Transmissibility of severe acute respiratory syndrome coronavirus 2 among household contacts of coronavirus disease 2019-positive patients: A community-based study in India.

BACKGROUND: This study identified the risk factors for severe acute respiratory syndrome coronavirus 2 infection among household contacts of index patients and determined the incubation period (IP), serial interval, and estimates of secondary infection rate in Kerala, India. METHODS: We conducted a cohort study in three districts of Kerala among the inhabitants of households of reverse transcriptase polymerase chain reaction-positive coronavirus disease 2019 patients between January and July 2021. About 147 index patients and 362 household contacts were followed up for 28 days to determine reverse transcriptase polymerase chain reaction positivity and the presence of total antibodies against SARS-CoV-2 on days 1, 7, 14, and 28. RESULTS: The mean IP, serial interval, and generation time were 1.6, 3, and 3.9 days, respectively. The secondary infection rate at 14 days was 43.0%. According to multivariable regression analysis persons who worked outside the home were protected (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.24-0.85), whereas those who had kissed the coronavirus disease 2019-positive patients during illness were more than twice at risk of infection (aOR, 2.23; 95% CI, 1.01-5.2) than those who had not kissed the patients. Sharing a toilet with the index patient increased the risk by more than twice (aOR, 2.5; 95% CI, 1.42-4.64) than not sharing a toilet. However, the contacts who reported using masks (aOR, 2.5; 95% CI, 1.4-4.4) were at a higher risk of infection in household settings. CONCLUSIONS: Household settings have a high secondary infection rate and the changing transmissibility dynamics such as IP, serial interval should be considered in the prevention and control of SARS-CoV-2.

Alagille Syndrome: A Case Report.

Alagille Syndrome (ALGS) is a rare, autosomal dominant inherited disorder that causes abnormalities of liver, eye, heart, skeleton and distinctive facial appearance. ALGS is caused by mutation in one of two genes: JAG1 and NOTCH2. There are some reports of Hearing Loss in patients with ALGS raising the possibility of involvement of both structural components of middle ear and sensorineural components of the inner ear. The present case study was to emphasize audiological perspectives of Alagille Syndrome in a nine year old female child. Audiologists must be well aware of the typical features and clinical perspectives of ALGS and should be an expert in selecting appropriate tests and in interpreting findings.

STEPS: A Solution for Ensuring Standards of TB Care for Patients Reaching Private Hospitals in India.

BACKGROUND: In India, the private sector diagnoses and treats more patients with TB than the public sector. Gaps in the TB care cascade were observed more among the patients diagnosed in the private sector. CONCEPT: The System for TB Elimination in Private Sector (STEPS) model evolved as a solution to address gaps in the quality of care for patients in the private sector by ensuring standards of TB care. STEPS has 3 components: a consortium of private hospitals, a coalition of all professional medical associations, and a STEPS center in each private hospital. STEPS centers act as a single window for notification, linkage for social welfare measures, contact investigation, chemoprophylaxis, direct benefit transfers, and treatment adherence support. INTERVENTION: STEPS was piloted in 14 districts in the state of Kerala. All 14 districts formed consortiums of private hospital management for policy support and a coalition of professional medical associations for advocacy with doctors. STEPS centers were established in 318 private hospitals. RESULTS: Notification to National TB Elimination Program from the private sector improved by 26% when compared to the previous year. Among the patients notified from the private sector, microbiologically confirmed cases increased by 81%, rifampicin resistance testing at baseline increased by 56%, and the percentage of those informed of their HIV status increased by 95%. The percentage of patients notified from the private sector with their treatment outcome reported improved from 39% (2018) to 99% (2019). CONCLUSION: The STEPS model demonstrated that a low-cost locally customized private sector engagement model is feasible and is beneficial to society. STEPS could be one of the major solutions for supporting patients reaching the private sector.

Clinical and VNG Features in Anterior Canal BPPV-An Analysis of 13 Cases.

