Utility of modified Mann assessment of swallowing ability (MMASA) in predicting aspiration risk and safe swallow in stroke patients.

Introduction: Aspiration pneumonia is one of the commonest causes of post-stroke mortality. We may be able to reduce this morbidity and mortality by assessing the risk of aspiration in stroke patients. Assessment of this risk can be done using a physician-administered screening protocol to assess dysphagia. A score of ≥95 is a good cut off to detect patients who can take oral feeds safely. Objectives: The primary objective was to predict aspiration risk using the Modified Mann Assessment Swallowing Ability (mMASA) scale. The secondary objective was to predict the safety of oral feeds using the same scale. Materials and Methods: An analytical cross-sectional study was conducted at a tertiary care rehabilitation centre in South India. A total of 100 stroke patients who underwent stroke rehabilitation in the study institution were divided into patients who were able to eat orally or not based on the mMASA scale. Demographic and stroke characteristics were recorded. The mMASA score was calculated and those with a score of ≥95 were given oral feeds. Those who scored <95 were given swallow therapy and re-evaluated in 2 weeks. Also, the mMASA score below which the patient was likely to develop aspiration pneumonia was detected using the receiver operating characteristic curve (ROC). Results: Out of the 100 patients, 37 patients had a score of ≥95 and were started on oral feeds and had no complications; the rest were started on 2 weeks of swallow therapy. On re-evaluation after swallow therapy, 12 more were started on oral feeds. The remaining 51 patients did not reach the cut-off score of ≥95 and were continued on nasogastric tube feeding. A total of 11 patients developed features of aspiration pneumonia; all of them belonged to the group of 51 patients who consistently had a mMASA score <95. The ROC curve determined that a score of <89 was a good cut off to predict patients who are at high risk of aspiration. Conclusion: The scale can be used to predict the likelihood of aspiration and readiness to start oral feeds in sub-acute stroke patients.

One-year mortality after acute stroke: a prospective cohort study from a comprehensive stroke care centre, Kerala, India.

OBJECTIVES: The primary objective was to report the 1-year all-cause mortality among patients with stroke. The secondary objectives were (1) to report the mortality stratified by type of stroke and sex and (2) to report predictors of 1-year mortality among patients with stroke. DESIGN: A prospective cohort study. SETTING: Institutional-stroke care unit of a tertiary care hospital PARTICIPANTS: Patients who were treated in the study institution during 2016-2020 for acute stroke and were followed up for a period of 1 year after stroke in the same institution. MAIN OUTCOME MEASURES: The main outcome measures were the mortality proportion of any stroke and first ever stroke cohorts at select time points, including in-hospital stay, along with 2 weeks, 2 months, 6 months and 1 year after index stroke. The secondary outcomes were (1) mortality proportions stratified by sex and type of stroke and (2) predictors of 1-year mortality for any stroke and first ever stroke. RESULTS: We recruited a total of 1336 patients. The mean age of participants was 61.6 years (13.5 years). The mortality figures for 2 weeks, 2 months, 6 months and 12 months after discharge were 79 (5.9%), 88 (6.7%), 101 (7.6%) and 114 (8.5%), respectively, in the full cohort. The in-hospital mortality was 45 (3.4%). The adjusted analysis revealed 3 predictors for 1-year mortality after first ever stroke-age, pre-treatment National Institutes of Health Stroke Scale (NIHSS) score and Modified Rankin Scale (mRS) score at baseline. The same for the full cohort had only two predictors-age and pre-treatment NIHSS score. CONCLUSION: Mortality of stroke at 1-year follow-up in the study population is low in comparison to several studies published earlier. The predictors of 1-year mortality after stroke included age, NIHSS score at baseline and mRS score at baseline.

Fluorodeoxyglucose-positron emission tomography (FDG-PET) of carotid arteries and non-alcoholic fatty liver disease (NAFLD): An analytical cross-sectional study from a teaching hospital, Kerala, South India.

