Health-seeking pathway of drug-resistant TB patients in Vadodara, India.

BACKGROUND: Health-seeking behaviour refers to patients' choices regarding their preferred healthcare destination and the timing of seeking assistance for treatment. Patients with TB usually first approach the private sector and/or lose several months' time in inappropriate diagnosis and treatment due to lack of awareness regarding the availability of standard treatment protocols. This can lead to poor outcomes such as drug-resistant TB (DR-TB) and/or death. METHODOLOGY: A cross-sectional study was conducted to examine the health-seeking pathway and delays in diagnosis and initiation of DR-TB treatment among patients registered with the DR-TB centre in Vadodara District (India). RESULTS: A total of 93 patients were enrolled in the study; the median age was 35 years (IQR 24-45). For the first visit, 59 (63%) patients chose a public healthcare facility, mainly because the facility was near their residence (n = 20, 21.5%). The median delay in reaching the first healthcare facility was 12 days (IQR 7.5-30). Delay in reaching second- and third-level care was respectively 25 days (IQR 9-68) and 16 days (IQR 4-67). CONCLUSION: Two-thirds of patients required visits to a second healthcare centre for diagnosis, while one third needed a third visit. The overall median delay for reaching the DR-TB centre was 60 days (IQR 26-122). The median duration from symptom onset to the first healthcare contact fell within the timeframe for screening symptoms in standard diagnosis.

CONTEXTE: Le comportement de recherche de santé fait référence aux choix des patients concernant leur destination préférée en matière de soins de santé et le moment où ils recherchent de l'aide pour le traitement. Les patients atteints de TB s'adressent généralement en premier lieu au secteur privé et/ou perdent plusieurs mois en diagnostics et traitements inappropriés en raison d'un manque d'information sur la disponibilité des protocoles de traitement standard. Cela peut conduire à des résultats médiocres tels que la TB résistante aux médicaments (DR-TB, pour l'anglais « drug-resistant TB ¼) et/ou la mort. MÉTHODOLOGIE: Une étude transversale a été menée pour examiner le parcours de recherche de soins et les retards dans le diagnostic et l'initiation du traitement de la DR-TB parmi les patients enregistrés au centre de DR-TB dans le district de Vadodara (Inde). RÉSULTATS: Au total, 93 patients ont participé à l'étude ; l'âge médian était de 35 ans (IQR 24­45). Pour la première visite, 59 patients (63%) ont choisi un établissement de santé public, principalement parce que l'établissement était proche de leur résidence (n = 20 ; 21,5%). Le délai médian pour atteindre le premier établissement de santé était de 12 jours (IQR 7,5­30). Le délai pour atteindre le deuxième et le troisième niveau de soins était respectivement de 25 jours (IQR 9­68) et de 16 jours (IQR 4­67). CONCLUSION: Deux tiers des patients ont dû se rendre dans un deuxième centre de soins pour obtenir un diagnostic, tandis qu'un tiers a dû se rendre dans un troisième centre. Le délai médian global pour atteindre le centre de lutte contre la TB était de 60 jours (IQR 26­122). La durée médiane entre l'apparition des symptômes et le premier contact avec les soins de santé correspondait au délai de dépistage des symptômes dans le cadre du diagnostic standard.

Hoarseness: its spectrum, associations and management in a tertiary care centre in India.

OBJECTIVE: To determine the demographic, aetiopathological and diagnostic profiles of patients presenting with hoarseness to a laryngology unit of a tertiary care centre in India. METHODS: A retrospective observational study was conducted. RESULTS: The 1033 patients who presented with dysphonia showed a male predominance (70 per cent), high rates of malignancy (18 per cent), late presentation (mean, 24 months) and poor follow-up trends (53 per cent with 3 months' follow up), which contrasts with data from developed countries. The patient population hailed from different states in India and neighbouring countries around India, serving as a good sample for the subcontinent. The majority (67 per cent) were managed conservatively; however, surgical management was the preferred choice for those who presented with airway stenosis (91 per cent) and laryngeal trauma (75 per cent). Significant associations between vocal professionalism level and co-morbidities and dysphonia aetiopathologies are discussed. CONCLUSION: These findings give insight into the trends of hoarseness in the developing Indian subcontinent, which can aid understanding and management.

