Early diagnosis of sickle cell retinopathy by using ocular coherence tomography in pediatric population (7-18 years) in central India.

BACKGROUND: Sickle cell disease (SCD) is the commonest inherited blood disorder leading to complications occurring due to vaso-occlusion including sight-threatening retinopathy. Retinopathy can be managed if diagnosed early and vision loss can be prevented. Since, very less data are available from India, hence, this study was conducted in children (7-18 years) with SCD to diagnose retinopathy by using ocular coherence tomography (OCT) in subclinical stages. METHODS: This cross sectional single-center study was performed in 7-18 years age group children with SCD without any visual symptoms. Enrolled participants underwent complete ophthalmological examination including macula and optic disc thickness measurements using Cirrus HD-OCT and results were analyzed. RESULTS: Among 55 participants, none had visual impairment. Significant fundoscopy finding (nonproliferative sickle cell retinopathy/NPSR) was found in three patients (5.4%), thinning of central macula in four patients (7.27%), inner macula thinning in eight patients (14.5%), outer macula thinning in one patient (1.81%), retinal nerve fiber layer thinning in five patients (9%), ganglion cell layer to inner plexiform layer thinning in eight patients (14.54%). Overall NPSR was found in 5.4% patients detected with fundoscopy, whereas retinal layer thinning was found in 14 patients (25.4%) using OCT. CONCLUSION: Despite of the significant prevalence of SCR, it is still underdiagnosed complication, leading to thinning of the retina from early ages; thus, its early diagnosis by regular screening using newer diagnostic methods can prevent progression to sight-threatening complications and provide better quality of life for these patients.

Serotypic and genotypic profile of dengue virus outbreaks in India between 2011 and 2017.

The epidemiology of dengue has been demonstrating significant changes in recent years, with rising incidence of infection in countries with known endemicity and occurrence of fresh outbreaks in previously unaffected territories. India, which has been a traditional hotspot dengue virus (DENV) transmission in the endemic south-east Asian region, has also been affected by the sweeping changes in dengue epidemiology. Two remarkable developments characterize the alterations witnessed by India 2011-2017. Firstly, all parts of the country have witnessed abrupt replacement of existing DENV lineages with emerging novel strains. Secondly, co-circulation of multiple serotypes of DENV have been reported from all across the country 2011-2017; thereby hinting at the transition of the country towards hyper-endemicity. Considering the potential clinical implications of such epidemiological transformation in terms increasing involvement of pediatric patients and growing predisposition to serious complications, the present review provides an update on the serotypic and genotypic profile of dengue outbreaks that have been witnessed by different zones of India between 2011 and 2017. Dividing the country into northern, southern, eastern, western, central and north-eastern zones, we describe discrete zone-specific distribution patterns of DENV serotypes and genotypes and observe simultaneous circulation of different DENV strains in different parts of the country. Random shifts in the genetic characteristics of the circulating strains and the widespread co- circulation of all four serotypes underscore the need for undertaking continuous and representative molecular surveillance of the circulating DENV strains across the country for prompt identification of emerging strains and novel mutants; gain insights into the formulation of Dengue vaccines and develop a clearer understanding of the molecular basis of immune evasion, disease epidemiology and pathogenesis.

Assessment of zinc inadequacy among tribal adolescent population of central India - A cross-sectional study.