Introduction: Evidence related to carotid artery F-fluorodeoxyglucose-positron emission tomography (FDG -PET) and non-alcoholic fatty liver disease (NAFLD) is limited from a low-resource setting. The present study aims to examine the association between FDG-PET uptakes by the carotid arteries in patients having different grades of NAFLD. Materials and Methods: An analytical cross-sectional study was done in a tertiary care center in South India for 1 year. Sonographically confirmed NAFLD patients of the age group 18 years and above were consecutively enrolled for the study after getting informed consent. Anthropometric measurements, ultrasonography for identifying the grades of fatty liver and FDG-PET were performed in the study participants. The data for the study were collected by the research personnel and entered in Microsoft Excel. The data were analyzed in the IBM SPSS version 20.0 software. Results: A total of 24 patients were in the final analysis. The mean age of patients in this study was 56.79 (11.26) years. Among the 24 patients, 95.83% (n = 23) were males. The mean FDG-PET uptake in the carotids was 1.75 (0.42) units. The FDG uptake was higher in the moderate NAFLD group (1.46 [0.40] v/s 2.04 [0.14]) and the difference was statistically significant with P < 0.001. The FDG uptake between the coronary artery disease (CAD) with NAFLD and non CAD with NAFLD groups was not statistically significant (1.60 [0.46] v/s 1.86 [0.36], P = 0.17). The FDG uptake in CAD patients with mild and moderate NAFLD had no statistical significance between the two groups (1.43 [0.45] v/s 2.00 [0.00], P= 0.06). Conclusion: The findings of this study showed increased uptake of FDG-PET in carotids in subjects with moderate fatty liver when compared with those with mild fatty liver.

Outcomes of Coronary Artery Disease Patients with Severe Left Ventricular Dysfunction Undergoing Surgical Management.

BACKGROUND: Surgical revascularization by coronary artery bypass grafting (CABG) is the gold standard treatment for coronary artery disease. But, in patients with severe left ventricular dysfunction (ischemic cardiomyopathy), the result of CABG is different from those with normal left ventricular function. The coronary artery disease pattern in the Indian subconti-nent is different from the western world, due to the diffuse nature of coronary involvement, the smaller size of native vessels, increased prevalence of diabetes mellitus and other risk factors, and more prevalence of severe left ventricular dysfunction. Most of the studies regarding the surgical outcomes in ischemic cardiomyopathy come from western countries. This study attempts to assess the outcomes of surgical management of ischemic cardiomyopathy in the Indian subcontinent. METHODS: A single-center retrospective cohort study was conducted at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. The data of CAD pa-tients, who underwent surgical coronary revascularization for severe LV dysfunction from January 2010 to December 2014, were collected from the hospital records and through tele-phonic interviews in a structured study proforma. A total of 146 patients satisfied the criteria and were followed up for a period of 5 years. RESULTS: The mean age of the study population was 55.6 (8.8) years. Male preponderance was observed (94.52%; N = 138). CABG alone was done in 62.3% (N = 91) of the study partici-pants. CABG with linear plication was done in 23.3% (N = 34), CABG with MV repair in 7.5% (N = 11), and CABG with DORS in 6.8% (N = 10). The majority of patients (N = 54, 37%) received 4 grafts. Thirty-day mortality observed in the study population was 11 (7.5%). The causes documented were cardiac causes in 9 (82%), cerebrovascular events in one (9%), and septicemia in one (9%). The mean of 5-year survival of the study population was 94.2 (3.5) months with 95% CI 87.32, 101.13. There was a substantial improvement in the degree of mitral regurgitation. Ejection fraction (EF) also showed improvement. The mean preoperative EF was 29.51 (4.84%) and that of post-op was 39.92 (9.0%). CONCLUSION: Despite the challenges of diffusely diseased coronary arteries, severe LV dysfunction, addressing associated significant MR and ventricular aneurysms, the outcome of surgical management of CAD with severe LV dysfunction, in the Indian population can be done with acceptable results. Randomized control studies in this subset can provide more solid evidence in this regard.

Compliance of Secondary Prevention Strategies in Coronary Artery Disease Patients with and without Diabetes Mellitus - A Cross-Sectional Analytical Survey from Kerala, India.

