Cost-effectiveness of the prevention of parent-to-child transmission guidelines of HIV in India.

Background: One of the modes of transmission of HIV infection in India is from mother-to-child. In 2014, Prevention of Parent-to-child Transmission (PPTCT) guidelines of HIV in India were implemented which included shifting from Option A to Option B and B+. The aim of the present study was to evaluate health and cost related outcomes after implementation of these new guidelines. Methods: A decision analytical model was used to compare the PPTCT Option A with the new WHO Option of B and B+. Transmissions in serodiscordant couples and infants at 18 months were considered as health outcomes. The estimation of the cost for PPTCT services and HIV treatment was done using Costing Tool for Elimination Initiatives (CTEI) developed by National Center for Global Health and Medicine (NCGM). Results: The reduction in transmission rates in HIV infants was 33%. In serodiscordant couples the reduction in risk of HIV transmission from Option A to Option B and B+ was 72% and 87%, respectively. The incremental cost-effectiveness ratio (ICER) per quality adjusted life years (QALY) gained by averting infant infection, and for both infant and partner was US$ 238 and US$ 181 for Option B and US$ 1265 and US$ 947 for Option B+, respectively. Conclusion: It was found that Options B and B+ are more cost-effective as compared to option A. This effectiveness further increases when prevention of partner infections in Option B and B+ is taken into account.

Implementation research: Road map from research to practice.

The challenge today is to make sure that the evidence available gets implemented for betterment of human wellbeing. The research which is closely associated with implementation, challenges and outcome of evidence in real life scenario is Implementation research (IR). The current prespective explains why there is a focus on IR by all icluding researchers, practitioners and policy makers. The approaches and study designs commonly used in the IR have been described. The IR is multi-disciplinary, multilevel and contextual in nature. The outcomes in IR are proximal. The article further describes the ethical issue and the way forward for IR. We need to do capacity building of practitioners, researchers and policymakers in IR.

Body fat content correlates with maximum aerobic capacity in healthy sedentary Indian males.

Background: Obesity is a multifactorial public health problem with varying effects on physical fitness determined by maximum aerobic capacity or VO2max. The relationship between body fat content and VO2max has shown varying results. The present study was planned as an experimental study to evaluate the relationship between body fat content and maximum aerobic capacity. Methods: 104 healthy Indian males [Age: 21 (4.87)years; Height: 171.4 (6.14)cm; Weight: 64.1 (8.57)kg] were evaluated for body fat content using body mass index (BMI), bioimpedance, skinfold thickness (SFT), body girth (BG) measurements, waist circumference (WC), and waist-hip ratio (WHR). Maximum aerobic capacity or VO2max for all subjects was determined indirectly from maximum heart rate achieved using an incremental treadmill protocol using Astrand and Astrand nomogram. Results: VO2max, when expressed in L/min, showed a statistically significant positive correlation with body fat irrespective of the method of estimation. VO2max, when expressed in ml/kg/min, showed negative correlation with five of the seven clinical parameters of fat estimation. Of these, a statistically significant negative correlation was seen with SFT. Conclusion: VO2max (L/min) shows a significant positive correlation with all methods of body fat estimation. VO2max (ml/kg/min) shows a significant negative correlation with skinfold thickness. Monitoring of body fat content using skinfold thickness could be studied further for its use in the early identification of young, healthy adult Indian males with low aerobic fitness.

Randomized control trial to study the efficacy and safety of platelet-rich plasma as intraoperative holding solution in hair restoration surgery: A pilot study.