Background & objectives: Zinc is a crucial micronutrient in adolescence, required for promoting growth and sexual maturation. Adolescents of some tribes may be at high risk of zinc deficiency due to dietary inadequacy and poor bioavailability of zinc from plant-based diets. This study aimed to evaluate the risk of zinc deficiency by estimating prevalence of inadequate zinc intake, prevalence of low serum zinc and stunting among tribal adolescents. Methods: A cross-sectional community-based survey was conducted among adolescents (10-19 yr) in three purposively selected districts where Bhil, Korku and Gond tribes were in majority. Structured data collection instrument comprising information about sociodemographic characteristics and dietary recall data was used. Anthropometric assessment was conducted by standardized weighing scales and anthropometry tapes, and blood sample was collected from antecubital vein into trace element-free vacutainers. Serum zinc was estimated using an atomic absorption spectrophotometer. Results: A total of 2310 households were approached for participation in the study, of which 2224 households having 5151 adolescents participated. Out of these enlisted adolescents, 4673 responded to dietary recall (90.7% response rate). Anthropometry of 2437 participants was carried out, and serum zinc was analyzed in 844 adolescents. The overall prevalence of dietary zinc inadequacy was 42.6 per cent [95% confidence interval (CI) 41.2 to 44.1] with reference to the estimated average requirement suggested by International Zinc Nutrition Consultative Group (IZiNCG) and 64.8 per cent (95% CI 63.4 to 66.2) with Indian Council of Medical Research-recommended requirements. Stunting was observed in 29 per cent (95% CI 27.2 to 30.8) participants. According to IZiNCG cut-offs, low serum zinc was detected in 57.5 per cent (95% CI 54.1 to 60.8) of adolescents, whereas it was 34.4 per cent (95% CI: 31.2-37.5) according to the national level cut-off. Interpretation & conclusions: Risk of dietary zinc inadequacy and low serum zinc concentration amongst adolescents of the Gond, Bhil and Korku tribes is a public health concern.

Metabolic syndrome in non-obese patients with OSA: learning points of a cross-sectional study from a tertiary care hospital in Central India.

STUDY OBJECTIVES: Obesity is often considered mandatory for the diagnosis of Metabolic Syndrome (MS). Data on the prevalence of MS in non-obese patients with Obstructive Sleep Apnea (OSA) is scarce. This study was aimed to determine the prevalence of MS in non-obese patients with OSA. METHODOLOGY: All consecutively diagnosed patients with OSA between October 2018 and November 2019 were screened for metabolic syndrome. Patients with OSA and BMI < 25 kg/m2 (NOOSA) vs BMI > 25 kg/m2 (obese OSA) were compared. Lean waist NOOSA was defined as BMI < 25 kg/m2 and WC < 80 cm (32 in.) for women or < 90 cm (36 in.) for men. RESULTS: During the study period, 502 patients were diagnosed with OSA. MS was observed in 35% of patients with NOOSA compared to obese patients with OSA (79%). In the NOOSA group, hypertension, impaired fasting glucose, diabetes mellitus and dyslipidemia were observed in 65, 48, 14 and 61% respectively and all of these parameters were significantly more common in the obese group (p < 0.001). Parameters of OSA severity (apnea-hypopnea index or AHI, time spent below 90% saturated or T90, and nadir oxygen) were significantly more severe in the obese group with OSA. Approximately 83% of patients in the NOOSA group had at least two metabolic risk factors, compared to the obese OSA group, in which 95% had two or more metabolic risk factors. Sixty-four percent of patients with NOOSA with lean waist had at least two metabolic risk factors. At BMI cut-offs of < 25, < 27 and < 30 kg/m2; 35, 46 and 57% of patients with OSA respectively had metabolic syndrome. CONCLUSION: Metabolic syndrome was observed in approximately one in three patients with OSA and BMI < 25 kg/m2. Approximately two of every three lean waist non-obese patients with OSA had at least two markers of metabolic syndrome. The role of OSA in the development of metabolic syndrome in non-obese individuals needs further exploration.

On Admission, Microcirculation Abnormality is an Independent Predictor of Sepsis and Sepsis-related Mortality: A Hospital-based Study.

Background: Microcirculatory derangement is the primary cause of organ dysfunction in patients with sepsis. Assessment of the microcirculation is usually done by means of indirect parameters (SvO2 transcutaneous PO2 serum lactate.) The aim of our study is to understand microcirculatory abnormalities in patients with sepsis by directly visualizing the tiny vessels using hand-held video microscopes (HVMs) and determining the role of this modality in the prediction of sepsis-related mortality. Methods: A longitudinal prospective hospital-based study was carried out in medical ward and ICU of a tertiary care hospital. Patients admitted with the presumed infectious disease were included. Evaluation of sublingual microcirculation was done in these patients from Day 1 to Day 5 Clinical and laboratory variables and microcirculation variables were compared between patients with or without sepsis and between survivors and non-survivors of sepsis. Chi-square test for categorical and Student's t-test or Wilcoxon rank-sum test for continuous variables were applied. Univariate and multivariate regression analyses were performed using the Cox-proportional hazard model. Results and discussion: On admission, microcirculation assessment measure, PPV (small), was significantly reduced in those with sepsis, as compared to those without sepsis. Multivariable models indicate the inverse relationship of PPV small with mortality. How to cite this article: Panda A, Revadi G, Sharma JP, Pakhare A, Singhai A, Joshi R, et al. On Admission, Microcirculation Abnormality is an Independent Predictor of Sepsis and Sepsis-related Mortality: A Hospital-based Study. Indian J Crit Care Med 2022;26(3):294-301.

Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India.

Background: The outcomes in critical illness depend on disease severity, practice protocols, workload, and access to care. This study investigates the factors affecting outcomes in mechanically ventilated coronavirus disease-2019 acute respiratory distress syndrome (COVID-19 ARDS) patients admitted in a tertiary teaching hospital intensive care unit (ICU) in Central India with reference to different time periods in pandemic. This is one of the largest series of mechanically ventilated COVID-19 ARDS patients, globally. Methods: This retrospective cohort study classified the entire data into four time periods (Period 1: April 2020 to June 2020; Period 2: July 2020 to September 2020; Period 3: October 2020 to December 2020; and Period 4: January 2021 to April 2021). We performed a multivariable-adjusted analysis to evaluate predictors of mortality, adjusted for baseline-severity, sequential organ failure assessment (SOFA score) and time period. We applied mixed-effect binomial logistic regression to model fixed-effect variables with incremental complexity. Results: Among the 56 survivors (19.4%) out of 288 mechanically ventilated patients, there was an up-gradient of survival proportion (0, 18.2, 17.4, and 28.6%) in four time periods. Symptom-intubation interval (OR 1.16; 95% CI 1.03-1.31) and driving pressures (DPs) (OR 1.17; 95% CI 1.07-1.28) were significant predictors of mortality in the model having minimal AIC and BIC values. Patients aged above 60 years also had a larger effect, but statistically insignificant effect favoring mortality (OR 1.99; 95% CI 0.92-4.27). The most complex but less parsimonious model (with higher AIC/BIC) indicated the protective odds of high steroid on mortality (OR 0.59; 95% CI 0.59-0.82). Conclusion: The outcomes in mechanically ventilated COVID-19 ARDS patients are heterogeneous across time windows and may be affected by the complex interaction of baseline risk and critical care parameters. How to cite this article: Saigal S, Joshi A, Panda R, Goyal A, Kodamanchili S, Anand A, et al. Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India. Indian J Crit Care Med 2022;26(9):1022-1030.

Combination of positional therapy with positive airway pressure for titration in patients with difficult to treat obstructive sleep apnea.

INTRODUCTION: Positional therapy has been described as add-on therapy to a mandibular advancement device, but the efficacy of combination of positional therapy and positive airway pressure (PPAP) has not been documented. We have found PPAP therapy as an effective method of titration in patients with difficult to treat OSA (obstructive sleep apnea). METHODOLOGY: This retrospective analysis was done in patients who had difficult to treat OSA, i.e., in whom titration in the supine position was unacceptable with any PAP device (CPAP or bilevel PAP) and could only be successfully titrated with a PAP device in the lateral position. This study describes our experience of PPAP therapy. Baseline characteristics and polysomnography data of patients who were successfully titrated in supine v/s lateral positions were compared. RESULTS: Of 272 consecutive patients with OSA selected for analysis, 218 patients (191 and 27 with CPAP and bilevel PAP, respectively) could be successfully titrated in supine position. Further 54 (20%) patients in whom titration in supine position was unacceptable were titrated in lateral position. Patients titrated with PAP in the lateral position therapy group had higher BMI, higher neck and waist circumference, and lower awake sPO2 and nadir sPO2 during sleep, and spent more time in sleep with sPO2 < 90%. CONCLUSION: Combination of positional therapy and PAP device is an effective way of titration for difficult to treat OSA patients. It can be tried in patients who fail titration in supine position.

Medication adherence, recall periods and factors affecting it: A community-based assessment on patients with chronic diseases in urban slums.