Objective: To define diagnostic VNG features in anterior canal BPPV during positional testing (Dix-Hallpike, supine head hanging, and McClure Pagnini tests). Study Design: A retrospective study of patients diagnosed with anterior canal BPPV across four referral centers in New Delhi, Kochi, Bangalore, and Dubai. Subjects and Methods: Clinical records of 13 patients with AC BPPV out of 1,350 cases, during a 3-years period, were reviewed and analyzed by four specialists. Results: Four patients had positional down beating nystagmus with symptoms of vertigo during the bilateral DHP maneuver. Seven cases had positional down beating nystagmus only on one side of DHP. Typical down beating nystagmus was seen in 10 out of 13 cases during the straight head hanging maneuver. Down beating torsional nystagmus was seen in 6 out of 13 cases. Down beating with horizontal nystagmus was seen in three cases (in DHP and MCP mainly) while pure down beating nystagmus during SHH was only seen in four cases. Conclusion: We conclude that anterior canal BPPV is a rare but definite entity. It may not be apparent on positional testing the first time, so repeated testing may be needed. The most consistent diagnostic maneuver is SHH though there were patients in which findings could only be elicited using DHP testing. We recommend a testing protocol that includes DHP testing on both sides and SHH. MCP testing may also evoke DBN with or without the torsional component. Reversal of nystagmus on reversal of testing position is unusual but can occur. The Yacovino maneuver is effective in resolving AC BPPV. We also propose a hypothesis that explains why DHP testing is sensitive to AC BPPV on either side, whereas MCP lateral position on one side is only sensitive to AC BPPV on one side. We have explained a possible role for the McClure Pagnini test in side determination and therapeutic implications.

Economics of cancer care: A community-based cross-sectional study in Kerala, India.

BACKGROUND: The estimated incidence of cancer cases in Kerala for 2014 was 31,400 and the mortality associated with it was 13,816. Although the treatment of cancer has shown remarkable advances, it has come with increasing costs. OBJECTIVE: The objective of this study is to estimate the economic burden of cancer in Vypin Block Panchayat at Ernakulam by analyzing the average total direct and indirect cost of cancer care, socioeconomic status, and cost of cancer care between government and private hospitals. MATERIALS AND METHODS: A cross-sectional study was conducted for 2 months from March to April 2018. The study was conducted by utilizing an annotated cost questionnaire for completion by patients. Total direct and indirect cost was estimated. Appropriate statistical tests were used. RESULTS: Direct cost for cancer care contributed 75% toward the cost of illness and the remaining was found to be indirect cost. Loss of income (44%) contributed to the largest chunk of indirect cost. The average direct cost for cancer care was found to be Rs. 25,606 and the average indirect cost was Rs. 8772. The average total cost of cancer care was calculated to be Rs. 34,378. Significant statistical variation was found between the cost of cancer care in private and government hospitals. The economic burden of cancer in this Vypin Block Panchayat was found to be Rs. 218,256,977/. CONCLUSION: The ratio of average income to average cost in this study is skewed which indicates the lack of affordability for cancer care in this population. A very large gap, therefore, exits between income levels and cost of cancer care clearly indicating a vast gap between affordability and cost of treatment, which clearly necessitates the need for a definite policy and state intervention for a mass cancer care program.

Small Fenestra Stapedotomy Versus Large Fenestra Stapedectomy in Improving Hearing Ability in Patients with Otosclerosis: Our 10 Years Experience.

The aim of this study was to review the experience with surgical treatment of otosclerosis over the last 10 years at Amrita Institute of Medical Sciences and Research Centre and to compare it with reported outcomes. A total of 125 patients who had reported between January 2008 and June 2018 were selected for the study. The inclusion criteria for the study included the age group 15-60 years, conductive hearing loss with intact tympanic membrane and an air-bone-gap (ABG) of more than 30 dB. The exclusion criteria included patients below 15 years of age and above 60 years of age, patients with chronic otitis media and the cases of revision stapes surgery. Audiological evaluation was conducted prior to the surgery and post operative audiological evaluation was also performed after 1 month to understand the difference in hearing. In all cases the same surgical technique was used, only the dimension of the foot plate removed varied. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) (version windows base system, SPSS Inc. Chicago IL USA) software. Mean age in years who underwent surgery is 37.8 ± 11.4 and duration of disease in months median 36 months (range 1-120 months). Of the 125 patients (42% males and 58% females), 73 patients underwent large fenestra stapedotomy, and 52 patients underwent small fenestra stapedotomy. There was significant improvement in the following hearing parameters studied (puretone average of air conduction thresholds-PTA, ABG) in both the groups after surgery. There was no significant difference between the small fenestra and large fenestra groups with respect to improvement in PTA and ABG. On comparison of SDS (pre and post surgery) statistically significant difference was noted only in small fenestra group. However, this difference of SDS was not significant in between group comparison (stapedotomy versus stapedectomy). In summary both techniques are safe and effective treatment for conductive hearing loss in otosclerosis patients. There appears to be no deleterious effects of either procedures on hearing function. Similar results can be obtained in experienced hands using either technique. The absence of serious complications makes it reasonable to perform stapes surgery in both ears in patients with bilateral otosclerosis with conductive hearing loss.