CONTEXT: There is limited data related to compliance of secondary prevention strategies for coronary artery diseases (CAD) among patients with and without diabetes. OBJECTIVES: The objective was to compare compliance to secondary prevention strategies for CAD including smoking cessation, weight management, blood pressure (BP) control, Low density lipoprotein (LDL) cholesterol control and adequate physical activity between patients with and without diabetes. SETTINGS AND DESIGN: This is a hospital-based cross-sectional analytical study. METHODS AND MATERIALS: The study questionnaire was used to collect data through interviews of CAD patients. Compliance to secondary prevention strategies was documented using European Society of Cardiology guidelines. STATISTICAL ANALYSIS: We used modified Poisson model to estimate adjusted prevalence ratios (Adj. PR) for estimating compliance. RESULTS: Among 1,206 participants with CAD, 609 (50.5%) had diabetes. The Adj. PR s for three targets - smoking cessation (Adj. PR 1.01, 95% CI 0.97, 1.06, P 0.50), ideal BMI (Adj. PR 0.99, 95% CI 0.92, 1.09, P 0.99) and adequate physical activity (Adj. PR 1.12, 95% CI 0.97, 1.29, P 0.12) showed no significant difference between the groups. There was poor BP control in patients with diabetes compared to those without the same (Adj. PR 0.19, 95% CI 0.15, 0.23, P < 0.0001). LDL cholesterol control was better in patients with diabetes in comparison to those without the same (Adj. PR 1.19, 95% CI 1.08, 1.31, P 0.0005). CONCLUSION: The compliance for secondary prevention of CAD among patients with diabetes is similar to those without diabetes except for poor control of hypertension and better control of LDL cholesterol.

Health-Related Quality of Life of Coronary Artery Disease Patients under Secondary Prevention: A Cross-Sectional Survey from South India.

BACKGROUND: Health-related quality of life (HRQOL) is emerging as an important outcome among patients with documented coronary artery disease (CAD). The primary objective of this study was to report the HRQOL of CAD patients under secondary prevention-related treatment and follow-up using the 36-Item Short Form (SF-36) tool. METHODS: This was an analytical cross-sectional survey done in a hospital/clinic setting. We recruited CAD patients 30 to 80 years old with 1 to 6 years of follow-up. Patients self-reported HRQOL using SF-36. RESULTS: We recruited 1206 patients, among whom 879 (72.9%) were male. The mean age of patients was 61.3 (9.6) years. Mean (± standard deviation) scores for physical functioning, role limitations due to physical health, pain, and general health were 66.48 ± 29.41, 78.96 ± 28.01, 80.96 ± 21.15, and 51.49 ± 20.19, respectively. The scores for role limitations due to emotional problems, energy/fatigue, emotional well-being, and social functioning were 76.62 ± 28.0, 66.18 ± 23.92, 76.91 ± 20.47, and 74.49 ± 23.55. In subgroup analysis, age, sex, type of CAD, and treatment showed no significant association with any of the 8 domains of QOL. In addition, hypertension and diabetes showed no significant association with the individual domains of HRQOL. CONCLUSION: Patients with coronary artery disease under secondary prevention-related treatment have suboptimal HRQOL under both physical and mental domains. The role of demographic factors, comorbidities, disease subtypes, and treatment options in modifying HRQOL among patients with CAD appears to be minimal.

Prevalence of acanthosis nigricans and its association with physical activity in adolescents - School-based analytical cross-sectional study from Kochi, Kerala.

INTRODUCTION: Acanthosis nigricans (AN) is a brown to black, poorly defined velvety hyperpigmentation of the skin. It is a predisposition factor for Type 2 diabetes, malignancies and various endocrinopathies. The available data regarding AN from Kerala is limited. Our study aims to estimate the prevalence of AN and to examine its association with physical activity among the adolescents of age 13-14 years. METHODOLOGY: This analytical cross-sectional study was conducted in two grades of a school in Ernakulam district between June and December 2018 among 400 adolescents of age 13-14 years. The study proforma and the Physical activity questionnaire, Adolescents (PAQ-Adolescents), were self-administered to the students and the data were collected. The principal investigator verified the presence of AN by observation in the neck, elbow and knuckles and recorded in the study proforma. Statistical analysis of the data collected was done using SPSS Software program (version 21). RESULTS: The mean age of the group was found to be 13.31 ± 0.46 years. The prevalence of AN was 14.5% in the study population. AN was most prevalent among obese adolescents (61.54%), adolescents with low exercise rate (23.94%), having family history of diabetes (21.18%), family history of hypertension (21.86%) and family history of both diabetes and hypertension (26.32%). The risk factors such as obesity, diabetes, hypertension, family history of diabetes, family history of hypertension and family history of both diabetes and hypertension had a positive association with AN had a negative association with physical activity with p=0.0001. In adolescents with increased exercise rate, there were no reported cases of AN. CONCLUSION: The results of our study show that there is a strong association between AN and children with obesity, family history of diabetes mellitus, hypertension and low physical activity. Regular adequate physical activity can prevent the onset of AN and thereby reduce the early onset of diabetes, metabolic syndrome, polycystic ovarian syndrome, coronary artery diseases and certain types of malignancies.

