Incidence and Risk Factors for Deep Venous Thrombosis and Its Impact on Outcome in Patients Admitted to Medical Critical Care.

Objectives: This study evaluated the incidence and risk factors for deep venous thrombosis (DVT) while on thromboprophylaxis, in patients admitted to the medical intensive care unit (MICU), and to assess its impact on outcomes. Methods: Consecutive patients admitted to the MICU underwent compression ultrasound of the jugular, axillary, femoral, and popliteal veins at admission, day 3 and 7 to screen for DVT. All patients were on pharmacological and/or mechanical thromboprophylaxis as per protocol. The primary outcome was the incidence of DVT (defined as occurrence on day 3 or 7). Secondary outcomes were death and duration of hospitalization. Risk factors for DVT were explored using bivariate and multivariable logistic regression analysis and expressed as risk ratio (RR) with 95% confidence intervals (CIs). Results: The incidence of DVT was 17.2% (95% CI 12.0, 22.3) (n = 35/203); two-thirds were catheter associated (23/35). There was no difference in mortality between those with and without incident DVT (9/35 vs 40/168, p = 0.81). The mean (SD) duration of hospitalization was longer in the DVT group (20.1 (17) vs 12.9 (8.5) days, p = 0.007). Although day 3 INR (RR 2.1, 95% CI 0.9-5.3), age >40 years (2.1, 0.8-5.3), vasopressor use (1.0, 0.4-2.9) and SOFA score (0.9, 0.85-1.1) were associated with the development of DVT on bivariate analysis, only central venous catheters (15.97, 1.9-135.8) was independently associated with DVT on multivariable analysis. Conclusions: Despite thromboprophylaxis, 17% of ICU patients develop DVT. The central venous catheter is the main risk factor. DVT is not associated with increased mortality in the setting of prophylaxis. How to cite this article: Krishnamoorthy A, Hansdak SG, Peter JV, Pichamuthu K, Rajan SJ, Sudarsan TI, et al. Incidence and Risk Factors for Deep Venous Thrombosis and Its Impact on Outcome in Patients Admitted to Medical Critical Care. Indian J Crit Care Med 2024;28(6):607-613.

Breast milk contains red cell isohaemagglutinins: An observational study of 176 mothers.

BACKGROUND AND OBJECTIVES: Maternal antibodies are transferred to the child, predominantly IgG, via the transplacental route, and mostly IgA through breast milk. Cases reported by us and others have shown the transfer of red cell allo-antibodies through breast milk. This study was conducted to assess the presence of isohaemagglutinins in breast milk, the range of titres, and the correlation between breast milk and maternal plasma titres. MATERIALS AND METHODS: A total of 176 mothers were recruited in this study. Breast milk was collected after sufficient feeding was established and within 2-5 days of delivery in a sterile container without any anticoagulant. Antibody screen, identification and titres were performed on maternal plasma as well as breast milk. RESULTS: Anti-A and anti-B in breast milk corresponding to their respective maternal blood groups were found in all the samples. This study has shown titres in the breast milk of anti-A and anti-B ranging from 2 to 1024 in both saline and Coombs phases. There was no association between plasma and breast milk titres, thus making it impossible to predict which mother may potentially transfer a larger amount of these haemagglutinins. Isotypes of anti-A and anti-B were evaluated in both plasma and breast milk of 11 samples, which showed predominantly IgG in 7 (63.63%) and predominantly IgA in 4 (36.36%) samples. CONCLUSION: Our study demonstrates the presence of a wide range of titres for IgG antibodies of the ABO blood group system in breast milk. The clinical impact of this finding needs to be studied further, as it assumes great relevance in developing countries where anaemia continues to challenge young infants.

Defining IL-6 levels in healthy individuals: A meta-analysis.