Prevalence of Neglected Tropical Diseases (Leishmaniasis and Lymphatic Filariasis) and Malaria Among a Migrant Labour Settlement in Kerala, India.

Neglected tropical diseases (visceral leismaniasis, lymphatic filariasis) and malaria are endemic in northern states of India. Kerala has become a hub of construction activities employing a large number of migrants from these endemic states. Studies on morbidity pattern among migrants in Kerala are lacking. It is essential to look into the burden of these infections among migrant laborers who can act as reservoirs and are a threat to native population. A cross sectional study was done among migrant laborers in Ernakulam district, Kerala. After getting informed consent, a questionnaire was administered to each participant to collect sociodemographic details and 5 ml of blood was collected for detection of antigens using rapid diagnostic tests (RDT). Of the 309 migrants tested, none of them were positive for leishmaniasis, while 3.8% were positive for malaria and 3.6% for filariasis. With 2.5 million migrant laborers in Kerala, the magnitude of the problem in absolute numbers is enormous. Active surveillance and treatment is needed to prevent the reemergence of these diseases in Kerala.

Detection of occult hepatitis B and window period infection among blood donors by individual donation nucleic acid testing in a tertiary care center in South India.

With the introduction of highly sensitive hepatitis B surface antigen immunoassay, transfusion associated HBV infection have reduced drastically but they still tend to occur due to blood donors with occult hepatitis B infection (OBI) and window period (WP) infection. Sera from, 24338 healthy voluntary blood donors were screened for HBsAg, HIV and HCV antibody using Vitros Enhanced Chemiluminescent Immunoassay. The median age of the donor population was 30 (range 18-54) with male preponderance (98%). All serologically negative samples were screened by nucleic acid testing (NAT) for viral DNA and RNA. NAT-positive samples were subjected to discriminatory NAT for HBV, HCV, and HIV and all samples positive for HBV DNA were tested for anti-HBc, anti-HBs, HBeAg. Viral load was determined using artus HBV RG PCR Kit. Of the 24,338 donors screened, 99.81% (24292/24338) were HBsAg negative of which NAT was positive for HBV DNA in 0.0205% (5/24292) donors. Four NAT positive donors had viral load of <200 IU/ml making them true cases of OBI. One NAT positive donor was negative for all antibodies making it a case of WP infection. Among OBI donors, 75% (3/4) were immune and all were negative for HBeAg. Precise HBV viral load could not be determined in all (5/5) NAT positive donors due to viral loads below the detection limit of the artus HBV RG PCR Kit. The overall incidence of OBI and WP infections was found to be low at 1 in 6503 and 1 in 24214 donations, respectively. More studies are needed to determine the actual burden of WP infections in Indian blood donors.

Oropharyngeal Dysphagia: neurogenic etiology and manifestation.

To determine the type, severity and manifestation of dysphagia in patients with neurogenic etiology. Clinical documentation was done on the different etiologies, its manifestation, assessment findings and management strategies taken for patients with neurogenic oropharyngeal dysphagia who were referred for assessment and management of dysphagia over a period of three months in a tertiary care teaching hospital. Flexible endoscopic examination was done in all the patients. The severity of dysphagia in these patients were graded based on Gugging Swallowing Screen (GUSS). A total of 53 patients with neurogenic oropharyngeal dysphagia were evaluated by an otolaryngologist and a speech language pathologist over a period of three months. The grading of severity based on GUSS for these patients were done. There were 30 patients with recurrent laryngeal nerve injury due to various etiologies, one patient with Neurofibroma-vestibular schwanoma who underwent surgical excision, 16 patients with stroke, two patients with traumatic brain injury, two patients with Parkinsonism and two patients with myasthenia gravis. The manifestation of dysphagia was mainly in the form of prolonged masticatory time, oral transit time, and increased number of swallows required for each bolus, cricopharyngeal spasms and aspiration. Among the dysphagia patients with neurogenic etiology, dysphagia is manifested with a gradual onset and is found to have a progressive course in degenerative disorders. Morbidity and mortality may be reduced with early identification and management of neurogenic dysphagia.

Improving outcomes and reducing costs by modular training in infection control in a resource-limited setting.

OBJECTIVE: To study the impact of modular training and implementation of infection control practices on all health-care-associated 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. SETTING: 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.

Muscle cell membrane damage by very low serum sodium.

A 63-year-old male was admitted with complaints of upper gastrointestinal symptoms with fatigue and myalgia. Investigations revealed severe hyponatremia with elevated creatine phosphokinase levels. Following further workup, it was diagnosed as a case of hyponatremia induced rhabdomyolysis. Because of prompt correction of hyponatremia, his renal function was preserved and myoglobinuria induced renal failure was avoided. The importance of early recognition of this potentially dangerous condition is emphasized.