OBJECTIVE: To evaluate medication adherence, the effect of recall periods on self-reported adherence and factors influencing medication adherence among patients of chronic diseases, such as hypertension and diabetes, particularly in the community. METHODS: A cross-sectional cohort study was conducted among individuals with hypertension and/or diabetes coming as outpatients in community camps organised in a cluster of urban slums. Responses towards questions regarding self-reported quantitative and qualitative adherence for one week and one month along with information on pill burden, socio-demographic and other factors were recorded using a mobile application. RESULTS: Among 379 participants living in urban slum communities, who were prescribed anti-hypertensive or oral anti-diabetic medications previously, mean medication adherence over previous one week was 67.99% (standard deviation (SD) ± 38.32) and 6.87 (SD ± 3.62) on a ten-point numeric scale. The medication adherence for one month showed a strong significantly positive correlation with that of 1 week for both percentage-based (r = +0.910, 95% CI = 0.864 to 0.950, P < .0001) and Likert (ρ = +0.836, 95% CI = 0.803 to 0.863, P < .0001) scales. Age (r = 0.219, 95% CI = 0.120 to 0.313, P = .043) and pill burden (r = -0.231, 95% CI = -0.145 to -0.322, P < .0001) were found to significantly affect medication adherence. The odds of random blood sugar reduction were found to be significant (OR 1.98, 95% CI = 1.30 to 3.00, P = .001) with adequate adherence. A linear regression equation was developed to predict medication adherence percentage for a patient which was found to have 61.8% predictive power using multilayer perceptron modelling. CONCLUSION: Overall, medication adherence was sub-optimal. Adherence assessments can be reliably performed using either one week or one month recall periods. With further refinement and validation, the regression equation could prove to be a useful tool for physicians.

Preparedness of primary and secondary health facilities in India to address major noncommunicable diseases: results of a National Noncommunicable Disease Monitoring Survey (NNMS).

BACKGROUND: The monitoring framework for evaluating health system response to noncommunicable diseases (NCDs) include indicators to assess availability of affordable basic technologies and essential medicines to treat them in both public and private primary care facilities. The Government of India launched the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) in 2010 to strengthen health systems. We assessed availability of trained human resources, essential medicines and technologies for diabetes, cardiovascular and chronic respiratory diseases as one of the components of the National Noncommunicable Disease Monitoring Survey (NNMS - 2017-18). METHODS: NNMS was a cross-sectional survey. Health facility survey component covered three public [Primary health centre (PHC), Community health centre (CHC) and District hospital (DH)] and one private primary in each of the 600 primary sampling units (PSUs) selected by stratified multistage random sampling to be nationally representative. Survey teams interviewed medical officers, laboratory technicians, and pharmacists using an adapted World Health Organization (WHO) - Service Availability and Readiness Assessment (SARA) tool on handhelds with Open Data Kit (ODK) technology. List of essential medicines and technology was according to WHO - Package of Essential Medicines and Technologies for NCDs (PEN) and NPCDCS guidelines for primary and secondary facilities, respectively. Availability was defined as reported to be generally available within facility premises. RESULTS: Total of 537 public and 512 private primary facilities, 386 CHCs and 334 DHs across India were covered. NPCDCS was being implemented in 72.8% of CHCs and 86.8% of DHs. All essential technologies and medicines available to manage three NCDs in primary care varied between 1.1% (95% CI; 0.3-3.3) in rural public to 9.0% (95% CI; 6.2-13.0) in urban private facilities. In NPCDCS implementing districts, 0.4% of CHCs and 14.5% of the DHs were fully equipped. DHs were well staffed, CHCs had deficits in physiotherapist and specialist positions, whereas PHCs reported shortage of nurse-midwives and health assistants. Training under NPCDCS was uniformly poor across all facilities. CONCLUSION: Both private and public primary care facilities and public secondary facilities are currently not adequately prepared to comprehensively address the burden of NCDs in India.

Impact of community-based health insurance and economic status on utilization of healthcare services: A household-level cross-sectional survey from rural central India.