BACKGROUND: Interleukin-6 (IL-6) is produced by and impacts different cell types in human. IL-6 is associated with different diseases and viral infections, including COVID-19. To our knowledge, no normal values were reported for IL-6 in the blood of healthy individuals. We have reviewed and performed a meta-analysis on a total of 140 studies, including 12,421 values for IL-6 in the blood of healthy adult donors. Among these studies, 83 did not report a mean value and the standard deviation. Therefore, for the statistical analysis, we used the values reported in 57 studies, which included 3166 values for IL-6. RESULTS: The reported values for IL-6 in the blood of healthy donors varied between 0 and 43.5 pg/ml. The pooled estimate of IL-6 was 5.186 pg/ml (95% confidence interval [CI]: 4.631, 5.740). As the age increased by 1 year, IL-6 values increased by 0.05 pg/ml (95% CI: 0.02, 0.09; p < .01). Though the heterogenicity, as determined by I2 statistics, was high in our study, the differences in IL-6 values are still at the level of a few pg/ml, which might be related to the differences in the conditions that influence IL-6 production in the healthy population. CONCLUSIONS: This is the first meta-analysis reporting the levels of IL-6 in the blood of healthy donors based on a large number of studies and donors. Therefore the 95% CI values determined in our study could well serve as a reference range for quick decision-making in clinical interventions, particularly those aiming to inhibit IL-6, especially urgent interventions, for example, COVID-19.

The prevalence, severity, and risk factors for dry eye disease in Dubai - a cross sectional study.

BACKGROUND: The prevalence of dry eye disease is increasing globally and requires the attention of healthcare professionals as it worsens patients' quality of life. No published studies on the epidemiology of dry eyes have been found in Dubai. PURPOSE: To describe the epidemiology, prevalence, severity, and associated factors of dry eyes in Dubai, United Arab Emirates, in 2019. METHODS: This was an analytical, cross-sectional, survey-based study. An online survey was distributed by email to Mohammed Bin Rashid University students, staff, and faculty and to the staff at Mediclinic City and Parkview Hospitals in Dubai, United Arab Emirates, from April-June 2019. The survey included demographic questions and the Ocular Surface Disease Index (OSDI). RESULTS: The survey was completed by 452 participants; the majority were females (288/452; 63.7 %). The prevalence of dry eyes in Dubai was estimated to be 62.6 % (283/452), with severely dry eyes being the most prevalent (119/283; 42 %). Females, high daily screen time (> 6 h), and the use of contact lenses were found to be associated with dry eyes (P-value < 0.05, 95 % confidence interval). Age was found to be negatively correlated with prevalence of dry eyes. Exposure to smoking/shisha, history of eye injury/surgery, and nationality were not associated with dry eyes. CONCLUSIONS: This is the first cross-sectional study to investigate the prevalence of dry eyes in Dubai (62.6 %). The majority of participants had severe dry eyes symptoms. Severely dry eyes were more common among females and users of contact lenses.

Diagnostic accuracy of urinary aquaporin-1 as a biomarker for renal cell carcinoma.

INTRODUCTION: Optimal patient selection plays a vital role in management of renal tumors with the introduction of nephron-sparing approaches and active surveillance. A reliable and accurate diagnostic biomarker will be a useful adjunct to decision-making. We studied the diagnostic accuracy of urinary aquaporin-1 (uAQP-1), an upcoming urinary biomarker, for renal cell carcinoma. MATERIALS AND METHODS: In this prospective biomarker study, urine samples were obtained preoperatively from 36 patients with an imaged renal mass suggestive of RCC and 24 healthy age-matched controls, chosen from among voluntary kidney donors. uAQP-1 concentrations were estimated with a sensitive and specific enzyme-linked immunosorbent assay (ELISA) and normalized by estimation of urinary creatinine. The Mann-Whitney U-test was used to compare differences between any two groups. A receiver operator characteristic (ROC) curve was plotted to analyze the diagnostic accuracy of uAQP-1 for RCC. RESULTS: The median uAQP-1 concentration among the cases and controls was 8.78 ng/mg creatinine (interquartile range [IQR]: 5.56-12.67) and 9.52 ng/mg creatinine (IQR: 5.55-12.45), respectively. There was no significant difference in uAQP-1 concentrations between the two groups. ROC analysis showed that, for a cutoff value of 8 ng/mg creatinine, the sensitivity and specificity of uAQP-1 as a diagnostic test were 47.2% and 66.7%, respectively, and area under the curve was 0.52 (95% confidence interval: 0.42-0.62). CONCLUSIONS: uAQP-1 concentrations did not discriminate between healthy individuals and patients with RCC. The results of this study suggest that uAQP-1 may not be a suitable diagnostic biomarker for RCC in the study population.

