Variations and Associated Factors in Symptom-to-Balloon (STB) Time and Door-to-Balloon (DTB) Time Before and After the COVID-19 Lockdown: A Hospital-Based Cross-Sectional Study.

INTRODUCTION: During the COVID-19 lockdown, India saw a major restriction in the movement of people. Patients with acute myocardial infarction (MI) required early interventions and follow-up of independent predictors like symptom-to-balloon (STB) time and door-to-balloon (DTB) time. This study aimed to determine changes in STB and DTB time before and after the COVID-19 lockdown and its associated risk factors. METHODS: A hospital-based cross-sectional study of 105 patients admitted to the cardiac care units (CCU) of two tertiary care centers in a district of Southern India for six months was conducted to compare the changes in STB and DTB time before and after the COVID-19 lockdown (three months before March 2020 and three months after March 2020), and data was collected from medical records. The data collected was then entered into Microsoft Excel (Microsoft Corporation, Washington, USA), numerically coded, and analyzed using SPSS Statistics version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). The Chi-square and Mann-Whitney U tests assessed the association between the dependent and independent variables. The STB/DTB time (before and after the COVID-19 lockdown) was the dependent variable, while the age, gender, co-morbidities, smoking status, and date of admission of patients (before and after the COVID-19 lockdown) were taken as the independent variables. A p-value of <0.05 was considered statistically significant. The predictor variables were identified using the regression method, where all variables with a significance of <0.2 were taken. RESULTS: The overall mean (±SD) STB time was 408.7 (±307.1) minutes, and the mean (±SD) DTB time was 161.7 (±261.6) minutes. The pre-lockdown mean STB time was 404.6 minutes, and the mean DTB time was 153 minutes, whereas the post-lockdown mean STB and DTB time were higher at 413.3 minutes and 171.6 minutes, respectively. Out of the total 105 patients, 95 (90.5%) had an STB time of ≥120 minutes, and 77 (73.3%) had an ideal DTB time of <90 minutes. There was no statistically significant variation in the STB and DTB time before and after the lockdown. Only the age group >60 years (38 (97.4%)) was found to be statistically significant with an STB time of ≥120 minutes after the lockdown (p-value=0.040), and patients referred from primary and secondary care centers (AOR (95% CI)=4.669 (1.129-19.298)) were found to be an independent factor in reducing DTB time before and after the COVID-19 lockdown. CONCLUSION: The efficiency of the health system, irrespective of the COVID-19 lockdown, was observed; nevertheless, a delay in the overall recognition of symptoms of MI was perceived. The importance of time factors in identifying the symptoms of non-communicable diseases (NCDs), especially MI and stroke, has to be ascertained among the general population.

Estimation of non-health gross domestic product (NHGDP) loss due to COVID-19 deaths in West Bengal, India.

OBJECTIVES: The state of West Bengal witnessed a significant surge of COVID-19 in all three waves. However, there is a gap in understanding the economic loss associated with COVID-19. This study estimates future non-health gross domestic product (NHGDP) losses associated with COVID-19 deaths in West Bengal, India. SETTING: Various open domains were used to gather data on COVID-19 deaths in West Bengal and the aforementioned estimates. PRIMARY AND SECONDARY OUTCOME MEASURES: The NHGDP losses were evaluated using the cost-of-illness approach. Future NHGDP losses were discounted at 3%. Excess death estimates by the WHO and Global Burden of Disease (GBD) were used. Sensitivity analysis was carried out by varying discount rates and average age of death (AAD). RESULTS: 21 532 deaths in West Bengal from 17 March 2020 to 31 December 2022 decreased the future NHGDP by $0.92 billion. Nearly 90% of loss was due to deaths occurring in the age group of 30 years and above. Majority of the NHGDP loss was borne by the 46-60 years age group. NHGDP loss/death was $55,171; however, the average loss/death declined with rise in age. Based on the GBD and WHO excess death estimates, the NHGDP loss increased to $9.38 billion and $9.42 billion, respectively. When the lower age interval is considered as AAD, the NHGDP loss increased to $1.3 billion. At 5% and 10% discount rates, the losses reduced to $0.767 billion and $0.549 billion, respectively. CONCLUSIONS: Results from the study suggest that COVID-19 contributed to a major economic loss in West Bengal. The mortality and morbidity caused by COVID-19, the substantial economic costs at individual and population levels in West Bengal, and probably across India and other countries, is another economic argument for better infection control strategies across the globe to minimise the impact of COVID-19.

Hypertension in urban slums of southern India: Burden, awareness, health seeking, control and risk factor profile.