Maxillary aneurysmal bone cyst: report of a rare case.

Everyone likes to see, hear, and know about rare things. An aneurysmal bone cyst (ABC) is an uncommon non-neoplastic lesion of the bone, mostly affecting long bones and spine. This rare jaw lesion usually affects the mandible but origin from the maxillary anterior region is even rarer. This paper describes a case of an ABC in an 8-year-old female child with a progressively increasing swelling in the right nasomaxillary region developed over a period of 1.5 months. Treatment consisted of the excision and enucleation of the lesion through an intraoral approach under general anesthesia. The higher prevalence in young adulthood has made the role of pedodontists vital in diagnosing ABCs, at the earliest.

Protein-energy malnutrition among preschool children in Oman: results of a national survey.

We assessed the prevalence of underweight, wasting and stunting among preschool children in Oman from March to December 1999. Within each region, samples of males and females in the age groups 0-5, 6-11, 12-23, 24-35, 36-47 and 48-60 months were drawn from the registers of health institutions and the weight and height/length of the children were measured. The total sample comprised 19,440 children; 9911 males and 9529 females. Data were analysed according to the World Health Organization protocols. The prevalence rates of wasting, stunting and underweight were 7.0%, 10.6% and 17.9% respectively at the national level. There were no sex differences.

Clinical studies on progressive retinal atrophy in 31 dogs.

During a 2-year period, 31 cases of a hereditary retinal degeneration in dogs bred in India were found mainly suspected for progressive retinal atrophy (PRA) with typical history of initial nyctalopia followed by hemeralopia. Out of 31 PRA suspected dogs, 8 dogs (26%) were from the age group of 1-5 years, 15 (48%) 6-10 years and the rest (26%) 11-15 years. The most predominant breed was Spitz (18 dogs, 58%). Detailed ophthalmologic examinations included Schirmer's tear test, fluorescein stain, applanation tonometry, slit lamp biomicroscopy and ocular ultrasound in appropriate cases. Ophthalmoscopic and fundoscopic changes included hyperreflectivity and discoloration of the tapetal area, marked attenuation of retinal vessels, depigmentation in non-tapetal area and optic disc atrophy with scalloped borders. Electroretinograms (ERG) recorded in 13 PRA-affected cases revealed non-recordable extinguished (flatline) ERG responses. A reduction mainly of a- and b-wave amplitudes in the ERG indicated a generalized photoreceptor disease.

Strain features and distributions in pneumococci from children with invasive disease before and after 13-valent conjugate vaccine implementation in the USA.

The effect of second-generation pneumococcal conjugate vaccines on invasive pneumococcal disease (IPD) strain distributions have not yet been well described. We analysed IPD isolates recovered from children aged <5 years through Active Bacterial Core surveillance before (2008-2009; n = 828) and after (2011-2013; n = 600) 13-valent pneumococcal conjugate vaccine (PCV13) implementation. We employed conventional testing, PCR/electrospray ionization mass spectrometry and whole genome sequence (WGS) analysis to identify serotypes, resistance features, genotypes, and pilus types. PCV13, licensed in February 2010, effectively targeted all major 19A and 7F genotypes, and decreased antimicrobial resistance, primarily owing to removal of the 19A/ST320 complex. The strain complex contributing most to the remaining ß-lactam resistance during 2011-2013 was 35B/ST558. Significant emergence of non-vaccine clonal complexes was not evident. Because of the removal of vaccine serotype strains, positivity for one or both pilus types (PI-1 and PI-2) decreased in the post-PCV13 years 2011-2013 relative to 2008-2009 (decreases of 32-55% for PI-1, and >95% for PI-2 and combined PI-1 + PI-2). ß-Lactam susceptibility phenotypes correlated consistently with transpeptidase region sequence combinations of the three major penicillin-binding proteins (PBPs) determined through WGS analysis. Other major resistance features were predictable by DNA signatures from WGS analysis. Multilocus sequence data combined with PBP combinations identified progeny, serotype donors and recipient strains in serotype switch events. PCV13 decreased the frequency of all PCV13 serotype clones and concurrently decreased the frequency of strain subsets with resistance and/or adherence features conducive to successful carriage. Our results serve as a reference describing key features of current paediatric IPD strains in the USA after PCV13 implementation.