Study of familial aggregation of autoimmune rheumatic diseases in Asian Indian patients with systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) and other autoimmune rheumatic diseases (AIRD) tend to co-aggregate in families, making positive familial history a risk factor. We aimed to estimate familial aggregation of AIRD in SLE patients and to compare between ones having a positive and negative family history of autoimmunity in our cohort. We included families of 157 consecutive SLE patients in a hospital-based, cross-sectional design for a three-generation pedigree study. Clinical and laboratory parameters of these patients were recorded. AIRD was seen in families of 39 SLE patients amounting to a familial prevalence of 24.8% [95% confidence interval (CI) 18.1, 31.6] with a relative risk (λ) of 4.3 for first-degree relatives (FDRs) and 1.1 for second-degree relatives (SDRs). SLE was the commonest AIRD seen in families of 19 patients with a familial prevalence of 12.1% (95% CI 7.0, 17.2) and λ of 78.2 for FDRs and 18.1 for SDRs. AIRD as a whole and SLE alone were seen more commonly with parental consanguinity (p < 0.05). Familial aggregation in SLE patients also showed a relatively higher percentage of affected males and lesser presentation with constitutional features (p < 0.05) than sporadic SLE patients. Rheumatoid arthritis (RA) was the second most common AIRD seen in 16/39 (41%) families with a RR of 3.1 in FDRs of SLE patients. In conclusion, Asian Indian SLE patients seem to have a high familial aggregation of AIRD, which is more pronounced in the background of parental consanguinity. SLE is the commonest AIRD seen amongst FDRs and SDRs of SLE patients, followed by RA, with FDRs being at highest risk.

Urinary tract infections in renal transplant recipients at a quaternary care centre in Australia.

BACKGROUND: Urinary tract infections (UTI) are the most common of infections after renal transplantation. The consequences of UTIs in this population are serious, with increased morbidity and hospitalisation rates as well as acute allograft dysfunction. UTIs may impair overall graft and patient survival. We aimed to identify the prevalence and risk factors for post-transplant UTIs and assess UTIs' effect on renal function during a UTI episode and if they result in declining allograft function at 2 years post-transplant. Additionally, the causative organism, the class of antibacterial drug employed for each UTI episode and utilisation rates of trimethoprim/sulfamethoxazole (TMP/SMX) prophylaxis were also quantified. METHODS: This was a retrospective study of 72 renal transplant patients over a 5-year period who were managed at the Royal Brisbane and Women's Hospital. Patient charts, pathology records and dispensing histories were reviewed as part of this study and all UTIs from 2 years post transplantation were captured. RESULTS: Of these patients, 20 (27.8%) had at least one UTI. Older age (p = 0.015), female gender (p < 0.001), hyperglycaemia (p = 0.037) and acute rejection episodes (p = 0.046) were risk factors for developing a UTI on unadjusted analysis. Female gender (OR 4.93) and age (OR 1.03) were statistically significant risk factors for a UTI on adjusted analysis. On average, there was a 14.4% (SEM 5.20) increase in serum creatinine during a UTI episode, which was statistically significant (p = 0.027), and a 9.1% (SEM 6.23) reduction in serum creatinine after the UTI episode trending toward statistical significance. (p = 0.076). Common organisms (Escherichia coli and Klebsiella pneumoniae) accounted for 82% of UTI episodes with 70% of UTI cases requiring only a single course of antibiotic treatment. Furthermore, the antibiotic class used was either a penicillin (49%) or cephalosporin (36%) in the majority of UTIs. The use of TMP/SMX prophylaxis for Pneumocystis carinii pneumonia prophylaxis did not influence the rate of UTI, with > 90% of the cohort using this treatment. CONCLUSIONS: There was no significant change in serum creatinine and estimated glomerular filtrate rate from baseline to 2 years post-transplant between those with and without a UTI.

Postoperative intraventricular blood: a new modifiable risk factor for early postoperative symptomatic hydrocephalus in children with posterior fossa tumors.