Seroprevalence of hepatitis A virus in patients with chronic liver disease from Kerala: impact on vaccination policy.

Hepatitis A virus (HAV) vaccination is recommended worldwide for patients with chronic liver disease to prevent decompensation due to superinfection with HAV. There are recent reports of decline in HAV seroprevalence in developing countries, where hepatitis A was considered hyperendemic. This phenomenon would have implication on policy of hepatitis A vaccination in chronic liver disease in our region. The aim of the study was to evaluate the seroprevalence of HAV antibodies in patients with chronic liver disease and to assess the relevance of hepatitis A vaccination in these patients. Three hundred patients (268 males and 32 females) with chronic liver disease, seen at the department of gastroenterology at Amrita institute of Medical Sciences and Research Centre, Cochin, were tested for the presence of IgG anti-HAV antibodies in their sera using a commercially available ELISA kit. The mean age of the patients was 53.7 years. Of these 280 patients (93.33%) tested positive for IgG anti-HAV. Routine vaccination without testing for HAV antibodies is not recommended in chronic liver disease, as there is a high prevalence of pre-existing antibodies in these patients in our region.

Colorectal cancer distribution in 220 Indian patients undergoing colonoscopy.

AIM: Colorectal cancer is one of the major cancers in the developed world. The incidence of colorectal cancer is low in India. The aim of the present study was to describe the anatomical distribution and age at diagnosis of colorectal cancer in India. METHODS: Retrospective descriptive analysis of anatomical distribution, age at diagnosis and demography of 220 cases (149 [67.7%] men) of adenocarcinoma of the colon or rectum diagnosed at colonoscopy over a period of five years. RESULTS: The mean age at diagnosis was 58.4 years (SD 13.3; range 23-85 years). Twenty-eight (12.7%) cases were below the age of 40 years. The majority (31.8%) cases were aged between 61-70 years. Most of the tumors (n=163, 74%) were located distal to the splenic flexure. Multivariate logistic regression analysis showed that bleeding per rectum (OR 2.8; 95% CI 1.2-6.2) was associated with distal cancer, and palpable mass (OR 3.9; 95% CI 1.7-8.6) was associated with proximal cancer. CONCLUSIONS: Almost one-third of the colorectal cancers in this series occurred in the seventh decade and were located distal to the splenic flexure.

Chronic pancreatitis. A prospective nationwide study of 1,086 subjects from India.

CONTEXT: Chronic pancreatitis is common in India. However, its risk factors are not clear. There is sparse data on the current prevalence of tropical pancreatitis in India. OBJECTIVE: To undertake a prospective nationwide study of the risk factors and clinical profile of chronic pancreatitis. SETTING: Thirty-two major centers from different regions of India contributed data on 1,086 patients to a common online website (www.ipans.org). MAIN OUTCOME MEASURES: Risk factors, clinical features complications and treatment of chronic pancreatitis. RESULTS: Of the 1,086 subjects, complete data on risk factors were available for 1,033 subjects. Idiopathic pancreatitis was the most common form of pancreatitis (n=622; 60.2%) and alcoholic chronic pancreatitis accounted for about a third of the cases (n=400; 38.7%); the rest (n=11; 1.1%) had rare risk factors. Smoking and cassava intake were documented in 292 (28.3%) and 189 (18.3%) subjects, respectively. Using well-defined criteria, only 39 (3.8%)cases could be labeled as 'tropical pancreatitis'. Pain occurred in 971 patients (94.0%). Four hundred and eighteen (40.5%) subjects had diabetes mellitus. Of alcohol consumers, alcoholism and female gender were independent risk factors for diabetes in subjects with chronic pancreatitis (OR=1.48, P=0.003; and OR=1.75, P<0.001, respectively). The most common complications were pseudocysts (15.8%) and biliary obstruction (8.2%). Pancreatic cancer occurred in 42 subjects (4.1%). Ultrasound detected calculi in 69.7%, ductal dilatation in 63.4% and atrophy in 27.3%. The majority of patients were on medical therapy (n=849; 82.2%); endotherapy and surgery accounted for the rest. About 50% percent of the patients with diabetes required insulin (198/418). CONCLUSIONS: In this first nationwide prospective survey of chronic pancreatitis in India, idiopathic pancreatitis was the most common form, followed by alcoholic pancreatitis. The classical form of tropical chronic pancreatitis is becoming less common.

Groove pancreatitis: a case report and review of literature.