INTRODUCTION: Hypertension is the leading risk factor for global disease burden. Inequalities in health among urban poor and non-poor is a matter of concern. The current study was done to estimate the prevalence of hypertension and to describe the health seeking and risk factor profile of people with hypertension in the urban slums of Kochi, Kerala, India. METHODS: Blood pressure of 5980 adults from 20 randomly selected slums were measured by door to door survey by trained nurses as a part of baseline assessment for a cluster randomised controlled trial. RESULTS: Prevalence of hypertension was found to be 34.8% (95% CI 33.5-34.9). Among those with hypertension, 66.9% were aware of their hypertensive status, of which 75.8% were initiated on treatment for hypertension. Proportion of hypertensive in the population who had their blood pressure under control was 24.5%. Among hypertensive, 53% were obese, 25.1% had diabetes mellitus, 14% had history of hospitalisation for high blood pressure. Of them, 60.3% had a per capita salt consumption above 8 g/day and 47.5% of them reported sitting for more than 8 h on a usual day. Mean monthly out of pocket expenditure for treatment of hypertension was $9(Median $8, IQR $16). CONCLUSION: One in three adults in urban slums of Kochi had hypertension. High rates of obesity, salt intake, physical inactivity prevails among the people with hypertension. Awareness, treatment initiation and control rate of hypertension are lower in urban slums as compared to non-slum urban areas. Slums require additional attention to ensure equitable and universal access to hypertension control.

Model-based estimation of burden of COVID-19 with disability-adjusted life years and value of statistical life in West Bengal, India.

OBJECTIVES: The COVID-19 pandemic has posed unprecedented challenges to health systems and populations, particularly in India. Comprehensive, population-level studies of the burden of disease could inform planning, preparedness and policy, but are lacking in India. In West Bengal, India, we conducted a detailed analysis of the burden caused by COVID-19 from its onset to 7 January 2022. SETTING: Open-access, population-level and administrative data sets for West Bengal were used. PRIMARY AND SECONDARY OUTCOME MEASURES: Disability-adjusted life years (DALYs), years of potential productive life lost (YPPLL), cost of productivity lost (CPL: premature mortality and absenteeism), years of potential life lost (YPLL), premature years of potential life lost, working years of potential life lost (WYPLL) and value of statistical life (VSL) were estimated across scenarios (21 for DALY and 3 each for YPLL and VSL) to evaluate the effects of different factors. RESULTS: COVID-19 had a higher impact on the elderly population with 90.2% of deaths arising from people aged above 45. In males and females, respectively, DALYs were 190 568.1 and 117 310.0 years, YPPLL of the productive population was 28 714.7 and 16 355.4 years, CPL due to premature mortality was INR3 198 259 615.6 and INR583 397 335.1 and CPL due to morbidity was INR2 505 568 048.4 and INR763 720 886.1. For males and females, YPLL ranged from 189 103.2 to 272 787.5 years and 117 925.5 to 169 712.0 years for lower to higher age limits, and WYPLL was 54 333.9 and 30 942.2 years. VSL (INR million) for the lower, midpoint and upper life expectancies was 883 330.8; 882 936.4; and 880 631.3, respectively. Vaccination was associated with reduced mortality. CONCLUSIONS: The losses incurred due to COVID-19 in terms of the computed estimates in West Bengal revealed a disproportionately higher impact on the elderly and males. Analysis of various age-gender subgroups enhances localised and targeted policymaking to minimise the losses for future pandemics.

Effectiveness of a community-based education and peer support led by women's self-help groups in improving the control of hypertension in urban slums of Kerala, India: a cluster randomised controlled pragmatic trial.

BACKGROUND: With less than 20% of people with hypertension achieving their target blood pressure (BP) goals, uncontrolled hypertension remains a major public health problem in India. We conducted a study to assess the effectiveness of a community-based education and peer support programme led by women's self-help group (SHG) members in reducing the mean systolic BP among people with hypertension in urban slums of Kochi city, Kerala, India. METHODS: A cluster randomised controlled pragmatic trial was conducted where 20 slums were randomised to either the intervention or the control arms. In each slum, participants who had elevated BP (>140/90) or were on antihypertensive medications were recruited. The intervention was delivered through women's SHG members (1 per 20-30 households) who provided (1) assistance in daily hypertension management, (2) social and emotional support to encourage healthy behaviours and (3) referral to the primary healthcare system. Those in the control arm received standard of care. The primary outcome was change in mean systolic BP (SBP) after 6 months. RESULTS: A total of 1952 participants were recruited-968 in the intervention arm and 984 in the control arm. Mean SBP was reduced by 6.26 mm Hg (SE 0.69) in the intervention arm compared with 2.16 mm Hg (SE 0.70) in the control arm; the net difference being 4.09 (95% CI 2.15 to 4.09), p<0.001. CONCLUSION: This women's SHG members led community intervention was effective in reducing SBP among people with hypertension compared with those who received usual care, over 6 months in urban slums of Kerala, India. TRIAL REGISTRATION NUMBER: CTRI/2019/12/022252.