Background: . Community-based health insurance (CBHI) is a health-financing mechanism based on voluntary membership, risk pooling, with a non-profit objective and relies on social capital as a driving force. It aims to improve equity in healthcare utilization in the community. We did this study to understand if CBHI schemes reach the poor, improve healthcare utilization and protect them from catastrophic health events. Methods: . Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, located in Wardha district of Maharashtra, India, runs a variety of CBHI schemes in surrounding villages. Many households (HHs) have opted for these schemes. We conducted a cross-sectional survey of all HHs of 35 villages and collected information about sociodemographics, inpatient healthcare utilization (in previous 5 years), outpatient healthcare utilization (in previous 1 year) and insurance status of the HHs. We derived wealth index based on 33 sociodemographic variables and classified HHs in quintiles of wealth index. We compared the distribution of healthcare utilization variables by insurance status and wealth index and used logistic regression to evaluate if health insurance independently improves healthcare utilization, after adjusting for confounders. Results: . Of a total of 7261 HHs surveyed, 2210 (30.4%) were uninsured, 4153 (57.2%) were insured under MGIMS CBHI schemes, and 898 (12.4%) had family insurance either from MGIMS or other providers. Insured HHs had a higher wealth index compared to uninsured. Mean (SD) hospitalization episodes in an HH were 0.82 (1.75) among uninsured, 1.13 (1.56) in CBHI insured and 1.21 (1.55) in those with family insurance. Within each category, healthcare utilization was lower for poor HHs (lowest quintile of wealth index) and higher for affluent HHs (higher quintiles of wealth index). Among those who were hospitalized, catastrophic health events were less in CBHI insured (7.9%) compared to uninsured (12.3%). After adjusting for socioeconomic status and other confounders, our data suggest that participating in a CBHI scheme increased odds of utilization of inpatient services (OR 1.18; 95% CI 1.04-1.33) and protected from catastrophic health events (OR 0.52; 95% CI 0.43-0.64). Conclusion: . CBHI schemes improve healthcare utilization and protect against catastrophic health expenditure among those who get hospitalized. However, there also exists a socioeconomic gradient both in membership and in utilization of healthcare services favouring those who are more affluent.

Improving the capacity of nurses for non-communicable disease service delivery in India: how do they fare in comparison to doctors?

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

Lung Ultrasound and Blood Gas-Based Classification of Critically Ill Patients with Dyspnea: A Pathophysiologic Approach.

INTRODUCTION: The objective of this study was to classify dyspneic patients and to evaluate outcome variables on the basis of lung ultrasound (LUS) and arterial blood gas (ABG) findings. METHODS: We performed a retrospective chart-based review in which we included patients with dyspnea admitted to our intensive care unit (ICU) between March 2015 and August 2016. On the basis of LUS (presence of A-lines/B-lines) and ABG (hypoxia/hypercarbia), patients were classified into six groups: (i) metabolic defect (dry lung, no hypoxia); (ii) perfusion defect (dry lung, hypoxia); (iii) ventilation defect (dry lung, hypoxia, and hypercarbia); (iv) ventilation and alveolar defect (wet lung, hypoxia, and hypercarbia); (v) alveolar defect-consolidation ([wet lung] hypoxia, no echocardiographic [ECG] abnormality); (vi) alveolar defect-pulmonary edema (wet lung [usually bilateral], hypoxia, ECG abnormality). The patient's demographic data, sequential organ failure assessment (SOFA) score, need for intubation, vasopressors, form of mechanical ventilation, ICU outcome, and length of stay were noted. RESULTS: A total of 244 out of 435 patients were eligible for inclusion in the study. The median age was 56 years. 132 patients (54.1%) required mechanical ventilation, and median SOFA score was 7. Noninvasive ventilation was required in 87.5% of patients with ventilation defect as compared to 9.2% with alveolar defect-consolidation (P < 0.0001). We had 21.7% mortality in patients with alveolar defect-consolidation, 10.8% mortality in patients with metabolic defect, and 8.7% mortality in patients with alveolar defect-pulmonary edema (P < 0.0001). CONCLUSION: This classification gives an organized approach in managing patients with dyspnea. It predicts that patients with alveolar defect-consolidation are most sick of all the groups and need immediate intervention.

Mapping the Characteristics of Critical Care Facilities: Assessment, Distribution, and Level of Critical Care Facilities from Central India.