Compliance to secondary prevention strategies for coronary artery disease: a hospital-based cross-sectional survey from Ernakulam, South India.

OBJECTIVES: The primary objective of the study was to report the compliance to secondary prevention strategies for coronary artery disease (CAD), such as smoking cessation, weight management, low-density lipoprotein (LDL) cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy from a resource-limited setting. DESIGN: Analytical cross-sectional survey with data collection using questionnaire administered by study personnel. SETTING: Institutional-two tertiary care hospitals and two cardiology clinics. PARTICIPANTS: Patients in the age group of 30-80 years with documented CAD with a minimum of 1 year and a maximum of 6 years of follow-up after diagnosis. MAIN OUTCOME MEASURES: The main outcome measures were the prevalence of individual compliance to secondary prevention strategies for CAD such as smoking cessation, weight management, LDL cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy. The secondary outcomes were the association of secondary prevention strategies with age, sex, domicile, socioeconomic status, insurance and type of treatment. RESULTS: We recruited a total of 1206 patients among whom 879 (72.9%) were males. The median age of patients was 62 (14) years. The compliance to smoking cessation was 93.86% (95% CI 91.66% to 96.06%), ideal body mass index was 63.76% (95% CI 61.05% to 66.47%), blood pressure control was 65.11% (95% CI 62.42% to 67.80%), LDL compliance was 36.50% (95% CI 33.18% to 39.82%), diabetes control was 51.23% (95% CI 46.10% to 56.36%) and adequate physical activity was 39.22% (95% CI 36.46% to 41.98%)respectively. Reported compliance for cardiovascular drugs therapy was 96% for antiplatelets, 89.4% for statins, 68.2% for beta blockers, 37.7% for renin angiotensin aldosterone system blockers, 81.28% for oral hypoglycaemic agents and 22% for insulin therapy. CONCLUSION: Compliance to secondary prevention strategies for CAD in resource limited settings are moderate. This needs further improvement for better outcomes related to CAD in future.

Intermediate Dose Prophylaxis in Adults with Haemophilia: A Clinical Audit from a Resource Limited Setting.

To address the scarcity of real world data on adult prophylaxis from developing world, a short term intermediate dose prophylaxis in adult haemophilia A patients was initiated. A total of eight patients aged > 18 years with moderate/severe haemophilia A were given an average dose of 23 IU/kg recombinant factor VIII (rFVIII) concentrate twice weekly for 2 months. A clinical audit was done on completion of four months. The mean age of the participants was 31.63 (± 6.98) years. The mean bleed rate during two months of episodic versus prophylactic regimen was 5.13 versus 0.63 (p = 0.01) and that of work days lost, hospital visits for hemophilia care were 30.63 (± 24.69) versus zero days, 20.63 (± 16.19) versus zero days respectively. The mean of factor VIII consumed during prophylaxis was 13,500 IU/month (i.e., 23 IU/kg/dose).The median time gap between prophylactic infusion to trough level was 67.50 h (60-74 h) and the median trough level observed was 2.50% (range 1-5%). The results of our clinical audit show that Intermediate dose prophylaxis with rFVIII concentrates in young adult patients with moderate/severe haemophilia A appears to be effective in reducing the frequency of bleeds.

Tricuspid Regurgitation in Ostium Secundum Atrial Septal Defects: Repair or Not?

BACKGROUND: Longstanding ostium secundum atrial septal defects lead to functional tricuspid regurgitation. Significant functional tricuspid regurgitation associated with left heart valve disease is addressed at the time of primary left heart valve surgery. In contrast, there is no global recommendation for tricuspid regurgitation associated with atrial septal defects. This study assesses changes in tricuspid regurgitation after isolated atrial septal defect closure. METHODS: Retrospectively, records were examined of 100 patients who underwent isolated ostium secundum atrial septal defect closure without tricuspid valve repair. Echocardiograms were done preoperatively and 3 days, 3 months, and 1 year after surgery. Data on tricuspid regurgitation status, right ventricle dimensions, and pulmonary artery hypertension status were collected and analyzed. RESULTS: After surgical closure, echocardiography showed a regression of tricuspid regurgitation to mild or less in 76% of patients at 3 days, 89% at 3 months, and 93% at 1 year. Severe pulmonary artery hypertension (32% patients preoperatively) showed statistically significant regression: 14% at 3 days, 10% at 3 months, and 2% at 1 year. Preoperatively, the mean right ventricular internal diameter was 37.9 mm, which decreased to 34 ± 5.5 mm (mean ± standard deviation) at 3 days, 32.3 ± 5.3 mm at 3 months, and 31.3 ± 5.4 mm at 1 year. It was also noted that regression favored patients who were <25 years old. CONCLUSION: Tricuspid valve repair may not be required in patients with ostium secundum atrial septal defect with functional tricuspid regurgitation.