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

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

Personalized allocation of acetylsalicylic acid therapy for secondary prevention of coronary artery disease.

Background: A single-daily dose of 75 mg of acetylsalicylic acid inhibits 100% of thromboxane-B2 synthesis within 30-60 min. Thromboxane-B2 synthesis then recovers slowly as new platelets are released from the bone marrow. Normally, only 10% of the platelets are replaced daily by new platelets entering circulation. Hence, 24 h after a dose of acetylsalicylic acid, thromboxane-B2 synthesis is still suppressed by more than 90%. Hence, there is an adequate anti-platelet effect even after 24 h of acetylsalicylic acid intake. However, some patients treated with once-daily acetylsalicylic acid may have an incomplete 24-h suppression of thromboxane-B2 synthesis due to increased platelet turnover. The response could be improved in such patients by twice-daily acetylsalicylic acid administration. This study aimed to identify such a group of patients who would benefit from a twice-daily dose of acetylsalicylic acid. Materials and methods: Serum thromboxane-B2 levels were measured in 79 patients with coronary artery disease receiving 75 mg of acetylsalicylic acid for secondary prophylaxis. Serum levels of thromboxane-B2 were measured after 4 and 24 h of acetylsalicylic acid intake. Patients were then classified into three groups: steady suppression group (serum thromboxane B2 is adequately suppressed at 4 and 24 h), i.e., adequate response to acetylsalicylic acid; fast recovery group (more than 10% rise in serum thromboxane-B2 levels at 24-h when compared to at 4-h) and non-responders (serum thromboxane-B2 levels of >3,100 pg/ml after 4 h of acetylsalicylic acid intake). Patients in the fast recovery group were given twice-daily acetylsalicylic acid and thromboxane-B2 levels were re-measured. Results: A total of 20 patients (24.3%) had steady suppression of thromboxane-B2 and 11 patients (13.9%) belonged to the fast recovery group, i.e., thromboxane-B2 levels were adequately suppressed at 4 h but had recovered by more than 10% at 24 h; which was adequately suppressed by twice-daily acetylsalicylic acid (p 0.004). A total of 48 patients (60.8%) were non-responders. Conclusion: Twice-daily acetylsalicylic acid may be beneficial if serum thromboxane-B2 levels at 4 h are <3,100 and >3,100 pg/ml at 24 h. If thromboxane-B2 levels at 4 and 24 h is <3100 pg/ml but if there is a >10% rise in serum thromboxane B2 at 24 h as compared to that at 4 h, then twice-daily acetylsalicylic acid should be considered. However, if thromboxane-B2 at 4 and 24 h is >3,100 pg/ml consider switching over to a P2Y12 inhibitor.

ICMR task force project- survey of the incidence, mortality, morbidity and socio-economic burden of snakebite in India: A study protocol.

BACKGROUND: Snakebite is possibly the most neglected of the NTDs (Neglected Tropical Diseases). Half of the global deaths due to venomous snakebites, estimated at 100,000 per year, occur in India. The only representative data on snakebite available from India is the mortality data from the RGI-MDS study (Registrar General of India- 1 Million Death Study) and another study on mortality from the state of Bihar. Incidence data on snakebite is available for 2 districts of the state of West Bengal only. Hospital-based data on snakebite admissions and use of ASV are gross underestimates as most snakebite victims in rural India depend more on alternate treatment methods which do not get represented in National registries. The proposed study is a multi-centric study to determine the incidence, morbidity, mortality and economic burden of snakebites in India covering all 5 geographical zones of the country. PROTOCOL: A community level surveillance for snakebite covering 31 districts in 13 states of India in order to obtain annual incidence of snakebites from the community. Frontline health workers will be trained to gather information on new cases of snakebite over the study period of 1-year, from "wards "(smallest administrative subunit of a village or town) that they represent in the study districts. Dedicated field officers would collect data on snakebites, victim characteristics, outcomes, utilization of health facilities on a questionnaire sheet designed for this purpose. The study duration is for 18 months from April 2022 to October 2023. DISCUSSION: The study would be the first of its kind in India looking prospectively at the incidence of snakebite covering 13 states in 5 zones of India and a population of 84 million. Our study covers 6.12% of the total population of the country as compared to the incidence study conducted in Sri Lanka which covered 1% of the total population.