BACKGROUND: In low- and middle-income countries such as India, where health systems are weak, the number of available Critical Care Unit (Intensive Care Unit [ICU]) beds is expected to be low. There is no study from the Indian subcontinent that has reported the characteristics and distribution of existing ICUs. We performed this study to understand the characteristics and distribution of ICUs in Madhya Pradesh (MP) state of Central India. We also aimed to develop a consensus scoring system and internally validate it to define levels of care and to improve health system planning and to strengthen referral networks in the state. METHODS: We obtained a list of potential ICU facilities from various sources and then performed a cross-sectional survey by visiting each facility and determining characteristics for each facility. We collected variables with respect to infrastructure, human resources, equipment, support services, procedures performed, training courses conducted, and in-place policies or standard operating procedure documents. RESULTS: We identified a total of 123 ICUs in MP. Of 123 ICUs, 35 were level 1 facilities, 74 were level 2 facilities, and only 14 were level 3 facilities. Overall, there were 0.17 facilities per 100,000 population (95* confidence interval [CI] 0.14-0.20 per 100,000 populations). There were a total of 1816 ICU beds in the state, with an average of 2.5 beds per 100,000 population (95* CI 2.4-2.6 per 100,000 population). Of the total number of ICU beds, 250 are in level 1, 1141 are in level 2, and 425 are in level 3 facilities. This amounts to 0.34, 1.57, and 0.59 ICU beds per 100,000 population for levels 1, 2, and 3, respectively. CONCLUSION: This study could just be an eye opener for our healthcare authorities at both state and national levels to estimate the proportion of ICU beds per lac population. Similar mapping of intensive care services from other States will generate national data that is hitherto unknown.

A study of spatial and meteorological determinants of dengue outbreak in Bhopal City in 2014.

BACKGROUND & OBJECTIVES: Dengue epidemics have been linked to various climatic and environmental factors. Dengue cases are often found in clusters; identification of these clusters in early phase of epidemic can help in efficient control by implementing suitable public health interventions. In year 2014, Bhopal City in Madhya Pradesh, India witnessed an outbreak of dengue with 729 recorded cases. This study reports spatial and meteorological determinants and, demographic and clinical characteristics of the dengue outbreak in Bhopal City. METHODS: A cross-sectional survey of all confirmed cases reported to District Unit of Integrated Disease Surveillance Programme (IDSP), Bhopal was carried out during June to December 2014. Data pertaining to clinical manifestations, health seeking and expenditure were collected by visiting patient's residence. Geographic locations were recorded through GPS enabled mobile phones. Meteorological data was obtained from Indian Meteorological Department website. Multiple linear regression analysis was used to test influence of meteorological variables on number of cases. Clustering was investigated using average nearest neighbour tool and hot-spot analysis or Getis- Ord Gi* statistic was calculated using ArcMap 10. RESULTS: The incidence of confirmed dengue as per IDSP reporting was 38/100,000 population (95% CI, 35.2- 40.7), with at least one case reported from 73 (86%) of the total 85 wards. Diurnal temperature variation, relative humidity and rainfall were found to be statistically significant predictors of number of dengue cases on multiple linear regressions. Statistically significant hot-spots and cold-spots among wards were identified according to dengue case density. INTERPRETATION & CONCLUSION: Seasonal meteorological changes and sustained vector breeding contributed to the dengue epidemic in the post-monsoon period. Cases were found in geographic clusters, and therefore, findings of this study reiterate the importance of spatial analysis for understanding the pace of outbreak and identification of hot-spots.

Assessment of primary care facilities for cardiovascular disease preparedness in Madhya Pradesh, India.

BACKGROUND: Government of India has launched National Program for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) to address high prevalence of non-communicable diseases (NCDs) in India. Cardiovascular diseases (CVDs) constitute a significant portion of NCD burden. While this program is yet to be launched in all districts of Madhya Pradesh state of India, we performed this study to understand facility-level gaps that need to be addressed to improve CVD services in primary care provided by the public sector. METHODS: This is a cross-sectional questionnaire based study. A standardized questionnaire was self-administered to 85 medical officers from as many primary care facilities from 24 districts of the state. These medical officers were working in two types of primary care facilities - primary health center (PHC) and community health centers (CHC). Facilities were assessed for 36 items in 5 domains (human-resource, equipment, drug supplies, point-of-care tests and laboratory services) with a focus on management of hypertension and diabetes mellitus in primary-care. Each item was to be answered as either present or absent at the facility where medical officer was working. We compared availability of an item across two levels of primary care facilities. All statistical analysis were done using Microsoft Excel. RESULTS: Availability of facilities was least in laboratory services, and human resource domains followed by drugs, and better in equipment and point-of-care supply domains. Across these domains, availability of items in CHCs was (37.1, 49.0, 56.1, 67.9 and 80.9 % respectively) and in PHCs (11.8, 18.2, 44.2, 55.1, and 55.3 % respectively). DISCUSSION: Current facility assessment study shows critical gaps in key items required for management of NCDs at primary care level. Human resource and laboratory services need to be strengthened the most, followed by sustained availability of all required drug classes, equipment and related supplies, and upgrading point-of-care testing. There are larger gaps in PHCs, which are level 1 facilities, as compared to CHCs, which are level 2 facilities in primary-care. CONCLUSIONS: Increasing burden of NCDs like hypertension and diabetes mellitus necessitates public health response through health systems. Therefore health system preparedness in form of trained human resources, functional laboratories and well stocked pharmacies are essential in primary care facilities.