Background: Hair restoration surgery is a definitive surgical procedure undertaken for androgenetic alopecia (AGA). Platelet-rich plasma (PRP) therapy has gained importance in recent times as a valuable adjunct to therapy in hair restoration. However, the various beneficial effects of PRP as intraoperative holding solution hair restoration surgery remain to be objectively defined. Methods: Twenty cases of AGA were allocated into two groups (PRP and non-PRP). The follicular grafts harvested were stored in platelet-rich plasma/chilled ringers lactate solution depending on subject/control and were implanted in receding hairline using hair implanters. Patients were reviewed at the end of 2 weeks, 4 weeks, 8 weeks, 3 months, and 6 months using clinical and folliculoscopic images. The analysis was performed using SPSS version 20.0. Results: Follicular growth as assessed using the percentage of grafts in actively growing phase posttransplant showed faster recovery from 'shock effluvium' in the PRP group when compared with the non-PRP group from Week 4, through Week 8 and 3 months with the 'lead' increases of percentage growth difference being statistically significant(P = 0.02) between the two groups. At the end of 6 months, 100% of patients recorded a hair shaft length of >10 mm in the PRP group, whereas only 20% achieved >10 mm length. The difference in hair densities between PRP and the non-PRP group from 4 weeks up to 6 months in the non PRP group remained significant (P < 0.05). Conclusion: Intraoperative PRP as a holding solution improves outcome in hair restoration surgery by a significant improvement in the mean density of the implanted follicular unit grafts at 6 months.

Normal measurements of brainstem and related structures for all ages: An MRI-based morphometric study.

Background: Knowledge of the normal size of the brain stem and certain related structures play an important role in diagnosis of aging and neurodegenerative conditions affecting the brain. There is no well-established normative data for development and age-related changes pertaining to the brain stem and related structures in the Indian context. The objective of this study was to assess various linear and angle measurements of the brain stem, cerebral peduncles, middle cerebellar peduncles, and proximal cervical cord for all ages in patients who have undergone MRI brain for unrelated pathologies. Methods: A record-based retrospective cross-sectional and analytical study. T1WI axial and sagittal images were studied for the following variables: Cerebral peduncle transverse thickness, Interpeduncular angle, Middle cerebellar peduncle transverse thickness, Ventral midbrain anteroposterior thickness, Midbrain height, Mamillopontine distance (MPD), Pontomesencephalic angle (PMA), Pons anteroposterior thickness, Medulla anteroposterior thickness and Spinal cord anteroposterior diameter. Results: Significant differences (p = 0.001) were observed in nearly all the variables among various age groups. Males demonstrated significantly higher mean values (at 5% level of significance) for a majority of the variables. Most of the variables measured, e.g. Cerebral peduncle, Middle cerebellar peduncle, Ventral midbrain thickness, Midbrain height, Pons, Medulla, and Spinal Cord diameter, showed a steady and sharp increase in values from infancy and reached maximum values during the third decade, followed by a variable degree of decline in values. Conclusion: Magnetic Resonance Imaging (MRI) morphometry of brainstem and related structures is easily doable and is also reproducible. Present study lays down normative data for the brainstem and certain related structures for all ages, which can be referred to in day-to-day practice.

Efficacy of early structured pulmonary rehabilitation program in pulmonary function, exercise capacity, and health-related quality of life for patients with post-tubercular sequelae: A pilot study.

Background: Residual structural changes in the lung along with pulmonary impairment remain in a large number of patients of tuberculosis after microbiological cure. The aim of this study was to determine whether 12 weeks of a structured pulmonary rehabilitation program (PRP) administered along with antitubercular treatment improved the baseline measurement of pulmonary function, exercise capacity, and health-related quality of life (HRQOL). Methods: A pilot study with single blind randomized control design was carried out in a tertiary care chest center. Spirometry, exercise capacity by 6-minute walk distance (6MWD), and HRQOL using St George respiratory questionnaire (SGRQ) score were evaluated in 62 patients, divided into 2 groups: intervention group (IG) (n = 31) and control group (CG) (n = 31) patients at baseline and at end of 12 weeks. IG completed 12 weeks of PRP. Results: Significant difference in forced expiratory volume in 1st second (FEV1) (2.94 L at baseline vs 3.18 L at end of 12 weeks of PRP, diff 0.239 L, p-0.001), forced vital capacity (FVC) (3.43 L vs 3.75L, p -0.00), 6MWD (440.6 m vs 574.6 m, p = 0.00), and SGRQ score of at baseline (24.5 m vs 11.1m, p = 0.00) was seen in the IG. At end of 12 weeks, there was statistically significant difference in FEV1(L) (p = 0.01, 95% CI -0.317 to -0.046), FVC(L) (p = 0.00, 95% CI -0.359 to -0.139),6MWD(m) (p = 0.00; 95% CI -101.6 to -49.57) between CG and IG. There was no statistically significant difference in SGRQ scores between the 2 groups (p = 0.231). Conclusion: PRP administered along with treatment is beneficial in reducing residual pulmonary impairment.