OBJECTIVE: To analyze factors associated with the development of early symptomatic hydrocephalus following posterior fossa tumor (PFT) surgery in children. METHODS: In this retrospective study, data from 148 children (age < 18 years) who underwent primary resection of their PFTs without preoperative permanent CSF diversion procedures were collected. The incidence of symptomatic hydrocephalus within 30 days of tumor resection was studied and its association with various demographic, tumor-related, and surgery-related risk factors was analyzed. RESULTS: At presentation, 131 (89%) of the 148 patients had symptomatic hydrocephalus. There were 99 males and 49 females (mean age 8.7 years; range 1 to 17 years). Postoperatively, 14 (9.4%) patients required shunt placement for symptomatic hydrocephalus. The indications for shunt surgery were persistent symptoms of raised intracranial pressure (n = 6, 43%), CSF leak from the wound (n = 7, 50%), and tense pseudomeningocele (n = 1, 7%). On multivariate analysis, age < 6 years (OR 5.9, 95% CI 1.6-22.6, p = 0.009) and the presence of intraventricular blood (IVB) on postoperative CT (OR 6.4, 95% CI 1.7-23.7, p = 0.006) were independent risk factors for developing symptomatic hydrocephalus. CONCLUSIONS: The incidence of postoperative symptomatic hydrocephalus in our series (9.4%) is lower than that reported in most previous studies. Age < 6 years and the presence of postoperative IVB were independent risk factors for developing symptomatic hydrocephalus. Of these, postoperative IVB is probably the only modifiable risk factor.

A randomized, controlled trial of an aerosolized vaccine against measles.

BACKGROUND: Aerosolized vaccine can be used as a needle-free method of immunization against measles, a disease that remains a major cause of illness and death. Data on the immunogenicity of aerosolized vaccine against measles in children are inconsistent. METHODS: We conducted an open-label noninferiority trial involving children 9.0 to 11.9 months of age in India who were eligible to receive a first dose of measles vaccine. Children were randomly assigned to receive a single dose of vaccine by means of either aerosol inhalation or a subcutaneous injection. The primary end points were seropositivity for antibodies against measles and adverse events 91 days after vaccination. The noninferiority margin was 5 percentage points. RESULTS: A total of 1001 children were assigned to receive aerosolized vaccine, and 1003 children were assigned to receive subcutaneous vaccine; 1956 of all the children (97.6%) were followed to day 91, but outcome data were missing for 331 children because of thawed specimens. In the per-protocol population, data on 1560 of 2004 children (77.8%) could be evaluated. At day 91, a total of 662 of 775 children (85.4%; 95% confidence interval [CI], 82.5 to 88.0) in the aerosol group, as compared with 743 of 785 children (94.6%; 95% CI, 92.7 to 96.1) in the subcutaneous group, were seropositive, a difference of -9.2 percentage points (95% CI, -12.2 to -6.3). Findings were similar in the full-analysis set (673 of 788 children in the aerosol group [85.4%] and 754 of 796 children in the subcutaneous group [94.7%] were seropositive at day 91, a difference of -9.3 percentage points [95% CI, -12.3 to -6.4]) and after multiple imputation of missing results. No serious adverse events were attributable to measles vaccination. Adverse-event profiles were similar in the two groups. CONCLUSIONS: Aerosolized vaccine against measles was immunogenic, but, at the prespecified margin, the aerosolized vaccine was inferior to the subcutaneous vaccine with respect to the rate of seropositivity. (Funded by the Bill and Melinda Gates Foundation; Measles Aerosol Vaccine Project Clinical Trials Registry-India number, CTRI/2009/091/000673.).

Differential item functioning for items in Berger's HIV Stigma Scale: an analysis of cohorts from the Indian, Swedish, and US contexts.

