using multilevel analysis of Indian data and related simulation results are reported. They take hierarchical structure into account and incorporate variables from all levels to get correct analysis and proper interpretation of data on current contraceptive use (including sterilization and modern methods).The data from an Indian State, Uttar Pradesh (UP), collected by the National Family Health Survey (NFHS) conducted during 10 October 1992 to 22 February 1993 was used. For model I, 7851 currently married women who were neither pregnant nor had continuing post-partum amenorrhoea (PPA) were considered. For model II, these women with at least one child (n = 6748) were used. Two-level logistic regression analysis was carried out for which women's level (level 1) and PSU (Primary Sampling Unit) level (level 2) variables were considered. The results were considered significant at the 5% level of significance. Simulation analysis using each model was also carried out.Model I reveals that those more likely to adopt contraception were women exposed to a TV message (odds ratio [OR] = 1.3; 95% CI: 1.1-1.6); whose houses were pucca (bricks and mortar) (OR = 1.3; 95% CI: 1.1-1.5); who were educated to high school level and above (OR = 2.9; 95% CI: 2.2-3.7); whose husbands were literate with schooling ofor =11 years (OR = 1.7; 95% CI: 1.4-2.1); and who hador =2 living sons (OR = 2.2; 95% CI: 1.1-4.4). Muslim and other religious women were less likely than Hindu women to adopt contraception (OR = 0.5; 95% CI: 0.4-0.6). Also, the PSU level availability of all weather road was positively associated with contraceptive adoption (OR = 1.4; 95% CI: 1.1-1.7). The PSU level variance, which is the unexplained PSU level variation after controlling for the considered characteristics, was significantly higher. The simulation results revealed that public health education (a TV message) was found to be more effective among less educated women. The PSU level availability of all weather road was as effective as public health education. Similar results were evident from the analysis of second data set (model II) with the noticeable finding that those whose last child is surviving are most likely to adopt contraception (OR = 8.82; 95% CI: 1.01-77.38).These results reveal that the survival status of the last child has a marked effect on the adoption of contraception in UP. They further support the idea that public health education (a TV message) is more effective among less educated women. Also, the PSU level presence of all weather road is equally effective. Consideration of higher level variables provides not only more accurate results but also important public health clues to help the policy planners.This study examined models for contraceptive adoption in Uttar Pradesh (UP) using a multilevel analysis technique. Data were obtained from an Indian State, UP, collected by the National Family Health Survey conducted from October 1992 to February 1993. 7851 currently married women who were neither pregnant nor had continuing postpartum amenorrhea were considered for model I, while 6748 women with at least one child were used for model II. Two-level logistic regression analysis was carried out, for which women's level (level 1) and primary sampling unit (PSU) (level 2) level variables were taken into account. Findings revealed that, in model I, women who were exposed to a TV message (odds ratio [OR] = 1.3; 95% confidence interval [CI]: 1.1-1.6), whose houses were made of bricks and mortar (pucca) (OR = 1.3; 95% CI: 1.1-1.5), who had a secondary education or above (OR = 2.9; 95% CI: 2.2-3.7), who had literate husbands (OR = 1.7; 95% CI: 1.4-2.1), and who had 2 or more living sons were more likely to adopt contraception. In addition, the PSU level availability of all weather road was positively associated with contraceptive adoption (OR = 1.4; 95% CI: 1.1-1.7). The PSU level variance, which was the unexplained PSU level variation after controlling for the considered characteristics, was significantly higher. In conclusion, the survival status of the last child has a marked effect on the adoption of contraception in UP.

Assessment of the efficacy of iron therapy has usually been done in populations/patients by monitoring changes in hemoglobin concentration, serum iron, percent transferrin saturation, and serum ferritin. In this study the protoporphyrin heme (P/H) ratio (a measure of free erythrocyte protoporphyrin) was measured before and after iron therapy in three groups of pregnant women, who received 60 mg (group A), 120 mg (group B), and 240 mg (group C) of elemental iron with folic acid (0.5 mg) per day for a period of 12 weeks, to evaluate its efficacy to monitor iron therapy. The three groups were comparable regarding the initial mean Hb concentration and serum ferritin levels. The initial mean P/H ratios were markedly elevated in all three groups and were different in the three groups, being highest in group A (113.2+/-92.6), intermediate in group B (87.5+/-62.5), and lowest in group C (69.8+/-43.3). The initial P/H ratio was significantly higher in group A than in group C (p0.05). This probably affected the efficacy of iron therapy in the three groups. The P/H ratio decreased significantly in each of the three groups after iron therapy (A and B: p0.001; C p0.01). Mean Hb concentration and serum ferritin increased in all three groups post therapy; however, the magnitude of change in P/H ratio in all three groups was much greater. This indicated that the predominant contributory factor for anemia was iron deficiency in this group of pregnant women. Serum iron and percent transferrin saturation are difficult to interpret in our population, as iron is freely available over the counter and is prescribed as soon as anemia is detected in patients; therefore, the reduction in P/H ratio may be used to monitor response to iron therapy in population groups.