Post vaccination antibody titres of hepatitis B surface antigen (anti-HBs) in a mixed cohort of health care workers.

Background: Hepatitis B (HepB) is an important vaccine preventable infection among healthcare workers (HCWs). Vaccination against Hep B virus, remains the foremost preventive approach. This study aims to measure the antibody titres to Hep B surface antigen (anti-HBs) in a mixed cohort of HCWs. It also aims to study the association between time since vaccination and the anti-HBs titres thus evaluating the duration of seroprotection. Methods: A total of 200 HCWs, including nursing students (n = 112), nursing staff (n = 49), laboratory technicians (n = 30) and doctors (n = 9) who had received all three doses of the Hep B vaccine and met the inclusion criteria of having taken all three doses of vaccine were included in this study. Anti-HBs titres were estimated by bioMérieux mini VIDAS® automated immunoassay based on the principle of enzyme-linked fluorescence assay. Results: Two hundred subjects aged 19 to 52 years were included in the study; mean age was 27.29 ± 0.568 years. Duration since vaccination in the study cohort was ≤ 5 years in 149 (74.5.0%), 6-10 years in 20 (10.0%) and >10 years in 31 (15.5%) subjects. Postvaccination antibody titres were > 100 mIU/ml in 85.0%, 10-100 mIU/ml in 11.0% and ≤ 10 mIU/ml in 3.5%. There was a decline noted in antibody titres as duration after vaccination increased. Increasing age was associated with falling protective titres. Conclusion: The study revealed that majority of the HCWs had adequate anti-HBs titres and were protected after vaccination.

Compare the efficacy of recommended peripheral intravascular cannula insertion practices with a standard protocol: A randomized control trial.

Background: Millions of patients admitted globally in health care setups require insertion of peripheral intravascular catheter for intravenous drugs or fluid administration. However, if proper precautions are not followed during insertion, it results in significant morbidity. This study was designed to study the efficacy and safety of recommended Centre for Disease Control and Prevention (CDC) guidelines for peripheral intravascular catheter insertion practice and its comparison with a standard insertion protocol being followed and their outcome. Methods: Patients were randomized and catheter was inserted as recommended by CDC guideline (Group 1, n = 100) or followed standard defined steps during insertion (Group 2, n = 100). Results: Almost double the patients had occurrence of thrombophlebitis in Group 1 (p = 0.02). No difference observed between catheter needle size and infection rates (p = 0.3). Infection rate increased significantly if second attempt is taken for insertion. The time required to insert catheter following CDC recommended protocol is less than as by standard surgical complete asepsis cleaning protocol (86.03 vs 109.40 s) (p = 0.001). Study also observed that insertion at wrist joint leads to higher incidence of thrombophlebitis. During 0-24 h, 6% (12) insertions turned positive followed by a dip during 25-48 h, 2% (5) insertions. 80% (159) insertions did not develop thrombophlebitis at the end of 72 h. Conclusion: It is thus amply demonstrated that meticulous adherence to insertion procedure with asepsis plays an important role in decreasing intravascular catheter associated morbidity. Other parameters like needle gauge, sites of insertion, have little bearing. The time required in following standard aseptic technique is significantly more but keeping in view the benefit to the patient it is highly recommended.

Risk factors for cardiovascular disease in a healthy young population: Family matters.