PURPOSE: To examine whether items in Berger's HIV Stigma Scale function differently with persons of different age, gender, and cultural backgrounds. METHODS: Secondary data from cohorts, collected in South India (n = 250), Sweden (n = 193), and the US (n = 603) were reanalyzed to evaluate DIF within, between, and across these cohorts. All participants had answered the revised version of the HIV stigma scale consisting of 32 items forming the subscales Personalized stigma, Disclosure concerns, Concerns about public attitudes, and Negative self-image. Differential Item Functioning (DIF) for these items was assessed using hybrid ordinal regression-IRT technique. When DIF was detected, the cumulative impact of DIF on individual subscale scores was evaluated. RESULTS: DIF was detected for 9 items within, between, or across cohorts, but the DIF was negligible in general. Detected DIF between the Swedish and Indian cohorts had a cumulative salient impact on individual scores for the subscale Disclosure Concerns; Disclosure concerns were overestimated in the Swedish cohort and both over- and underestimated in the Indian cohort. CONCLUSIONS: The items in the 32-item version of the HIV stigma scale did not seem to be particularly prone to present DIF. The DIF between the Indian and Swedish cohort for items in the subscale Disclosure Concerns could, however, result in both type I and type II errors if scores should be compared between the Indian and Swedish cohort.

CERAD Neuropsychological Battery-Arabic Version: Regression-Based and Stratified Normative Data and Effects of Demographic Variables on Cognitive Performance in Older Omanis.

BACKGROUND AND OBJECTIVES: Normative data on cognitive performance for the Omani population are scarce. In this study, we tested a sample of older (≥50 years) community-dwelling Omanis on the Consortium to Establish a Registry for Alzheimer's Disease neuropsychological battery-Arabic version (CERAD-ArNB). We analyzed the participants' cognitive performance and how it was affected by their sex, age, and level of education. METHODS: We enrolled 150 older Arabic-speaking Omanis from March 2014 to June 2015. Most of the participants were visitors to patients admitted to a tertiary referral center in the Sultanate of Oman. All participants underwent screening to ensure normal cognitive function before taking the CERAD-ArNB. We used multiple regression analysis and stratification according to demographic variables to illustrate the normative data. RESULTS: A total of 125 participants, 65 men (52%) and 60 women (48%), met the inclusion criteria and completed the testing. Multiple regression and univariate analyses showed that although sex and age significantly affected cognitive performance on some CERAD-ArNB subtests, education level had by far the greatest effect. CONCLUSIONS: Lower education level was associated with poorer CERAD-ArNB performance in a sample of cognitively normal Omanis aged 50 years and older. The normative data obtained from this study will help clinicians correctly interpret cognitive performance in the Omani elderly population, and probably in other, culturally similar Arabic-speaking communities.

Awareness and implementation of nine World Health Organization's patient safety solutions among three groups of healthcare workers in Oman.

BACKGROUND: The pressing need to reduce burgeoning poor safety measures affecting millions worldwide has alerted World Health Assembly to set-up mechanisms to increase patient safety. In response to such needs, World Health Organization (WHO) formulated nine life-saving patient safety solutions that would be essential to lower reduce healthcare-related harm. There is a paucity of research examining awareness of such nine patient safety solutions. This study has been designed and conducted to compare self-estimated awareness and practice of the World Health Organization's nine "Life-saving Patient Safety Solutions" aide memoirs among different groups of healthcare workers in Oman. METHODS: All nationwide healthcare workers (nurses, physicians and allied health professionals) in hospitals and primary healthcare under the auspice of Ministry of Health were the target population of this survey. Participants were selected by a simple, systematic random sampling from the list of staff in each representative institution. The study was conducted from November 2012 to February 2013. A total of 800 participants (590 from health centers and 210 from hospitals) were invited to participate in this study. RESULTS: A total number of 763 healthcare professionals consented to participate. The overall response rate was 95 % with the majority being nurses, female staff and who had an average of more than 4 years of experience. Overall, 85 % of the participants self-estimated awareness of the nine life-saving patient safety solutions showed the nurses being the most aware, followed by physicians with the allied health professionals showing suboptimal awareness. The primary healthcare center staff demonstrated higher awareness compared to hospital staff. There was a complex relationship between health professional's age, place of work and awareness and practice. CONCLUSION: This study lays the foundation for international comparisons of self-estimated awareness and practice towards nine patient safety solutions. The data from Oman indicates the need for more attention to be directed towards heightening awareness and practice of the nine patient safety solutions.

COST OF INTENSIVE CARE IN INDIA.