Cerebral palsy is a major cause of crippling in children, but it's etiology is poorly understood. This case control study was done to assess some of the identified risk factors for cerebral palsy, 125 cerebral palsy cases selected from hospital clinic and 125 age and sex matched neighbourhood controls, all aged less than 5 years and residing in Delhi (India) were studied. Information regarding antenatal, natal and postnatal period was collected by mother's interview, and wherever available, from hospital records with the study subjects. Most common type of cerebral palsy was spastic (88%). Quadriplegia was the commonest topographical subtype (86.4%). Birth asphyxia was found to be present in only 25.6% of cases. The commonest risk factor amongst cases was low birth weight (28.8%). The multivariate odds ratios (confidence limits) for the risk factors found to be significantly associated with cerebral palsy were 36.1 (7.76-160) for birth asphyxia, 13.8 (4.95-38.3) for low birth weight, 37.4 (4.47-313) for neonatal convulsion, 23 (4.7-112) for neonatal jaundice, 14.4 (3.69-56.4) for neonatal infection, 24.9 (2.78-223) for instrument assisted delivery and 15.4 (1.57-152) for antepartum hemorrhage. Precipitate labour, caesarean section, twins, toxemia, breech delivery and head injury were not found to be significantly associated with cerebral palsy. Thus birth asphyxia, low birth weight, neonatal convulsions, neonatal jaundice, neonatal infection, instrument assisted delivery and antepartum hemorrhage are significant risk factors for cerebral palsy.

Maximum likelihood method with probit transformation was applied to estimate median age at which chest circumference (CC) overtook head circumference (HC) in 1206 children from rural areas of Ballabhgarh in Haryana and in 1505 children from a slum population in Delhi. The results showed that, in case of rural area, this phenomenon occurred at an average age of 31.36 months and in children from urban slums, at an average age of 28 months. In both the areas, this phenomenon occurred at an average age of 20 to 21 months in normally nourished children. In children with grade I malnutrition, this was delayed by about 10 months as compared to those with normal nutrition and in children with grade II or worse malnutrition, this was further delayed by another 9 to 13 months on an average as compared to those with grade I malnutrition. These differences were found to be statistically significant (p < 0.001). These results indicate that the longer the delay in CC overtaking HC, the chance is higher for the children to be severely malnourished. Considering the relative ease of measuring head and chest circumferences, this parameter (age of CC crossing HC) could be useful in assessing the long term trend in the improvement of childhood nutrition in developing countries.

To test the hypothesis that fluconazole plus standard care is superior to the standard care for diabetic foot wounds infected with deep-seated fungal infections.We carried out a randomized, controlled, open-label, parallel-arm study in 75 patients with both fungal and bacterial infections in deep tissues of diabetic foot wounds. Thirty-seven patients (control group) were given standard care (surgical debridement + culture-specific antibiotics + offloading + glycaemic control) and 38 patients (treatment group) were given fluconazole 150 mg daily plus standard care. Wound surface area was measured every 2 weeks until the endpoints (complete epithelialization or skin grafting) were met.By week 4, the mean wound surface area reduced to 27.3 from 111.5 cm(2) in the treatment group, as opposed to 67.1 from 87.3 cm(2) in the control group. Subsequently, the mean wound surface areas were remarkably smaller in the treatment group compared with the control group, and statistically significant differences (P ≤ 0.05) in mean wound surface area were observed between the treatment group and the control group at week 6. However, no statistically significant (P ≤ 0.47) difference in complete healing was observed between the treatment group and the control group, 20 vs. 24. The mean wound healing time for the treatment group was 7.3 weeks, whereas for the control group it was 11.3 weeks (P ≤ 0.022). Similarly, the probability of wound healing in the treatment group was 50 vs. 20% in the control group at week 10.Fluconazole plus standard care was superior to standard care alone in accelerating wound reduction among patients with diabetes with deep-seated fungal infections in diabetic foot wounds. Those in the treatment group who did heal, healed more quickly (P ≤ 0.022), but overall healing was not different.

Naloxone-induced withdrawal was studied in seven patients currently dependent only on injecting buprenorphine, within 3 to 6 hours of their last dose. Withdrawal severity began to rise from 5 minutes and reached a peak at 60 minutes after 1.2 mg naloxone given intravenously. The mean withdrawal severity score was significantly higher at 30, 60 and 90 minutes compared to the baseline. The most frequent withdrawal signs and symptoms were mydriasis, systolic hypertension, tachypnoea, muscle pains, yawning, anxiety, restlessness and craving.