Low Dose Prophylaxis in Hemophilia Care.

Hemophilia is an inherited bleeding disorder which causes impaired blood clotting. The severity of disease depends on the type of Hemophilia, level of clotting factor concentrate (CFC), phenotypic heterogeneity and the development of inhibitors. The currently accepted standard of care of this disease is prophylaxis therapy (PT) with CFC. Prophylaxis therapy for Hemophilia is given in developed countries for the last few decades. On the contrary, episodic therapy (ET) is still the mode of treatment in middle and low income countries. ET is documented to have several potential risks such as increased bleeding rate, disability due to haemarthrosis, poor quality of life and increased chances of mortality. Several studies conducted in developed countries have confirmed the clinical efficacy of PT in Hemophilia treatment. Currently, there exist several challenges for implementation of this effective treatment in resource poor nations. Low dose prophylaxis (LDP) has been developed as a solution to minimize these challenges and to provide better care for subjects with Hemophilia from low resource countries. The impact of LDP was evaluated by several recent studies and the reported clinical outcomes seem to suggest an optimistic future for this line of therapy. Several themes related to Hemophilia care like inhibitor development, tolerance, pharmacokinetics of CFCs and cost-benefit analysis of different prophylaxis regimens are currently understood poorly. These distinct elements are highly relevant to assess the actual benefits of LDP regimen in a global scale.

Health-related quality of life (HRQOL) in children and adolescents with congenital heart disease: a cross-sectional survey from South India.

OBJECTIVE: There are limited data on health-related quality of life (HRQOL) for children and adolescents with uncorrected congenital heart disease (CHD) from low-income and middle-income countries where late presentation is common. We sought to compare HRQOL of children and adolescents with uncorrected CHD to that of controls using the Pediatric Quality of Life Inventory (PedsQL 4.0). METHODS: The study design is a cross-sectional analytical survey. The study setting was (1) Hospital-based survey of patients with CHD and their parents. (2) Community survey of controls and their parents. Subjects included (1) Children/adolescents with CHD between the ages of 2 years and 18 years and their parents enrolled in a previous study (n=308). (2) Unmatched community controls (719 children/adolescents, aged 2-18 years) and their parents. Participants were given PedsQL 4.0 to fill out details. Parents assisted children 5-7 years of age in filling the questionnaires. Children younger than 5 years had only parent-reported HRQOL and those above 5 years had both self-reported and parent-reported HRQOL. RESULTS: The median (IQR) total generic HRQOL from self-reports for CHD subjects and controls were 71.7 (62.0, 84.8) and 91.3 (82.6, 95.7), respectively. The corresponding figures for parent-reports were 78.3 (63.0, 90.5) and 92.4 (87.0, 95.7) respectively. The adjusted median difference was -20.6 (99% CI -24.9 to -16.3, p<0.001) for self-reported and -14.1 (99% CI -16.7 to -11.6, p<0.001) for parent-reported total HRQOL between patients with CHD and controls. Cardiac-specific HRQOL by self-reports was 75.0 (53.6, 92.9) for heart problems, 95.0 (73.8, 100.0) for treatment barriers, 83.3 (66.7, 100.0) for physical appearance, 87.5 (62.5, 100.0) for treatment-related anxiety, 91.7 (68.8, 100.0) for cognitive problems and 83.3 (66.7, 100.0) for communication. The values for parent-reports were 71.4 (53.6, 85.7), 100.0 (75.0, 100.0), 100.0 (75.0, 100.0), 81.3 (50.0, 100.0), 100.0 (81.2, 100.0) and 83.3 (50.0, 100.0), respectively. CONCLUSIONS: Children and adolescents with uncorrected CHD reported significant reductions in overall quality of life compared with controls.