OBJECTIVES: The majority of patients in India access private sector providers for curative medical services. However, there is scanty information on the cost of treatment of critically ill patients in this setting. The study evaluates the cost and extent of financial subsidy required for patients admitted to an intensive care unit (ICU) in India. METHODS: Data on direct medical, direct nonmedical, and indirect cost were prospectively collected from critically ill patients admitted to a tertiary teaching hospital in India. Willingness-to-pay (WTP) amount was obtained from the next-of-kin following admission and the actual cost paid by the family at discharge was recorded. RESULTS: The main diagnoses (n = 499) were infection (26 percent) and poisoning (21 percent). The mean APACHE-II score was 13.9 (95 percent confidence interval [CI], 13.3-14.5); 86 percent were ventilated. ICU stay was 7.8 days (95 percent CI, 7.3-8.3). Hospital mortality was 27.9 percent. Direct medical cost accounted for 77 percent (US$ 2164) of the total treatment cost (US$ 2818). Indirect cost and direct nonmedical cost contributed to 19 percent (US$ 547.5) and 4 percent (US$ 106.5), respectively. Average total and daily ICU cost were US$ 1,897 and US$ 255, respectively. Although the family's WTP was 53 percent (US$ 1146; 95 percent CI, 1090-1204) of direct medical cost, their final contribution was 67.7 percent (US$ 1465; 95 percent CI, 1327-1604). CONCLUSIONS: The cost of an ICU admission in our setting is US$ 2818. Although the family's contribution to expenses exceeded their initial WTP, a substantial subsidy (33 percent) is still required. Alternate financing strategies for the poor and optimization of ICU resources are urgently required.

INCIDENCE OF, AND RISK FACTORS FOR, MALNUTRITION AMONG CHILDREN AGED 5-7 YEARS IN SOUTH INDIA.

Protein-energy malnutrition is a major health problem contributing to the burden of disease in developing countries. The aim of this study was to assess the incidence of, and risk factors for, malnutrition among school-going children in south India. A total of 2496 children aged 5-7 years from rural and urban areas of south India were recruited in 1982 and followed up for malnutrition over a period of 9 years. Their body heights and weights were measured every six months and socio-demographic factors such as mother's education and father's education and relevant household characteristics and hygiene practices collected. Body mass index and height-for-age z-scores were used to determine children's levels of underweight and stunting, respectively, classified as normal, mild/moderate or severe. Risk factor analysis was done for pre-pubertal ages only using Generalized Estimating Equations with cumulative odds assumption. There was a significant difference between male and female children in the incidence of severe underweight and stunting (6.4% and 4.2% respectively). Children in households with no separate kitchen had 1.3 (1.0-1.6) times higher odds of being severely underweight (p=0.044) compared with those with a kitchen. Children without a toilet facility had significantly higher odds of severe underweight compared with those who did. Children with illiterate parents had higher odds of severe stunting than those with literate parents. In conclusion, the prevalence of malnutrition among these south Indian children has not changed over the years, and the incidence of severe malnutrition was highest in children when they were at pubertal age. The risk factors for stunting were mostly poverty-related, and those for underweight were mostly hygiene-related. Adolescent children in south India should be screened periodically at school for malnutrition and provided with nutritional intervention if necessary.

Antiretroviral therapy adherence measurement in non-clinical settings in South India.

Optimal adherence to antiretroviral therapy (ART) is key to viral suppression, but may be impeded by psychosocial consequences of HIV-infection such as stigma and depression. Measures of adherence in India have been examined in clinic populations, but little is known about the performance of these measures outside clinical settings. We conducted a cross-sectional study of 151 Tamil-speaking people living with HIV/AIDS (PLHA) in India recruited through HIV support networks and compared single item measures from the Adult AIDS Clinical Trial Group (AACTG) scale, a visual analog scale (VAS), and a question on timing of last missed dose. Depression was measured using the Major Depression Inventory (MDI) and HIV-related stigma was measured using an adaptation of the Berger Stigma Scale. Mean age was 35.6 years (SD ± 5.9); 55.6% were male; mean MDI score was 11.9 (SD ± 9.1); and mean stigma score was 67.3 (SD ± 12.0). Self-reported perfect adherence (no missed doses) was 93.3% using the AACTG item, 87.1% using last missed dose, and 83.8% using the VAS. The measures had moderate agreement with each other (kappa 0.45-0.57). Depression was associated with lower adherence irrespective of adherence measure used, and remained significantly associated in multivariable analyses adjusting for age and marital status. Stigma was not associated with adherence irrespective of the measure used. The VAS captured the greatest number of potentially non-adherent individuals and may be useful for identifying PLHA in need of adherence support. Given the consistent and strong association between poorer adherence and depression, programs that jointly address adherence and mental health for PLHA in India may be more effective than programs targeting only one.