Does seasonal migration for sugarcane harvesting influence routine immunization coverage? A cross-sectional study from rural Maharashtra.

A cross-sectional study was conducted to estimate and to compare immunization coverage and to understand reasons of partial/non-immunization among children of seasonal migrant sugarcane harvesting laborers and nonmigrating children. Caretakers of a total of 420 children between 12 and 23 months age were interviewed in 30 clusters consisting 14 children from each cluster (seven from each group) by expanded program on immunization cluster survey method. Statistical analysis was performed with proportions, their 95% confidence intervals (CI), Chi-square test, and binary logistic regression. Full immunization coverage rate was 89.5% (95% CI: 86.5-92.5) for children in nonmigrating group and 70.5% (95% CI: 66.0-74.9) for migrant group. Reasons cited for unimmunized/partially immunized were, place or time of vaccination not known, unavailability of immunization services at site, inconvenient time of sessions, unaware of need for vaccination etc. Thus full immunization coverage rate was significantly lower among children of seasonal migrant sugarcane harvesting laborers.

Feasibility of Self-Management of Hypertension and Diabetes Using Patient-Generated Health Data Through M-health in Central India.

INTRODUCTION: Digital health innovations are modern solutions for the management and treatment of diseases, particularly non-communicable diseases. This study was conducted to assess the feasibility of the management of diabetes and hypertension through patient-generated health data (PGHD). METHODS: A mobile application (One Health) was used for the entry of data on blood pressure, blood glucose, physical activity, and dietary intake for six months by the patients. Frequency of application download, monthly data entry, and change in control of blood pressure and glycemic markers during six months of application use were used to assess the feasibility and impact of the application for the management of hypertension and type 2 diabetes mellitus (T2DM). RESULTS: A higher proportion of patients entered data generated non-invasively (blood pressure) as compared to data generated via invasive techniques (glycemic control measures). The frequency of monthly data entry remained unchanged during One Health use. At the end of six months, control of hypertension and glycemic control was achieved in 53.3% and 33.9% of patients, respectively. Furthermore, there was a significant reduction of mean diastolic blood pressure (0.60 (±2.31); p=0.03) and glycosylated hemoglobin (0.657 (±1.808); p=0.04). DISCUSSION: The acceptability of One Health appears to be associated with the frequency of data entry. The entry of health data by patients was sufficient to effect positive change in health indicators. Although mobile applications enable the monitoring and management of chronic health conditions, additional research shall help in optimizing interventions to be adopted as acceptable tools of patient management.

Effect of pulmonary rehabilitation in patients with post-tuberculosis sequelae with functional limitation.