Background: India faces an epidemic of cardiovascular disease (CVD). This study sought the effect of family history of CVD and/or its risk factors (CVD-risk) on the presence of risk factors for CVD, in a healthy young college population. Methods: Blood pressure (BP), heart rate (HR), anthropometric variables, fasting blood sugar and lipid fractions were measured in two hundred healthy individuals (163 men and 37 women), aged 17-22 years. Data were analysed to elicit effect of CVD-risk on measured parameters. Results: All but one subject, had family history of a CVD-risk. Men with family history of coronary heart disease had higher diastolic BP (79.24 ± 7.7 vs 75.99 ± 7.49 mmHg, p = 0.007) and triglycerides (118.66 ± 57.98 vs 85.82 ± 50.89 mg/dL, p < 0.0001) compared with those without similar family history. Men with family history of hypertension (HTN) had higher diastolic BP (78.75 ± 7.15 vs 75.84 ± 8.37 mmHg, p = 0.019) and low-density lipoprotein (86.24 ± 25.38 vs 78.21 ± 17.93 mg/dL, p = 0.019), as well as lower high-density lipoprotein (50.27 ± 8.4 vs 53.96 ± 10.38 mg/dL, p = 0.019). Women with family history of diabetes mellitus had lower high-density lipoproteins (49.89 ± 8.05 vs 59.53 ± 11.44, p = 0.006). Family history of dyslipidaemia was associated with significantly higher triglycerides (146.14 ± 46.19 vs 98.44 ± 56.19 mg/dL, p = 0.002) in men and in subjects across sex. HDL was contrarily higher, in women with family history of cerebrovascular accident/HTN and men with family history of coronary heart disease/HTN. The proportion of pre-HTN, overweight/obese, impaired fasting glucose and borderline high triglycerides was 88.3%, 36.8%, 11% and 38.7% in men and 64.9%, 37.8%, 18.9% and 48.7% in female subjects. Conclusion: Young adults with a family history of CVD-risk already have an incomplete/atypical CVD risk profile.

Health technology assessment of varicella vaccine in the Armed Forces.

Background: The Indian Armed Forces, on entry, vaccinates all cadets and recruits with varicella vaccine for the prevention of varicella. This health technology assessment (HTA) report puts forth evidence for HTA of varicella vaccination in the Armed Forces in various domains namely clinical, societal, ethical, economic, and legal. Methods: The policy question under each domain has been developed according to best-practice methods for HTA. The costs included were hospitalization cost due to varicella infection; training lost cost; the varicella vaccine cost; cost of the side effects of vaccine; and the outbreak investigation cost. The incremental cost-effectiveness ratio (ICER) for varicella cases averted and man-days saved, and quality-adjusted life years (QALYs) gained due to varicella vaccination strategy were calculated. Results: Evidence suggests a reduction of 81% in hospitalization rates with 19392 man-days saved per 1 lakh population due to varicella vaccination strategy. The ICER for varicella cases averted is estimated to be Rs 56732/- per case averted and Rs 5687/- per man-day saved. QALYs gained due to two-dose varicella vaccination strategy is estimated to be 1152 per 1 lakh population with cost per QALY gained Rs 95735/-. Conclusion: The study showed a large reduction in hospitalizations and consequently man-days lost after the introduction of the vaccination strategy. The QALYs was another aspect of importance brought out by this study. Thus, a two-dose vaccination strategy for varicella-zoster virus (VZV) for the Armed Forces trainees is a cost-effective policy.

Susceptibility of cadets and recruits to chickenpox: A seroprevalence study.

BACKGROUND: Regular outbreaks of chickenpox are reported among cadets and recruits in the army undergoing training, resulting in morbidity and loss in terms of training days. Vaccination policy in the army mandates that all cadets and recruits be vaccinated against chickenpox on joining the training centers. However, 100% vaccination of trainees is not achieved. Hence, seroprevalence data among cadets and recruits were collected with the aim to assess the need for vaccination against chickenpox. METHODS: The data were collected from cadets and recruits undergoing training in military training centers by simple random sampling. Blood samples were collected from all study participants for IgG enzyme-linked immunosorbent assay for varicella zoster. A structured questionnaire was also used to collect information from all participants. RESULTS: A total of 2041 cadets and recruits between the ages of 19-29 years were studied of which 96.1% were males. Of all participants, 49.9% were seropositive showing varicella zoster virus (VZV) IgG antibody in the serum, and 29.1% study participants gave positive history of having had varicella in the past. The sensitivity of definite positive history of varicella when compared with presence of VZV IgG antibodies was found to be 55.50% while specificity was found to be 97.17%. CONCLUSION: A very large majority of cadets and recruits that joined the army are susceptible to chickenpox. Hence, the risk of repeated chickenpox outbreaks in these training centers remains very high. As the sensitivity of history of past infection of chickenpox is relatively low, it cannot be used as a tool to determine the susceptibility of the trainees to the infection.