Pressure-controlled versus volume-controlled ventilation for acute respiratory failure due to acute lung injury (ALI) or acute respiratory distress syndrome (ARDS).

BACKGROUND: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) account for one-quarter of cases of acute respiratory failure in intensive care units (ICUs). A third to half of patients will die in the ICU, in hospital or during follow-up. Mechanical ventilation of people with ALI/ARDS allows time for the lungs to heal, but ventilation is invasive and can result in lung injury. It is uncertain whether ventilator-related injury would be reduced if pressure delivered by the ventilator with each breath is controlled, or whether the volume of air delivered by each breath is limited. OBJECTIVES: To compare pressure-controlled ventilation (PCV) versus volume-controlled ventilation (VCV) in adults with ALI/ARDS to determine whether PCV reduces in-hospital mortality and morbidity in intubated and ventilated adults. SEARCH METHODS: In October 2014, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Isssue 9), MEDLINE (1950 to 1 October 2014), EMBASE (1980 to 1 October 2014), the Latin American Caribbean Health Sciences Literature (LILACS) (1994 to 1 October 2014) and Science Citation Index-Expanded (SCI-EXPANDED) at the Institute for Scientific Information (ISI) Web of Science (1990 to 1 October 2014), as well as regional databases, clinical trials registries, conference proceedings and reference lists. SELECTION CRITERIA: Randomized controlled trials (RCTs) and quasi-RCTs (irrespective of language or publication status) of adults with a diagnosis of acute respiratory failure or acute on chronic respiratory failure and fulfilling the criteria for ALI/ARDS as defined by the American-European Consensus Conference who were admitted to an ICU for invasive mechanical ventilation, comparing pressure-controlled or pressure-controlled inverse-ratio ventilation, or an equivalent pressure-controlled mode (PCV), versus volume-controlled ventilation, or an equivalent volume-controlled mode (VCV). DATA COLLECTION AND ANALYSIS: Two review authors independently screened and selected trials, assessed risk of bias and extracted data. We sought clarification from trial authors when needed. We pooled risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data with their 95% confidence intervals (CIs) using a random-effects model. We assessed overall evidence quality using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. MAIN RESULTS: We included three RCTs that randomly assigned a total of 1089 participants recruited from 43 ICUs in Australia, Canada, Saudi Arabia, Spain and the USA. Risk of bias of the included studies was low. Only data for mortality and barotrauma could be combined in the meta-analysis. We downgraded the quality of evidence for the three mortality outcomes on the basis of serious imprecision around the effect estimates. For mortality in hospital, the RR with PCV compared with VCV was 0.83 (95% CI 0.67 to 1.02; three trials, 1089 participants; moderate-quality evidence), and for mortality in the ICU, the RR with PCV compared with VCV was 0.84 (95% CI 0.71 to 0.99; two trials, 1062 participants; moderate-quality evidence). One study provided no evidence of clear benefit with the ventilatory mode for mortality at 28 days (RR 0.88, 95% CI 0.73 to 1.06; 983 participants; moderate-quality evidence). The difference in effect on barotrauma between PCV and VCV was uncertain as the result of imprecision and different co-interventions used in the studies (RR 1.24, 95% CI 0.87 to 1.77; two trials, 1062 participants; low-quality evidence). Data from one trial with 983 participants for the mean duration of ventilation, and from another trial with 78 participants for the mean number of extrapulmonary organ failures that developed with PCV or VCV, were skewed. None of the trials reported on infection during ventilation or quality of life after discharge. AUTHORS' CONCLUSIONS: Currently available data from RCTs are insufficient to confirm or refute whether pressure-controlled or volume-controlled ventilation offers any advantage for people with acute respiratory failure due to acute lung injury or acute respiratory distress syndrome. More studies including a larger number of people given PCV and VCV may provide reliable evidence on which more firm conclusions can be based.