Hypocholesterolaemia as a prognostic factor in venomous snakebite: a retrospective study from a single centre in Kerala, India.

BACKGROUND: Studies have suggested a association between serum cholesterol values and severity of envenoming. The objective of the study was to correlate the serum cholesterol levels with severity of envenoming in victims of snakebite, across snake species in our patient population. METHODS: Retrospective secondary data analysis of health records of a cohort of snakebite victims treated at Little Flower Hospital, Angamaly, Kerala during June 2006-January 2008 was performed. The cholesterol values were assessed in 205 consecutive patients admitted with snakebite envenoming, within 24 h of admission and 10 h of overnight fasting. Lipid fractions were estimated from fasting serum through the standard CHOD-PAP method on a Hitachi analyzer. The cholesterol level was compared between victims with mild and serious envenoming to assess the proportion among each category with a low cholesterol (defined as ≤150 mg/dl as per institutional criteria). In addition, low cholesterol as a marker of severity was compared with other laboratory parameters suggesting severe envenoming such as low fibrinogen, low platelet count, neutrophilia, elevated creatinine, d-dimer, hepatic transaminases and albuminuria. RESULTS: Of the 146 victims with serious degree of snakebite envenoming 116 (79%) had low cholesterol values ≤150 mg%, while 30 (21%) had values >150 mg%. Of the patients with low cholesterol, 116 (78%) had serious envenoming, while 22% had mild envenoming. By contrast, 30 patients (21%) had values >150 mg%. The risk of moderate-severe envenoming with low cholesterol was 2.7 times (170%) that of victims with normal or high cholesterol on admission. CONCLUSIONS: A low cholesterol on admission in victims of snake envenoming suggested a more severe degree of envenoming and likelihood of complications.

Association of lipoprotein (a) with coronary artery disease in a South Asian population: A case-control study.

INTRODUCTION: Coronary artery disease (CAD), the leading cause of mortality worldwide, is characterised by an earlier onset and more severe disease in South Asians as compared to Western populations. METHODS: This is an observational study on 928 individuals who attended three tertiary care centres in Kerala, India from 2014-to 2017. The demographic, anthropometric, behavioural factors and the lipoprotein (Lp(a)) and cholesterol values were compared between the two groups and across disease severity. The Chi-square test was used to compare the categorical variables and independent sample t-test for the continuous variables. Multivariable logistic regression was performed to investigate the association of demographic, clinical and behavioural factors with the disease. Odds ratios are presented with a 95% confidence interval. In individuals below 50 years, two logistic regression models were compared to investigate the improvement in modelling the association of the independent factors and Lp(a) with the occurrence of the disease. RESULTS: We included 682 patients in the diseased group and 246 patients treated for non-coronary conditions in the control group. Those in the control group were significantly younger than in the diseased group(p<0.002). Significantly more patients were diabetic, hypertensive, tobacco users and consumers of alcohol in the diseased group. Multivariable logistic regression on data from all age groups showed that age (OR = 2.55, 95% CI 1.51-4.33, p = 0.01), diabetes (OR = 3.71, 95% CI 2.42-5.70, p = 0.01), hypertension (OR = 3.03, 95% CI 2.12-4.34, p = 0.01) and tobacco use (OR = 5.44, 95% CI 3.39-8.75, p = 0.01) are significantly associated with the disease. Lp(a) (OR = 1.22, 95% CI 0.87-1.72) increased the odds of the disease by 22% but was not statistically significant. In individuals below 50 years, Lp(a) significantly increased the likelihood of CAD (OR = 3.52, 95% CI 1.63-7.57, p = 0.01). Those with diabetes were seven times more likely to be diseased (OR = 7.06, 95% CI 2.59-19.21, p = 0.01) and the tobacco users had six times the likelihood of disease occurrence (OR = 6.38, 95% CI 2.62-15.54, p = 0.01). The median Lp(a) values showed a statistically significant increasing trend with the extent/severity of the disease in those below 50 years. CONCLUSION: Age, diabetes, hypertension and tobacco use appear to be associated more with the occurrence of coronary artery disease in adults of all ages. Lipoprotein(a), cholesterol and BMI categories do not seem to be related to disease status in all ages. However, in individuals below 50 years, diabetes, tobacco use and lipoprotein (a) are significantly associated with the occurrence of the disease.

Psychological distress and burnout among healthcare worker during COVID-19 pandemic in India-A cross-sectional study.