Estimating the proportion and IgG antibody response to SARS-CoV-2 in individuals joining a central educational institute from different parts of India by Enzyme-linked immunosorbent assay (ELISA) based serology.

BACKGROUND: Antibody response to SARS-CoV may be estimated to give trends and patterns emerging in a population during an evolving epidemic. The novel coronavirus has opened a new chapter in the history of pandemics and understanding the disease epidemiology. METHODS: The study was a cross-sectional descriptive study. Institutional Ethical clearance and informed consent were taken for participation in the study. The study population included all personnel reporting to the institute for training courses, permanent posting or joining back from leave during the study period of 2 months (16 June to 16 August 2020). The sample size was calculated assuming the prevalence of COVID-19 to be 1% with the absolute precision of 0.5% and 5% level of significance, and finite correction for population size of 500, and the calculated sample size was 377. Inclusion criteria were all personnel reporting to the institute from different states and districts. Exclusion criteria-Any personnel reported for a short visit of lesser than 14 days. Demographic details and details of any likely exposure to a confirmed COVID-19 case were noted. A blood sample was collected, and serological tests were done using ErbaLisa COVID-19 IgG kit by Calbiotech, as per the manufacturer's instructions. RESULTS: Overall seropositivity of IgG COVID-19 antibodies was 7.5% (31/413) (95% CI: 5.3-10.4%). Study population (n = 413) comprised of an adult population in the age range of 21 years-53 years, and the mean age was 31.4 years (SD = 6.2 years). CONCLUSION: As the personnel joining the institute have come from various parts of the country the study provides an estimation of antibodies against COVID-19.

MRI Changes in the Temporomandibular Joint after Mandibular Advancement.

PURPOSE: Esthetic dental and skeletal component correction can affect the temporomandibular joint (TMJ). Arthrogenic TMJ dysfunction can be present in the joint at the outset or it can develop during the treatment or later. The aim of the present study was to examine the changes found on magnetic resonance imaging (MRI) studies of the TMJ in patients with skeletal Class II malocclusion who had undergone combined orthodontic and bilateral sagittal split ramus osteotomy (BSSRO) advancement. Our objective was to measure the changes in the disc position, condylar translation, secondary bony changes, and joint effusion on MRI before and after treatment. MATERIALS AND METHODS: An analytical, single-surgeon, single-institution, retrospective radiological (MRI) study was designed. We included patients who had undergone combined orthodontic and BSSRO advancement from 2011 to 2018. All 36 patients were examined using a 1.5-Tesla MRI unit (Siemens Symphony, Erlangen, Germany) with a 6 × 8-cm diameter surface coil, which allowed for simultaneous imaging of both TMJs. RESULTS: Analysis using the Wilcoxon signed rank test revealed statistically significant differences in the pre- and post-treatment groups in the changes in the position of the disc from anterior disc displacement with reduction (ADDWR) to the normal position (P = .008), condylar translation from excessive to normal (P = .046), and an increase in secondary bony changes (P = .005). CONCLUSIONS: Combined orthodontic and orthognathic movement in the treatment of skeletal Class II malocclusion can increase secondary bony changes, improve the disc position in ADDWR cases, and control excessive translation of the TMJ. No improvement was noted in the position of the disc in those with anterior disc displacement without reduction, hypomobility and joint effusion.

Projections for novel coronavirus (COVID-19) and evaluation of epidemic response strategies for India.