Small for gestational age births among South Indian women: temporal trend and risk factors from 1996 to 2010.

BACKGROUND: The birth weight and gestational age at birth are two important variables that define neonatal morbidity and mortality. In developed countries, chronic maternal diseases like hypertension, diabetes mellitus, renal disease or collagen vascular disease is the most common cause of intrauterine growth restriction (IUGR). Maternal nutrition, pregnancy induced hypertension, chronic maternal infections, and other infections such as cytomegalovirus, parvovirus, rubella and malaria are the other causes of IUGR. The present study examines the secular trend of Small for Gestational Age (SGA) over 15 years and risk factors for SGA from a referral hospital in India. METHODS: Data from 1996 to 2010 was obtained from the labour room register. A rotational sampling scheme was used i.e. 12 months of the year were divided into 4 quarters. Taking into consideration all deliveries that met the inclusion criteria, babies whose birth weights were less than 10(th) percentile of the cut off values specific for gestational ages, were categorized as SGA. Only deliveries of live births that occurred between 22 and 42 weeks of pregnancy were considered in this study. Besides bivariate analyses, multivariable logistic regression analysis was done. Nagelkerke R(2) statistics and Hosmer and Lemeshow chi-square statistics were used as goodness of fit statistics. RESULTS: Based on the data from 36,674 deliveries, the incidence of SGA was 11.4% in 1996 and 8.4% in 2010. Women who had multiple pregnancies had the higher odds of having SGA babies, 2.8 (2.3-3.3) times. The women with hypertensive disease had 1.8 (1.5-1.9) times higher odds of having SGA. Underweight women had 1.7 (1.3 - 2.1) times and anaemic mothers had 1.29 (1.01 - 1.6) times higher odds. The mothers who had cardiac disease were 1.4 (1.01 - 2.0) times at higher odds for SGA. In teenage pregnancies, the odds of SGA was 1.3 (1.1 - 1.5) times higher than mothers in the age group 20 to 35 years. CONCLUSIONS: There is a significant reduction in the incidence of SGA by 26% over 15 years. The women with the above modifiable risk factors need to be identified early and provided with health education on optimal birth weight.

Are Indian patients with juvenile-onset ankylosing spondylitis taller than reference population ?

BACKGROUND & OBJECTIVES: Paucity of growth retardation has been observed by us in patients with juvenile-onset ankylosing spondylitis (JAS) in a tertiary care health centre in south India. We, therefore, undertook this pilot study to assess and compare anthropometry of patients with JAS who were 15 yr and older with that of adult onset ankylosing spondylitis (AAS) and matching Indian reference population. METHODS: Consecutive male patients (December 2009- October 2012) with JAS and AAS fulfilling Modified New York Criteria were selected after applying inclusion and exclusion criteria. Demography and anthropometry were noted. Height of both patient groups as well as their parents and siblings were compared with that of the reference population. Mid-parental height and delta height were derived. Those with delta height of >8.5 cm were compared with the remaining. Multivariate logistic regression was done for variables that were found to be significant by chi-square in bivariate analysis. Similar analysis was done for BMI also. RESULTS: There was no significant difference in anthropometric variables between JAS and AAS groups. Twenty eight of the 30 (93.33%) JAS patients were taller as compared to the reference population. Twenty six (86.67%) AAS patients were taller than the reference population. The mean heights of JAS (170.67 ± 6.94 cm) and AAS (168.2 ± 5.94 cm) patients were significantly higher than the reference value of 163.11 cm; both p0 <0.001. Logistic regression revealed that tallness in JAS was associated positively with hypermobility (OR=23.46,95%CI 1.2-447.2, p0 =0.036). No significant association was detected for height in AAS and for BMI in both JAS and AAS groups. INTERPRETATION & CONCLUSIONS: No growth retardation was seen in patients with JAS in our study. Majority of patients with JAS and AAS were taller than reference population. The difference between mean height of JAS and AAS was not significant. Larger studies involving different populations are required to confirm these findings.