BACKGROUND: Pulmonary rehabilitation improves dyspnea, functional limitation and quality of life in patients with chronic respiratory disease especially Chronic obstructive pulmonary disease (COPD). Whether Pulmonary rehabilitation (PR) will have similar effect in patients with post-tuberculosis sequelae or not and whether the two morphological variants will respond similarly or not was the purpose of our study. METHODS: Adult patients fulfilling the inclusion criteria of a diagnosis of post-tuberculosis sequelae with functional limitation (modified medical research council [mMRC] grade 1 or more) were recruited over a period of two years. A baseline health assessment in the different domains of health was done at the beginning and repeated just after the completion of the rehabilitation program at 6 weeks. RESULTS: 26 patients completed the PR protocol of our study. Dyspnea improved from an mMRC grade of 1.5 to 0.7 post-PR (p < 0.001). 6MWD increased by 34 meters from a baseline value of 408.6 meters to 442.7 meters post-PR. (p-value 0.3) St. George's Respiratory Questionnaire (SGRQ) symptom score decreased by 13 points, SGRQ activity score decreased by 18 points, SGRQ impact score decreased by 18 and SGRQ total score decreased by 17 points with p-values of 0.037, 0.002, 0.004 and 0.002 for SGRQ symptom score, SGRQ activity score, SGRQ impact score, SGRQ total score respectively. Depression Anxiety Stress Scale (DASS) Stress score decreased by 6.7, DASS Anxiety score decreased by 6.6, and DASS Depression score decreased by 5.5 points. Intergroup comparison revealed both bronchiectasis predominant group and fibrosis predominant group responded similarly to PR. CONCLUSION: PR improved parameters assessing dyspnea, quality of life and mental health indices significantly. Improvement in functional capacity was not statically significant. Both the morphological variants responded similarly to the PR.

Study on Assessing Serum Lactate as an Early Prognostic Determinant in Sepsis Outcome.

BACKGROUND: Apart from being one of the main causes of death, sepsis has recently been considered a chronic critical illness. This has resulted in the implementation of standard treatment recommendations for management, with a focus on the initial phases of treatment. Early detection of sepsis and prognostic grading are now crucial for management. Despite the fact that sequential organ failure assessment score (SOFA), acute physiology, and chronic health evaluation II score (APACHE II) have been widely used in sepsis, there have been shortcomings such as feasibility and many lab parameters involved. As a result, this study was conducted to evaluate the role of serum lactate as an early marker and to compare it to current scoring systems for determining the outcome of sepsis. METHODS AND MATERIAL: This was an observational hospital-based study with 60 individuals recruited over a one-year period from July 2021 to June 2022. Serum lactate, as well as the other laboratory tests required for the computation of SOFA and APACHE II, were performed. The baseline data and the trend of lactate vs standard scores were examined in the first 48 hours, as well as their impact on outcomes in sepsis patients (as measured by mortality rates- patients were followed up for 28 days). The diagnostic accuracy of these scores was calculated using the area under the receiver operating characteristic (ROC) curve (AUROC). RESULTS: The study enrolled 60 people out of a total of 162 people who were screened. The mean age was 48.4 years, with the highest mortality occurring between the ages of 41 and 60 years. Of the total 60 participants, 34 (56.6%) were male, with the respiratory tract being the most common source of infection for sepsis (36.67%). In our study, 46 patients survived while 14 patients died. The mean lactate on admission was 3.1 mmol/L in survivors and 4 mmol/L in non-survivors, whereas APACHE II was 9 and 12.36, and SOFA was 3.63 and 7.79, respectively, in survivors and non-survivors. Serum lactate and prognosis scores were compared in the survivor and non-survivor groups, and the difference in diagnostic accuracy was found to be statistically significant. CONCLUSIONS: Serum lactate can be used as an early recognition marker in patients with a probability of sepsis and serial lactate monitoring has a similar diagnostic accuracy in predicting outcomes as the traditional prognostic scoring systems SOFA and APACHE II.

Empathy Among Medical Students: An Exploratory Cross-Sectional Survey.

Context In the context of healthcare, effective communication and empathy are fundamental skills for physicians, as empathy correlates positively with patient satisfaction, compliance, treatment adherence, and lower rates of physician burnout, depression and anxiety. This study aimed to assess empathy levels and related factors among undergraduate medical students. Methods A cross-sectional study in a Central Indian medical institute examined empathy levels and factors associated with it among medical students, utilizing various scales and statistical analyses. Results This study found that while empathy levels were relatively high among undergraduate students, there was a decline as they progressed through medical education, particularly after the first year of clinical exposure. The study identified several factors associated with empathy levels, including perceived stress, emotional separation, and social support. Notably, individuals experiencing higher levels of stress and emotional separation tended to have higher empathy levels. Conclusions The study's findings suggest that medical education should incorporate interventions to enhance empathy, including addressing stress, providing social support, and exposing students to the emotional aspects of patient care.