BACKGROUND: The World Health Organization on 11 March 2020, declared COVID-19 as a pandemic. India initiated social distancing measures to combat the epidemic of COVID-19. The course of the epidemic of COVID-19 for India was predicted using stochastic probability-based mathematical modeling. METHODS: Data synthesis for the top few countries affected was studied for various factors affecting the epidemic. For projections of infected cases for India, the modified susceptible-exposed-infectious-removed/recovered framework modified for the effect of social distancing (Rho) was used. Simulation was carried out for 10,000 runs using Python. Projections for infected cases and hospitalization requirement were estimated. RESULTS: The epidemic curve will peak in the third week of June in India with 17,525,869 and 2,153,200 infected people with reproduction number of 1.8 and Rho of 0.7 and 0.6, respectively. Compared with the baseline scenario of no social distancing, for transmissibility with R0 = 1.8, the reduction in infections due to social distancing measure is 78% (Rho = 0.7) and 97% (Rho = 0.6). Similarly for R0 = 2.2 and 2.4, the reduction in infected numbers slightly lowers to 62% and 66% with Rho = 0.7 and 92% and 75% with Rho = 0.6, respectively. With R0 = 1.8 and Rho = 0.6, the Intensive Care Unit (ICU) bed requirement is 107,660, whereas if transmissibility is high, the ICU bed requirement would increase to 1,994,682. CONCLUSIONS: The social distancing measures seem to have been working for India in absence of treatment in sight for COVID-19. Although with the government's response strategy of social distancing, the peak of the epidemic is extended giving more months for preparedness to the country; however, the sustainability of these measures is uncertain.

Health technology assessment of fixed-dose combination regimen in treatment of newly diagnosed smear-positive pulmonary tuberculosis: A meta-analysis.

BACKGROUND: Evidence-based policy decision-making is introduction of newer technology that it is 'not inferior' to existing technology. Multiple randomised clinical trials (RCTs) on tuberculosis (TB) treatment have shown mixture of favourable, unfavourable and non-significant changes in outcomes with the use of fixed-dose combination (FDC) regimens. The aim of this study was to assess clinical effectiveness of FDC regimen as compared to the use of separate drugs in anti-TB treatment. METHODS: Systematic literature search was carried out. RCTs with newly diagnosed smear-positive pulmonary TB cases were included. Defined outcomes were smear conversion, relapse, adverse reactions and patient compliance. RESULTS: Initial search revealed 457 articles, out of which 7 were included for meta-analysis. Pooled risk ratio for smear conversion rate at the end of intensive phase was 1.01 (95% confidence interval [CI], 0.99-1.03; p = 0.40). Similarly, smear conversion rate at the end of treatment showed no significant difference (relative risk (RR) = 1.01; 95% CI, 0.99-1.02; p = 0.45). Pooled risk ratio for combined smear conversion rates was 1.01 (95% CI, 0.99-1.02). However, relapse rates showed marginally higher trend with FDC regimens (RR, 1.56; 95% CI, 0.95-2.56; p = 0.49). Pooled analysis for adverse events showed no significant difference (RR = 0.98; 95% CI, 0.86-1.11; p = 0.70). Analysis of patient compliance showed marginal increase among FDC group (RR = 1.02; 95% CI, 0.96-1.09; p = 0.47)). CONCLUSION: Fixed-dose combination (FDC) formulations are not inferior in treatment outcomes. It may also ease programme managers and patients by improving compliance. However, increase in relapse rates needs further evaluation through large multicentric studies before implementing policy change in the national programme.

Seroprevalence of influenza A H1N1 (swine) infection in the human population in a cantonment.