A cross-sectional survey of 507 in- and out-patients, with diagnosed Type 2 diabetes mellitus (T2DM) was undertaken to study the relationships between personal, disease and treatment-related factors and diabetes control in a tertiary care hospital. On multivariate logistic regression analysis, self-efficacy (odds ratio (OR) = 2.94; 95% confidence interval (CI) = 1.92–4.54); P < 0.001) was the single most important determinant of current diabetes control (HbA1c ≤ 7%), along with absence of hyperglycemic symptoms in the past year (OR = 1.83; 95% CI = 1.15–2.93, P < 0.01), current treatment with oral medication (OR = 1.77; 95% CI = 1.17–2.66; P < 0.007), and adherence to dietary restrictions (OR = 2.7; 95% CI = 1.28–5.88; P < 0.009). Self-efficacy was itself influenced by educational status, employment, availability of family support, and positive mental attitudes. Our findings suggest that health care delivery inputs, patients’ personal characteristics including education and attitude, and family support for care are complexly processed to determine patients’ ability to manage their disease, which ultimately influences disease outcomes.

SUMMARY The present study was conducted to investigate the frequency and types of life events experienced by psychiatric outpatients and to compare these with the events experienced by a control sample consisting of their normal relatives. One hundred and sixty-six patients and an equal number of marked controls were studied. Semi-structured interviews were conducted with the help of an event list. Results showed that; the patients experienced a significantly higher number of events compared to matched controls in previous one year. Desirable as well as undesirable events in all areas of life functioning were experienced more frequently by patients. Results are discussed in the light of existing information and suggestions offered for use of suitable methodology for further studies in this area.

To determine the frequency of chromosomal aberrations particularly 22q11 deletion in Indian children ≤2 years with different types of conotruncal malformations and their association with abnormal aortic arch. Additionally, extracardiac features were also studied.Conventional cytogenetic and fluorescence in situ hybridization analyses were performed in 254 patients with conotruncal defects. Multivariable logistic regression analysis was performed to ascertain extracardiac features helpful in identifying high-risk patients with deletion.Chromosomal abnormalities were identified in 52 (21%) children, of whom 49 (94%) showed 22q11 deletion and 3 (6%) had abnormalities of chromosome 6, 2 and X. None of the 11/254 children with tetralogy of Fallot with absent pulmonary valve showed deletion. The association of 22q11 deletion with right sidedness of the aortic arch varied with the type of conotruncal defect. The eight extracardiac features in combination showed 93.5% agreement with the presence of deletion.The extracardiac features along with specific type of conotruncal defect and associated cardiovascular anomaly should alert the clinician for 22q11 deletion testing. However, if deletion analysis is not possible, specific extracardiac features (six dysmorphic facial features, thin long fingers and hypocalcemia) can help to identify an increased risk of 22q11 deletion in patients with conotruncal defect.

The objective was to find out the effect of Integrated Amrita Meditation Technique (IAM) on the stress hormones: adrenaline and cortisol. One hundred and fifty healthy subjects were randomized into three groups. Blood was collected at 0 hour, 48 hours, 2 months, and 8 months after the first visit. Adrenaline was analyzed by ELISA and cortisol by Chemiluminescent method. In the IAM, PMR and control groups 44, 44, and 36 came, respectively, for the baseline visit. Within group, cortisol and adrenaline levels reduced in the IAM 48 hours onwards and the fall sustained until 8 months (P<.05). ANCOVA (Repeated measures) on adrenaline taking the four levels of observation showed a highly significant (P=.001) drop in the IAM group. The mean cortisol values between groups were not statistically significant (P=.138). IAM Technique was effective in reducing adrenaline and cortisol levels within group comparisons.

Dental fluorosis is a major public health problem in 17 states of India. Earlier studies have reported that Jowar (a type of millet) consumption interacts with fluoride (F) in the body and enhances fluorosis. We conducted this study to determine the association between jowar consumption and severity of dental fluorosis.A community based case control study was carried out in villages having different F levels (low, medium, and high) in drinking water in North Karnataka, India. 352 school Children (12-15 years, male 58%) with severe dental fluorosis classified by ThylstrupFejerskov Index (1988) were selected as cases. 428 school children (12-15 years, male 48.8%) with no dental fluorosis were selected randomly from the same area as controls. Exposure ascertainment of jowar consumption was done by 24-h diet recall and food frequency questionnaire. Ion selective electrode method was used to estimate the F level in spot urine samples of subjects and in drinking water. Multiple logistic regression analysis was done using SPSS V. 11.01Children who consumed jowar had 2.67 times more chance of getting severe dental fluorosis compared to those who did not [Odds Ratio (OR) 2.67, CI 1.98-3.62]. Children from high F level villages (OR 1.91, CI 1.27-2.85) had higher odds of severe dental fluorosis compared to children from medium and low F level villages. Daily jowar consumers (OR 2.14, CI 1.64-3.09) and weekly consumers (OR 1.68, CI 1.31-3.45) had higher risk for dental fluorosis compared to non jowar consumers. Children who started consuming jowar before 8 years of age had significantly higher proportion of severe dental fluorosis compared to their counterparts. Urinary F excretion among jowar consumers was significantly lower than non-jowar consumers.Jowar consumption was positively associated with severity of dental fluorosis in this population.