BACKGROUND: COVID-19 has inundated the entire world disrupting the lives of millions of people. The pandemic has stressed the healthcare system of India impacting the psychological status and functioning of health care workers. The aim of this study is to determine the burnout levels and factors associated with the risk of psychological distress among healthcare workers (HCW) engaged in the management of COVID 19 in India. METHODS: A cross-sectional study was conducted from 1 September 2020 to 30 November 2020 by telephonic interviews using a web-based Google form. Health facilities and community centres from 12 cities located in 10 states were selected for data collection. Data on socio-demographic and occupation-related variables like age, sex, type of family, income, type of occupation, hours of work and income were obtained was obtained from 967 participants, including doctors, nurses, ambulance drivers, emergency response teams, lab personnel, and others directly involved in COVID 19 patient care. Levels of psychological distress was assessed by the General health Questionnaire -GHQ-5 and levels of burnout was assessed using the ICMR-NIOH Burnout questionnaire. Multivariable logistic regression analysis was performed to identify factors associated with the risk of psychological distress. The third quartile values of the three subscales of burnout viz EE, DP and PA were used to identify burnout profiles of the healthcare workers. RESULTS: Overall, 52.9% of the participants had the risk of psychological distress that needed further evaluation. Risk of psychological distress was significantly associated with longer hours of work (≥ 8 hours a day) (AOR = 2.38, 95% CI(1.66-3.41), income≥20000(AOR = 1.74, 95% CI, (1.16-2.6); screening of COVID-19 patients (AOR = 1.63 95% CI (1.09-2.46), contact tracing (AOR = 2.05, 95% CI (1.1-3.81), High Emotional exhaustion score (EE ≥16) (AOR = 4.41 95% CI (3.14-6.28) and High Depersonalisation score (DP≥7) (AOR = 1.79, 95% CI (1.28-2.51)). About 4.7% of the HCWs were overextended (EE>18); 6.5% were disengaged (DP>8) and 9.7% HCWs were showing signs of burnout (high on all three dimensions). CONCLUSION: The study has identified key factors that could have been likely triggers for psychological distress among healthcare workers who were engaged in management of COVID cases in India. The study also demonstrates the use of GHQ-5 and ICMR-NIOH Burnout questionnaire as important tools to identify persons at risk of psychological distress and occurrence of burnout symptoms respectively. The findings provide useful guide to planning interventions to mitigate mental health problems among HCW in future epidemic/pandemic scenarios in the country.

Effectiveness of Framingham and ASCVD Risk Scores in Predicting Coronary Artery Disease - A Comparative Study with Syntax Score.

OBJECTIVES: Primary objective was to determine an association between Atherosclerotic Cardiovascular Disease (ASCVD) and Framingham (FRS) risk scores with Syntax score(SS). Secondary objective was to determine sensitivity, specificity and discriminative ability of FRS and ASCVD risk scores in detecting Coronary Artery Disease (CAD) and predicting its severity. MATERIALS AND METHODS: This is a cross-sectional study carried out in the Comprehensive Health Clinic of Amrita Institute of Medical Sciences, Kochi, Kerala. Patients voluntarily visiting the clinic for a health check-up were referred to Cardiology based on a positive treadmill test result where they underwent a coronary angiogram. Secondary data on patients' demographics, prior history of cardiovascular diseases, investigations and interventional procedures was collected from the hospital registry. The risk scores were calculated using the data through online calculators. Analysis was carried out using SPSS. RESULTS: Chi-square analysis showed significant association between FRS and SS. Both FRS and ASCVD risk scores have good sensitivity for CAD while having good specificity for patients with high Syntax score (SS≥33). ROC curve showed that ASCVD risk score has a higher positive likelihood ratio than FRS for predicting CAD and high Syntax Score Patients. CONCLUSION: The study concludes that FRS and ASCVD risk scores are effective risk predicting models for CAD. FRS is a more sensitive risk score than ASCVD risk score in predicting CAD whereas ASCVD risk score has a higher ability to differentiate patients with CAD and high Syntax Score than FRS.

A comparison of clinical outcomes between vaccinated and vaccine-naive patients of COVID-19, in four tertiary care hospitals of Kerala, South India.