Circulatory and catecholamine changes during head-up tilt testing in neurocardiogenic (vasovagal) syncope.

Changes in heart rate, arterial pressure, norepinephrine and epinephrine levels were compared in 19 consecutive patients (10 men and 9 women, mean age 46 +/- 16 years) with neurocardiogenic syncope and 11 age- and sex-matched control subjects (5 men and 6 women, mean age 49 +/- 15 years) during head-up tilt testing. Norepinephrine and epinephrine levels were measured at the baseline supine position, in the initial upright position, every 90 seconds during the 70 degrees upright tilt, at the time of termination due to hypotension and syncope (or at 15 minutes in control subjects), and at 40 seconds and 1 minute and 40 seconds in the supine position after terminating the head-up tilt test. Baseline norepinephrine, epinephrine and heart rate were slightly higher in patients. Despite a significant decrease in mean arterial pressure during head-up tilt testing in patients (51 +/- 20 mm Hg; p < 0.001), norepinephrine levels in patients and control subjects at the time of terminating the head-up tilt test were comparable (459 +/- 204 vs 473 +/- 172 pg/ml). A fivefold increase in epinephrine levels (73 +/- 53 to 345 +/- 260 pg/ml; p < 0.01) were seen in patients, whereas control subjects had insignificant change (38 +/- 16 to 65 +/- 44 pg/ml). It is concluded that diminished neuronal sympathetic activity and enhanced adrenomedullary activity is demonstrated during head-up tilt testing in patients with neurocardiogenic syncope.

Double-shot magnetic resonance imaging of cerebral lesions: fast spin-echo versus echo planar sequences.

The authors compared two new rapid MRI techniques: double-shot echo-planar imaging (DS-EPI) versus double-shot fast spin-echo (DS-FSE) in the evaluation of cerebral lesions. The authors examined 35 patients with 37 lesions, which were hyperintense on long TR images. Patients were scanned with both DS-EPI and DS-FSE with a time of repetition (TR) of 10,000 milliseconds and an echo time (TE) of 80 milliseconds. Conspicuity was determined from region of interest measurements to calculate contrast to noise ratio (C/N). Visual comparisons between DS-EPI and DS-FSE, and between DS-EPI and T2-weighted conventional spin-echo (CSE) were also performed to evaluate the sequences' ability to depict hemorrhage. The mean C/N for both sequences was comparable: 36.7 for DS-FSE and 35.6 for DS-EPI, with no statistically significant difference (p = 0.77). With regards to depicting blood products, DS-EPI proved far more effective than DS-FSE and comparable to CSE. Also, DS-EPI proved to be more time-efficient, requiring 1.67 seconds per section, while DS-FSE required 3.33 seconds per section. Whereas DS-FSE and DS-EPI are comparable in their ability to depict hyperintense cerebral pathology, DS-EPI is more time-efficient, and therefore appears preferable. Because of the high magnetic susceptibility of DS-EPI, geometric distortion degrades visualization of lesions in the posterior fossa or near the sinuses. On the other hand, the high magnetic susceptibility results in high conspicuity of blood products.

Coronary artery surgery and direct coronary artery thrombolysis during acute myocardial infarction.

Twelve patients underwent direct coronary artery streptokinase thrombolysis during acute evolving myocardial infarction. Ten patients had restoration of orthograde pulmonary blood flow. Eight patients had significant myocardial salvage and clinical stabilization. Nine patients had subsequent coronary artery bypass surgery with no major hematological or cardiac complications. Five of these had surgery performed immediately. Two patients with no myocardial salvage after streptokinase had urgent surgery because of other critical coronary lesions. Seven patients with thrombolytic salvage of myocardium underwent urgent coronary artery bypass surgery without incident. The occurrence of two reinfarctions in streptokinase-improved patients waiting for surgery suggests that delay is unwarranted and coronary bypass surgery is needed to insure success.

Effect of tense ascites on esophageal body motility and lower esophageal sphincter pressure.