BACKGROUND: Various serosurveys and studies were conducted globally on pandemic influenza. H1N1 virus reported so far provides ample evidence of differing perspectives, regarding its epidemiology especially with regard to prevalence, populations groups, and behaviour related to vaccine acceptance. A multigroup, cross-sectional survey among 658 healthy subjects was carried out, in Pune among students, health-care workers (HCWs), and soldiers to assess the seroprevalence of pandemic influenza H1N1 virus and its associated factors. METHODS: The total sample size, based on forecasted prevalence of 33%, worked out to be 640. We studied 658 subjects including 103 students, 201 HCWs, and 354 serving soldiers. The sample for each group was selected from the respective study population by simple random sampling using a random number table. Haemagglutination inhibition test was carried out at the National Institute of Virology. RESULTS: The overall seroprevalence of pandemic influenza H1N1 (2009) virus was found to be 46.5% (95% confidence interval 42.6-50.4) which was adjusted to 39.4% after excluding those vaccinated. The availability of vaccine for high-risk group such as HCWs did not find much favour with the HCWs who did not accept vaccine for various reasons. Whereas only one student was vaccinated, 21.4% of HCWs and 32.5% of soldiers were vaccinated. CONCLUSION: Based on high seroprevalence of antibodies against H1N1 virus during pandemic, vaccination of general population is not recommended. However, high-risk groups and HCWs need to be protected with flu vaccine. There is a need to encourage HCWs for accepting vaccination.

A systematic review and cost-effectiveness analyses of the new World Health Organization guidelines for the treatment of HIV-positive adults in India.

BACKGROUND: The World Health Organization (WHO) in 2013 has revised its guidelines on antiretroviral therapy (ART) treatment for human immunodeficiency virus (HIV)-positive adults and further updated it in 2016. Based on the WHO recommendations, in May 2017, National AIDS Control Organisation, India recommended initiation of ART treatment for all people living with HIV, regardless of CD4 count, clinical stage, age, or population. This systematic review aims to assess the clinical effectiveness and cost implication of the new guidelines for India. METHODS: A systematic and comprehensive literature search on PubMed, OvidSP, Cochrane Library, and Google Scholar was carried out. Studies reporting either acquired immunodeficiency syndrome (AIDS) or mortality or both as outcome variables were selected. A meta-analysis of the available studies was carried out. The risk ratio was calculated to assess the reduction in AIDS or mortality or both. Cost-effectiveness analysis using health technology principles evaluating the lives saved in terms of incremental cost-effectiveness ratio and cost per quality-adjusted life years gained was carried out. RESULTS: Nine eligible studies were included for the meta-analysis. For India, the pooled relative risk of AIDS or mortality or both being 0.84 (95% confidence interval [CI], 0.76-0.92) and 0.78 (95% CI, 0.68-0.89) for ART initiation at CD4 count of ≤350 vs CD4 count of ≤500 and at CD4 count of ≤500 vs CD4 count > 500 cells/mm3, respectively. The incremental cost for per additional life saved is US$ 2592 and US$ 2357 for ART initiation at ≤500 and > 500 CD4 count, respectively. CONCLUSION: The adoption of the new WHO guidelines is beneficial with substantial reduction in AIDS or mortality or both. This study suggests that adopting new WHO guidelines is cost-effective for India.

Therapeutic Efficacy of Cranioplasty After Decompressive Craniectomy for Traumatic Brain Injury: A Retrospective Study.

PURPOSE: Autologous bone removed at the time of decompressive craniectomy (DC) is always the first choice for cranioplasty. The aim of this study was to evaluate the therapeutic efficacy of cranioplasty after DC by measuring the changes in the Functional Independence Measure (FIM) score, as well as to draw a comparison with the pre-cranioplasty FIM score and to evaluate the differences in the outcomes of cases managed by 2 methods: autologous bone (group I) or titanium mesh (group II). MATERIALS AND METHODS: We included 47 patients (36 male and 11 female patients) who underwent unilateral cranioplasty after DC for traumatic brain injury at our institute from 2008 to 2017 in this analytical single-institution retrospective study. The primary binary predictor variable was cranioplasty reconstructive material (autologous bone or mesh). The primary outcome variable of interest was increased, decreased, or unchanged FIM score. The secondary outcome variables included evaluation of immediate complications. The Mann-Whitney U test was used to evaluate differences between scores. RESULTS: Group I (n = 26) underwent cranioplasty using autologous bone flap, whereas group II (n = 21) underwent cranioplasty using dynamic titanium mesh. Increases in FIM scores on the motor function subscale for group I (P = .01278) and group II (P = .00112) were statistically significant. Increases in FIM scores on the cognition subscale for group I (P = .17384) and group II (P = .9492) were statistically insignificant. Evaluation of the primary outcome variable (ie, increased, decreased, or unchanged FIM scores) and secondary outcome variables (ie, immediate complications) showed a statistically insignificant difference between the 2 groups with respect to improvement (P = .51). CONCLUSIONS: This study showed that cranioplasty, irrespective of the reconstructive material, after DC in patients with traumatic brain injury results in a significant functional improvement apart from form and esthetics.