CONTEXT: Groove pancreatitis is a rare type of segmental pancreatitis characterized by fibrous scars of the anatomic space between the dorsocranial part of the head of the pancreas, the duodenum, and the common bile duct. CASE REPORT: A 40-year-old man, with a past history of chronic alcohol consumption presented with epigastric pain radiating to the back and intermittent vomiting and a weight loss of 9 kg. A CT of the abdomen revealed swelling of the pancreatic head, a hypodense mass and duodenal wall thickening with luminal narrowing. Peripancreatic fluid and dense strands were also seen. Upper gastrointestinal endoscopy revealed an edematous, shiny, reddish raised mucosa having a polypoid appearance with narrowing of the second portion of the duodenum. Histological examination of the duodenal biopsy specimens showed preservation of the crypt-villus ratio, and the submucosa showed Brunner gland hyperplasia. These findings appeared consistent with the diagnosis of groove pancreatitis. Presently, the patient is on conservative medical management with analgesics, proton pump inhibitors and a pancreatic enzyme supplement. CONCLUSIONS: Groove pancreatitis often masquerades as pancreatic head carcinoma. This condition should be kept in mind when making the differential diagnosis between pancreatic masses and duodenal stenosis. In all cases of focal pancreatitis involving the head or uncinate process of the pancreas with involvement of the adjacent duodenum, the possibility of groove pancreatitis should be considered.

Agenesis of the dorsal pancreas with chronic calcific pancreatitis. case report, review of the literature and genetic basis.

CONTEXT: Agenesis of the dorsal pancreas is a rare developmental anomaly. This anomaly may be complicated by recurrent acute and chronic pancreatitis. CASE REPORT: We report the case of a 28-year-old female with agenesis of the dorsal pancreas and chronic calcific pancreatitis. The diagnosis of agenesis of the dorsal pancreas is discussed and the genetic changes leading to it are reviewed. The possibility of the patient having tropical pancreatitis is mentioned. CONCLUSIONS: This is probably the first report of chronic calcific pancreatitis complicating agenesis of the dorsal pancreas.

Tropical pancreatitis - a distinct entity, or merely a type of chronic pancreatitis?

Tropical pancreatitis was described 50 years ago as a disease of the tropical regions, particularly southern India, with young age at onset, malnutrition, rapid progression, severe pancreatic damage with multiple large ductal calculi, and absence of history of alcoholism or biliary tract disease as its hallmarks. Over the years, chronic pancreatitis in southern India has shown a change, with increase in older patients, occurrence of milder disease including milder diabetes, increasing longevity, and increasing association with alcoholism and smoking. This article looks at changes in the disease and in dietetic, environmental and socioeconomic factors over the years, in an attempt to understand the environment-gene interactions in its causation. This analysis shows that tropical pancreatitis may represent one end of the wide spectrum of chronic pancreatitis in the tropics, with alcoholic pancreatitis representing the other extreme.

Factors predicting successful outcome following neostigmine therapy in acute colonic pseudo-obstruction: a prospective study.

AIM: To evaluate predictors of neostigmine response in patients with acute colonic pseudo-obstruction. METHODS: Twenty-seven patients with acute colonic pseudo-obstruction were enrolled in the study. All patients had received initial conservative management such as nil orally, nasogastric suction, rectal tube placement and correction of electrolyte imbalance for the first 24 h. Those who did not resolve with conservative management received 2 mg neostigmine intravenously. The same dose was repeated after 24 h in patients who did not response to the first dose (initial non-responders), or in those patients who relapsed after an initial response (initial responders). All non-responders to neostigmine underwent colonoscopic decompression followed by 2 mg neostigmine infusion for 30 min. A sustained response was defined as the resolution of symptoms and colonic dilatation on a plain radiograph. RESULTS: The study enrolled 27 patients; 18 were male (67%), and the median age was 60 years (range 18-78 years). Eight (30%) patients had spontaneous resolution. Initial response with neostigmine was observed in 16 (84%) patients, of which 10 (63%) had a sustained response. Nine patients (three initial non-responders and six initial responders) had received a second dose of neostigmine. A sustained response was seen only in five initial responders. Four patients who did not respond to neostigmine underwent colonoscopic decompression followed by neostigmine infusion and had a sustained response. Neostigmine responders were more likely to be postoperative patients (11 of 15 (73%) vs one of four (25%), P = 0.07), less likely to have electrolyte imbalance and to be on antimotility agents (three of 15 (20%) vs four of four (100%), P = 0.009 and two of 15 (13%) vs four of four (100%), P = 0.003). CONCLUSIONS: Electrolyte imbalance and usage of anti-motility agents are factors associated with a poor response, while postoperative patients showing good response to neostigmine therapy.