THE PROBLEM CONSIDERED: This multi-centric study analyzed data of COVID-19 patients and compared differences in symptomatology, management, and outcomes between vaccinated and vaccine-naive patients. METHODS: All COVID-19 positive individuals treated as an in-or out-patient from the 1stMarch to 15th May 2021 in four selected study sites were considered for the study. Treatment details, symptoms, and clinical course were obtained from hospital records. Chi-square was used to test the association of socio-demographic and treatment variables with the vaccination status and binary logistic regression were used to obtain the odds ratio with a 95% confidence interval. RESULTS: The analysis was of 1446 patients after exclusion of 156 with missing data of which males were 57.3% and females 42.7%. 346 were vaccinated; 189 received one dose and 157 both doses. Hospitalization was more in vaccinated (38.2% vs 27.4%); ICU admissions were less in vaccinated (3.5% vs 7.1%). More vaccinated were symptomatic (OR = 1.5); half less likely to be on non-invasive ventilation (OR = 0.5) while vaccine naive patients had 4.21 times the risk of death. CONCLUSION: Severe infection, duration of hospital stays, need for ventilation and death were significantly less among vaccinated when compared with vaccine naive patients.

Pulmonary Hypertension Registry of Kerala, India (PRO-KERALA): One-year outcomes.

BACKGROUND: Short term outcomes of patients with pulmonary hypertension are not available from low and middle-income countries including India. METHODS: We conducted a prospective study of 2003 patients with pulmonary hypertension, from 50 centres (PROKERALA) in Kerala, who were followed up for one year. Pulmonary hypertension (PH) was mainly diagnosed on the basis of Doppler echocardiography. The primary outcome was a composite end-point of all-cause death and hospital admission for heart failure. All cause hospitalisation events constituted the secondary outcome. RESULTS: Mean age of study population was 56 ± 16 years. Group 1 and Group 2 PH categories constituted 21.2% and 59% of the study population, respectively. Nearly two-thirds (65%) of the study participants had functional class II symptoms. 31% of Group 1 PH patients were on specific vasodilator drugs.In total, 83 patients (4.1%) died during the one-year follow-up period. Further, 1235 re-hospitalisation events (61.7%) were reported. In the multivariate model, baseline NYHA class III/IV (OR 1.87, 95% C.I. 1.35-2.56), use of calcium channel blockers (OR 0.18, 95% C.I. 0.04-0.77), vasodilator therapy (OR 0.5, 95% C.I. 0.28-0.87) and antiplatelet agents (OR 1.80, 95% C.I. 1.29-2.51) were associated with primary composite outcome at one-year (p < 0.05). CONCLUSION: In the PROKERALA registry, annual mortality rate was 4%. More than half of the patients reported re-hospitalisation events on follow up. Uptake of guideline directed therapies were suboptimal in the study population. Quality improvement programmes to improve guideline directed therapy may improve clinical outcomes of PH patients in India.

A Sustainable Community-Based Model of Noncommunicable Disease Risk Factor Surveillance (Shraddha-Jagrithi Project): Protocol for a Cohort Study.

BACKGROUND: India has a massive noncommunicable disease (NCD) burden, at an enormous cost to the individual, family, society, and health system at large, despite which prevention and surveillance are relatively neglected. If diagnosed early and treated adequately, risk factors for atherosclerotic cardiovascular disease would help decrease the mortality and morbidity burden. Surveillance for NCDs, creating awareness, positive lifestyle changes, and treatment are the proven measures known to prevent the progression of the disease. India is in a stage of rapid epidemiological transition, with the state of Kerala being at the forefront, pointing us towards likely disease burden and outcomes for the rest of the country in the future. A previous study done by the same investigators in a population of >100,000 revealed poor awareness, treatment of NCDs, and poor adherence to medicines in individuals with CVD. OBJECTIVE: This study aimed at assessing a sustainable, community-based surveillance model for NCDs with corporate support fully embedded in the public health system. METHODS: Frontline health workers will check all individuals in the target group (≥age 30 years) with further follow-up and treatment planned in a "spoke and hub" model using the public health system of primary health centers as spokes to the hubs of taluk or district hospitals. All data entry done by frontline health workers will be on a tablet PC, ensuring rapid acquisition and transfer of participant health details to primary health centers for further follow-up and treatment. RESULTS: The model will be evaluated based on the utilization rate of various services offered at all tier levels. The proportions of the target population screened, eligible individuals who reached the spoke or hub centers for risk stratification and care, and community-level control for hypertension and diabetes in annual surveys will be used as indicator variables. The model ensures diagnosis and follow-up treatment at no cost to the individual entirely through the tiered public health system of the state and country. CONCLUSIONS: Surveillance for NCDs is an essential facet of health care presently lacking in India. Atherosclerotic cardiovascular disease has a long gestation period in progression to the symptomatic phase of the disease, during which timely preventive and lifestyle measures would help prevent disease progression if implemented. Unfortunately, several asymptomatic individuals have never tested their plasma glucose, serum lipid levels, or blood pressure and are unaware of their disease status. Our model, implemented through the public health system using frontline health workers, would ensure individuals aged≥30 years at risk of disease are identified, and necessary lifestyle modifications and treatments are given. In addition, the surveillance at the community level would help create a general awareness of NCDs and lead to healthier lifestyle habits. TRIAL REGISTRATION: Clinical Trial Registry India CTRI/2018/07/014856; https://tinyurl.com/4saydnxf. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27299.