BACKGROUND: Esophageal motility and lower esophageal sphincter (LES) pressure change with rapid changes in intraabdominal pressure (IAP); the response of these to slow change in IAP is not known. AIMS: To study esophageal body motility and LES pressures in patients with cirrhosis with tense ascites in the basal state and after paracentesis. METHODS: Twenty four patients with cirrhosis of liver and tense ascites and 13 with cirrhosis without ascites (controls) were studied. Basal intragastric (IGP) and LES pressures, and esophageal body response to water swallows, were recorded using a water perfusion system; IAP was measured in patients with ascites. In patients with ascites, the study was repeated twice: after paracentesis of two liters of fluid and after adequate control of ascites. RESULTS: Basal IGP (p = 0.002) and duration of esophageal contraction (p = 0.01) were lower in controls, but basal LES pressures were similar in the two groups. After control of ascites, IAP (p = 0.02) and IGP (p = 0.005) decreased; amplitude and duration of distal esophageal contraction decreased (p < 0.05). The frequency of high-amplitude waves also decreased (p = 0.04). LES pressure remained unaltered. CONCLUSIONS: Esophageal contraction duration is increased in the presence of ascites, and decreases after control of ascites; LES pressure is not affected by ascites.

Early changes in esophageal motility after endoscopic variceal sclerotherapy or ligation.

INTRODUCTION: Endoscopic variceal sclerotherapy (EVS) and ligation (EVL) are reported to be associated with altered esophageal motility. Most studies have been in patients with alcoholic cirrhosis and ascites. AIMS: To study the early effect of EVS and EVL in patients with portal hypertension without ascites. METHODS: Forty six portal hypertensive patients without ascites underwent esophageal manometry 24 h prior to EVS or EVL and within 24 h of two subsequent sessions. Nineteen such patients but without prior gastrointestinal bleed were studied once as controls. RESULTS: The protocol was completed in 35 patients (cirrhosis--16, noncirrhotic portal hypertension--19; 27 men; mean age 36 years). Basal midexpiratory lower esophageal sphincter pressure was similar in the study group (mean [SD] 20.1 [9.1] mmHg) and controls (17.6 [6.0] mmHg); the pressure did not change following EVS or EVL. Amplitude of contractions in the lower 5 cm of the esophageal body was similar in the two groups (84.8 [43.1] mmHg and 95.9 [59.6] mmHg), and decreased (63.6 [34.0] mmHg; p = 0.03) after two sessions of variceal therapy. The duration of contraction did not change following intervention. Nonperistaltic waves > 2 of 10 swallows were present during the baseline study in 9 patients in each group; 13 and 21 patients (p < 0.02 compared to baseline) developed them after the first and second sessions of therapy, respectively. Percentage of abnormal waves also increased following therapy. Thirteen patients developed esophageal ulcers; there was no correlation between the presence of ulcers and dysmotility. There was no difference in the changes between the EVS and EVL groups, and between patients with cirrhosis and noncirrhotic portal hypertension. CONCLUSION: Both EVS and EVL affect esophageal motility; these changes do not cause significant esophageal symptoms.

Hazard analysis and critical control points of weaning foods.

Hazards and critical control points were identified during the preparation, feeding and storage of weaning foods fed to the children (6-24 months) belonging to low income group (LIG) families using survey methods, spot and indepth observations and microbial analysis. High microbial counts were obtained for the weaning food samples procured from the families that were rated as poor for both personal hygiene and environmental sanitation. Food samples that were held at ambient temperature (25-35 degrees C) showed high counts of coliforms, AMCC, yeast and mold, Staphylococcus aureus and Bacillus cereus. Spice mixtures and mop samples also revealed high counts for all these organisms. Coliforms were not isolated from the water samples of all the 10 households. However, a high count of Bacillus cereus (10(3-5)/ml) was observed in water samples of two selected households. The hazards and critical control points identified were high initial contamination of raw foods, poor environmental sanitation and personal hygiene, feeding of overnight moist foods stored at ambient temperature and insufficient steaming of these foods.

Seven Strains of Enterovirus D68 Detected in the United States during the 2014 Severe Respiratory Disease Outbreak.

Clusters of severe respiratory disease in the United States were reported to the CDC beginning in August 2014. Enterovirus D68 (EV-D68) was identified from 83% (30/36) of initial severe cases. Investigations in August and September found severe EV-D68 cases to be widespread across the United States. We report seven EV-D68 genomes from the outbreak.