The aim of the study was to examine the association of a trend in body mass index (BMI) status with current blood pressure in a cohort of school children from South India. A population of 25,228 children was selected using stratified random sampling method. Height and weight were measured in 2003-2004. Height, weight and blood pressure were measured in 2005-2006. A total of 12,129 children aged 5-16 years having paired data were analysed. Blood pressure and BMI values were converted to Z scores using International paediatric reference values. An increase in Z BMI meant that the child is moving to a higher BMI level with respect to his or her age and sex. In the cohort, 62.4% children had a higher Z BMI at follow-up than at baseline. Children with higher Z BMI at follow-up were labelled as positive BMI status group (PBSG) and the remaining as negative BMI status group (NBSG). The positive trend in BMI was more in rural areas, government schools and girls. In all subgroups, PBSG showed significantly higher systolic blood pressures (SBPs) than NBSG. PBSG showed significantly higher diastolic blood pressures (DBPs) in urban area, government schools and girls when compared with NBSG. Prevalence of first instance systolic hypertension was more in PBSG in all the subgroups except in rural children. Prevalence of diastolic hypertension was significantly higher in PBSG in urban subgroup only. BMI status trends are associated with blood pressure distribution in children.

Four regimens of prophylactic antibiotics were utilized in 122 consecutive patients of stages III and IV carcinoma of the upper aero-digestive tract undergoing major resections in a randomized single-blind study. Ampicillin, gentamicin, cephalexin and metronidazole were used in different combinations for periods of 5 or 10 days. A cephalexin-metronidazole protocol for 10 days was associated with lowest post-operative infection rate. Oral-oropharyngeal resection and use of pectoralis major myocutaneous flap were the most important factors contributing to infection.

A prospective randomized study was conducted to compare the efficacy of long-term endoscopic sclerotherapy vs. propranolol in Child class B and C patients with variceal bleeds within the 30 days before the study. Forty-five and 46 patients were randomized to receive sclerotherapy and propranolol, respectively, after preentry stratification for Child scores. Sclerotherapy was administered with 1% polidocanol at 10-day intervals until obliteration of varices was achieved. Propranolol was administered to achieve a reduction in resting pulse rate of 25%. Rebleeding occurred in 19 patients undergoing sclerotherapy and in 31 receiving propranolol (p less than 0.05). The number of episodes of rebleeding was higher (p less than 0.05) in the propranolol group (n = 64) than in the sclerotherapy group (n = 35). The mean bleeding risk factor, number of hospitalizations for rebleeding and blood transfusion requirement were also significantly higher in the propranolol-treated patients. The median bleed-free period was more than 36 mo in the sclerotherapy group and 2.5 mo in the propranolol group (p less than 0.01). The median survival time was significantly longer in the sclerotherapy group (greater than 36 mo) than in the propranolol group (greater than 24 mo). We conclude that in decompensated cirrhotic patients, long-term endoscopic sclerotherapy is superior to propranolol in preventing rebleeding and improving survival.

To establish the normal limits for various pulsed Doppler echocardiographic indices of left ventricular diastolic function, 92 healthy volunteers aged from 5 to 75 years were prospectively studied. The influence of various variables including age, gender, body surface area, fractional shortening, and left ventricular mass on these parameters was also assessed. Mean (2SD) values for 15 direct and 11 derived parameters were analyzed from transmittal inflow velocity waveform. No statistically significant differences were observed between males and females for any of these parameters. On stepwise multivariate linear regression analysis, age was found to be an independent strong determinant (p < 0.001) of peak velocity of early diastolic filling wave, area of atrial filling period, deceleration slope, normalized peak filling rate, and early filling fraction. There was a significant correlation between heart rate and time to peak early diastolic velocity, total diastolic time period, early diastolic period, atrial filling period, and atrial filling fraction. It was further observed that a significant correlation (p < 0.001) persisted between both age and heart rate with area of early filling period, one-third filling area, one-half filling area, ratio of early to atrial peak velocity and area, atrial filling fraction, and one-third filling fraction. None of the parameters were found to correlate with fractional shortening or left ventricular mass. Thus an effort was made to establish normal limits for various Doppler-derived parameters in healthy volunteers for future comparison in diseased states. Age and heart rate were found to have a significant influence on pattern of diastolic filling and should be taken into account while studying transmittal flow pattern in diseased states.