Sibling Risk Factor Study in Premature Coronary Artery Disease.

BACKGROUND: Family history of premature coronary artery disease as a risk factor in first degree relatives has been well established by various studies. This study aims at identification and assessment of the presence of risk factors in asymptomatic siblings of patients with documented premature coronary artery disease. Prevalence of Systemic Hypertension in siblings (both male and female) of patients with premature coronary artery disease (males <45yrs, females <55yrs, confirmed by coronary angiography) was analysed. Other risk factor prevalence estimation was also done which included, dyslipidaemia, diabetes mellitus, tobacco use, alcohol intake, obesity, passive smoke exposure, diet and exercise. The study also estimated the percentage of sibling awareness regarding the risk factors for cardiovascular disease. MATERIALS AND METHODS: This was a cross sectional study where all patients (both In and Out patient), visiting Amrita Institute of Medical Sciences, Kochi and diagnosed as having angiographically proven Premature Coronary Artery Disease from December 2014 to June 2016 were identified and risk factor screening was done for both male and female siblings of any age of these patients. Laboratory tests included fasting blood sugar and fasting lipid profile were analysed after sample collection. RESULTS: 47.6% of male siblings and 35.7% of female siblings were found to be hypertensive, 17.3% of the male siblings and 18.7% of the female siblings were found to have abnormal levels of LDL cholesterol, 22.7% of male siblings and female siblings were found to have abnormal fasting plasma sugar levels, 30.5% of male siblings and 20% of male siblings were found to be overweight. 19.1% of male siblings and 21.4% of female siblings were found to be obese. Only 18.1% of male siblings and 5.7% of female siblings performed any kind of exercise on a regular basis. Among male siblings, 21.9% of male siblings were currently using tobacco in some form. Among non-smokers in both sexes, as many as 36% were exposed to some form of passive smoke. Almost half of the male siblings (49.5%) consumed alcohol containing beverages on a regular basis. CONCLUSIONS: Previously undetected risk factors were found to be highly prevalent among the studied siblings. Significant number of siblings were was found to be hypertensive and in addition some had elevated fasting blood sugar levels. Other modifiable risk factors like obesity, alcohol consumption, tobacco use, passive smoking and lack of exercise were also found to be widely prevalent. An important aspect that the study highlighted is the widespread lack of awareness in the study population about risk factors for disease.

Estimation of the economic burden of COVID-19 using disability-adjusted life years (DALYs) and productivity losses in Kerala, India: a model-based analysis.

OBJECTIVES: From the beginning of the COVID-19 pandemic, clinical practice and research globally have centred on the prevention of transmission and treatment of the disease. The pandemic has had a huge impact on the economy and stressed healthcare systems worldwide. The present study estimates disability-adjusted life years (DALYs), years of potential productive life lost (YPPLL) and cost of productivity lost (CPL) due to premature mortality and absenteeism secondary to COVID-19 in the state of Kerala, India. SETTING: Details on sociodemographics, incidence, death, quarantine, recovery time, etc were derived from public sources and the Collective for Open Data Distribution-Keralam. The working proportion for 5-year age-gender cohorts and the corresponding life expectancy were obtained from the 2011 Census of India. PRIMARY AND SECONDARY OUTCOME MEASURES: The impact of the disease was computed through model-based analysis on various age-gender cohorts. Sensitivity analysis was conducted by adjusting six variables across 21 scenarios. We present two estimates, one until 15 November 2020 and later updated to 10 June 2021. RESULTS: Severity of infection and mortality were higher among the older cohorts, with men being more susceptible than women in most subgroups. DALYs for males and females were 15 954.5 and 8638.4 until 15 November 2020, and 83 853.0 and 56 628.3 until 10 June 2021. The corresponding YPPLL were 1323.57 and 612.31 until 15 November 2020, and 6993.04 and 3811.57 until 10 June 2021, and the CPL (premature mortality) were 263 780 579.94 and 41 836 001.82 until 15 November 2020, and 1 419 557 903.76 and 278 275 495.29 until 10 June 2021. CONCLUSIONS: Most of the COVID-19 burden was contributed by years of life lost. Losses due to YPPLL were reduced as the impact of COVID-19 infection was lesser among the productive cohorts. The CPL values for individuals aged 40-49 years old were the highest. These estimates provide the data necessary for policymakers to work on reducing the economic burden of COVID-19 in Kerala.