Revisiting anatomical variants on screening chest radiographs in Indian adolescents: A cross sectional observational pilot study.

BACKGROUND: Knowledge of normal variation and measurements on a chest radiograph is essential to interpret any abnormality. There is paucity of information about normal measurement ranges and variations in young adolescents, particularly from Indian subcontinent. The aim of this study was to analyze certain normal variations on screening chest radiographs of healthy Indian adolescents and the objectives were to measure/assess (1) degree of inspiration, (2) cardiothoracic ratio (CTR), (3) presence of gastric fundic bubble, (4) fundocupolic distance, (5) presence of splenic flexure, (6) difference in height of diaphragmatic domes and (7) effect of inspiration on the CTR. METHODS: Digital chest radiographs obtained during routine medical examinations for all consecutive medical graduate aspirants in the year 2016 at a medical college, were analyzed for the above mentioned parameters using DICOM viewing software. RESULT: A total of 558 chest radiographs were analyzed. The mean age of the subjects was 18.50 (SD = 1.002) (range: 17-22 years). There were 497 (89.1%) male and 61 (10.9%) female. Degree of inspiration was at 5th, 6th, 7th and 8th ribs in 29 (5.1%), 259 (46.4%), 264 (47.3%) and 6 (1%) respectively. Mean maximum transverse cardiac diameter, internal thoracic diameter, CTR were 1153.22 ± 120.01, 2935.24 ± 224.86 and 0.39 ± 0.03 respectively. Females had slightly higher CTR (0.40 ± 0.035) as compared to the males (0.39 ± 0.032) (p = 0.009). Gastric fundic bubble was visualized in 91% subjects. Mean fundo-cupolic distance was 8.75 ± 8.00. Mean value for difference in the level of two domes of diaphragm was 15.28 ± 5.38. CONCLUSION: The study highlights normal range of inspiration, CT ratio, fundocupolic distance and diaphragmatic dome level difference on screening chest radiographs in healthy Indian adolescents.

Association between intimate partner violence & HIV/AIDS: Exploring the pathways in Indian context.

BACKGROUND & OBJECTIVES: Violence against women cutting across diverse socio-economic classes is an under-recognized human rights violation in the world. This analysis was undertaken to examine the prevalence along with predictors of intimate partner violence (IPV) and its association with HIV/AIDS and sexually transmitted infections (STIs) in Indian ever-married women. METHODS: The data obtained from 2005 to 2006 third round of National Family Health Survey-3 (NFHS-3) were used in this study. Analyses were conducted on ever-married women by linking individual women data including violence information and HIV test results. RESULTS: The analyses indicated all forms of violence to be prevalent in India. The prevalence of lifetime IPV reported was 35.3 per cent. Multivariate analysis using logistic regression identified younger age of women, higher number of children, low level of education of women as well as her partner, working status of women, higher spousal age, rural residence, alcohol consumption by husband, childhood witness of violence among parents, nuclear household and lower standard of living to be positively associated with the experience of IPV by the women (P<0.05). HIV-positive status of women, as well as women from high HIV prevalent State, were at increased odds of IPV (P<0.05). INTERPRETATION & CONCLUSIONS: Significantly higher reporting of HIV/STIs by women experiencing IPV hints at new pathways that link violence and HIV. Further, our analysis showed a high prevalence of IPV in India.