Estimating epidemiological and economic burden and community derived disability weights for snake bite in Kerala: a study protocol.

Background: In India, geographical variation, lack of data and underreporting on cases and deaths due to snakebite makes it difficult to estimate socio-economic burden of snakebites. Previous studies measuring economic burden of snakebite in low-and-middle-income countries (LMICs) using different approaches have been conducted, but none so far in India. The proposed study aims to provide evidence on disability weights, epidemiological and economic burden due to snakebites in Kerala state, India. Protocol: A cross-sectional community based study for estimating epidemiological and economic burden of snakebite, recruiting victims of snakebite occurring over a nine month period prior to start and over the three month period of the study, across Ernakulam district, Kerala state, India. For the community derived disability weights, 60 adult patients admitted and treated at Amrita Institute of Medical Sciences, Kochi or Little Flower Hospital, Angamaly would be interviewed. The sample size to determine the mortality rate is calculated at 108,458 persons in Ernakulam.The study will measure annual incidence, mortality, treatment cost of snakebites along with community-derived disability weights for snakebites. Standard methods for analysis and reporting of mortality, morbidity, years of lives lost, years lived with disability, disability weights, and costs of treatment will be calculated and presented. The study will be started in March 2021 and is expected to be completed by June 2021. Discussion: This protocol is the first published for estimating epidemiological, economic burden and community derived disability weights for snakebites in India. Besides, the Global Burden of Disease has not attached a particular disability weight to snakebite and this would be an attempt to do so.The protocol has been developed using guidelines for both cross-sectional studies and  for conducting community derived disability weights. The evidence generated will contribute to knowledge regarding epidemiology, economic burden and community-derived disability weights for snakebites in India and other LMICs.

Uncontrolled Blood Pressure and Associated Factors Among Persons With Diabetes: A Community Based Study From Kerala, India.

The coexistence of raised blood pressure (BP) in people with type 2 diabetes mellitus (T2DM) is a major contributor to the development and progression of both macrovascular and microvascular complications. The aim of our study was to determine the prevalence of uncontrolled BP and its associated factors in persons with T2DM in a district in Kerala. METHODS: The study was conducted in Ernakulam district in Kerala, and a total of 3,092 individuals with T2DM were enrolled after obtaining consent. Those with a BP "above or equal to 140 mmHg" and/or "above or equal to 90 mmHg" were thus considered to have uncontrolled BP. If the BP was equal or >140 and/or 90 mmHg, a repeat reading was taken after 30 min and the average of the two was considered. Basic demographic details were enquired along with electronic measurement of BP, HbA1c estimation and screening for diabetic retinopathy, peripheral arterial disease (PAD), and peripheral neuropathy. Quantitative and qualitative variables were expressed as mean (SD) and proportions, respectively. The model for determinants of uncontrolled BP was developed adjusting for age, gender, education, duration of diabetes, occupation, body mass index (BMI) and clustering effect. RESULTS: The mean age of the study population was 59.51 ± 9.84 years. The mean duration of T2DM was found to be 11.3 ± 6.64 years. The proportion of uncontrolled HTN adjusted for clustering was 60% (95% CI 58 and 62%). Among them, only one in two persons (53.3%) had a history of hypertension. Age >60 years [adjusted odds ratio (aOR) 1.48, 95% CI 1.24, 1.76; p < 0.001], unemployment (aOR 1.33, 95% CI 1.01, 1.75; p < 0.01), duration of diabetes > 11 years (aOR 1.42, 95% CI 1.19, 1.68; p < 0.001), and BMI ≥23 (aOR 1.33, 95% CI 1.10, 1.59; p < 0.002) were found to be independent determinants of high BP levels when adjusted for the aforementioned variables, gender, education, and cluster effect. The association between complications, such as peripheral neuropathy, PAD, and retinopathy showed a higher risk among those with uncontrolled BP. Retinopathy was 1.35 times more (95% CI 1.02, 1.7, p < 0.03), PAD was 1.6 times more (95% CI 1.2, 2.07, p < 0.001), and peripheral neuropathy was 1.5 (95% CI 1.14, 1.9, p < 0.003) times more compared to their counterparts. CONCLUSION: Target BP levels were far from being achieved in a good majority of the persons with T2DM. To reduce further macrovascular and microvascular events among people with T2DM, effective awareness and more stringent screening measures need to be employed in this population.