Addition of bioimpedance-derived body cell mass improves performance of serum creatinine-based GFR estimation in a chronic kidney disease cohort.

PURPOSE: Serum creatinine-based glomerular filtration rate (GFR) estimating equations are imprecise and systemic overestimate GFR in chronic kidney disease (CKD) populations with low muscle mass. Bioimpedance devices can measure body cell mass (BCM), a surrogate for muscle mass which has been included in a published GFR estimating equation. This BCM GFR equation is validated and compared with MDRD and CKD-EPI 2021 equations in an Indian CKD population. METHODS: Patients with stable CKD stages 1-5 and voluntary kidney donors underwent measurement of serum creatinine, DTPA GFR and bioimpedance on the same day. BCM GFR was tested for consistency, agreement and performance with respect to DTPA GFR. RESULTS: A total of 125 study participants were enrolled, including 106 patients with CKD (Stage 1: 8; stage 2: 32, stage 3: 42, stage 4: 20 and stage 5: 4 patients) and 19 voluntary kidney donors, with 66% males, and a mean age of 43.3 (± 16.5) years. The median bias of BCM GFR was 5.45 ml/min/1.73 m2 [95% confidence interval (CI) 4.2-8.3], absolute precision was 10.16 ml/min/1.73 m2 [95% CI 4.5-12.6], P30 was 59.1% [95% CI 50.0-67.7] and accuracy was 8.62% [95% CI 6.4-20.0]. Kappa measurement of agreement was the highest for BCM GFR-based staging (0.628 vs 0.545 for MDRD and 0.487 for CKD-EPI). CONCLUSION: BCM-based GFR estimating equation performed better than MDRD and CKD-EPI equations in this Indian CKD population, and BCM GFR-based KDIGO staging was associated with lesser misclassification than the MDRD and CKD-EPI equations. TRIAL REGISTRATION (PROSPECTIVE): Clinical Trials Registry of India (CTRI/2019/11/021850).

Factors Affecting Best-Tolerated Dose of Pirfenidone in Patients with Fibrosing Interstitial Lung Disease.

The aim of the study was to examine the best-tolerated dose of pirfenidone, the adverse effects profile, and potential factors other than drug dose influencing the tolerability of pirfenidone in patients with fibrosing interstitial lung diseases (ILDs). We performed an observational retrospective study of 113 patients with IPF and other fibrosing ILDs treated with pirfenidone. Baseline liver function tests (LFTs) and dose escalation of pirfenidone were recorded for all patients. The best-tolerated dose was continued if the patient did not tolerate full dose (2400 mg) despite repeated dose escalation attempts. Potential risk factors such as age, height, weight, body mass index (BMI), body surface area (BSA), gender, smoking, and presence of comorbidities were analyzed between 3 groups of best-tolerated pirfenidone doses: 2400 mg/day vs. <2400 mg/day, 2400 mg/day vs. 1800 mg/day, and 2400 mg/day vs. 1200 mg/day. A total of 24 patients tolerated 2400 mg/day, and 89 patients tolerated <2400 mg/day (43 tolerated 1800 mg/day, 45 tolerated 1200 mg/day and 1 tolerated 600 mg/day). Patients who tolerated 2400 mg/day were taller and had a larger BSA as compared to those tolerating <2400 mg/day. Overall, males tolerated the drug better. Presence of comorbidities or smoking did not affect the tolerance of pirfenidone, except for the presence of cerebrovascular diseases. Various adverse effects did not have any significantly different frequencies between the compared groups. Moreover, 71.7% of patients experienced at least one side effect. 1200 mg/day was the best-tolerated dose in the majority of the patients. Male patients with a larger BSA and greater height showed better tolerability of pirfenidone overall.

Cost-effectiveness of population-based screening for oral cancer in India: an economic modelling study.

Background: Oral cancer screening reduces mortality associated with oral cancer. The current study evaluated the cost-effectiveness of commonly used screening techniques, namely conventional oral examination (COE), toluidine blue staining (TBS), oral cytology (OC), and light-based detection (LBD) in the Indian scenario. Methods: The study used a Markov modelling approach to estimate the cost and health outcomes of four different approaches (COE, TBS, OC, and LBD) for screening oral cancer over time from a societal perspective. The discount rate was assumed as 3%. The outcomes estimated were oral cancer incident cases, deaths averted, and quality-adjusted life years (QALYs). To address the high burden of risk factors (tobacco and/or alcohol) in India, two Markov models were developed: Model A adopted a mass-screening strategy, whereas Model B adopted a high-risk screening strategy versus no screening. Probabilistic sensitivity analysis (PSA) was undertaken to address any parameter uncertainty. Findings: Mass-screening using LBD at three years had the least incident cases (3271.68) and averted the maximum number of oral cancer deaths (459.76). High-risk screening using COE at ten years interval incurred the least lifetime cost of 2,292,816.21 US$ (182,794,468.26 INR). The high-risk strategies (US$/QALY), namely COE 5 years (-29.21), COE 10 years (-90.68), TBS 10 years (-60.54), and LBD 10 years (-13.51), were dominant over no-screening. Interpretation: The most cost-saving approach was the conventional oral examination at an interval of 10 years for oral screening in high-risk populations above 30 years of age. Funding: Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Efficacy of flupirtine for postoperative pain: A systematic review and meta-analysis.

Background and Aims: Flupirtine has been used for various chronic pain conditions, but its utility in the perioperative period as an analgesic is still inconclusive. This systematic review and meta-analysis aimed to assess the efficacy of flupirtine for postoperative pain. Methods: PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) were explored for the randomised controlled trials (RCTs) which compared flupirtine with other analgesic/placebo for perioperative pain in adult patients undergoing surgery. The standardised mean difference (SMD) of pain scores, the need for rescue analgesia and all adverse effects were assessed. Heterogeneity was assessed using Cochrane's Q statistic test and I2 statistic. Cochrane Collaboration's tool was used to evaluate the risk of bias and the quality of the RCTs. Results: A total of 13 RCTs (including 1,014 patients) that evaluated the use of flupirtine for postoperative pain were included in the study. The pooled SMD of postoperative pain scores revealed that flupirtine and other analgesics were comparable at 0, 6, 12 and 24 hours (P > 0.05), while at 48 hours, flupirtine showed poor pain control (P = 0.04) as compared to other analgesics. There were no significant differences at other time points and on comparison of flupirtine with placebo. The side effect profile was comparable between flupirtine and other analgesics. Conclusion: The current evidence suggests that perioperative flupirtine was not superior to other most commonly used analgesics and placebo for the treatment of postoperative pain.

The impact of a "short-term" basic intensive care training program on the knowledge of nonintensivist doctors during the COVID-19 pandemic: An experience from a population-dense low- and middle-income country.

BACKGROUND: The utility of basic intensive care unit (ICU) training comprising a "1-day course" has been scientifically evaluated and reported in very few studies, with almost no such study from resource-limited settings. AIM: The study assessed the utility of basic ICU training comprising of a "1-day course" in increasing the knowledge of nonintensivist doctors. MATERIALS AND METHODS: This is an observational study conducted at a medical university in North India in 2020. The participants were nonintensivist doctors attending the course. The course was designed by intensivists, and it had four domains. The participants were categorised on the basis of their duration of ICU experience and broad speciality. Pretest and posttest was administered, which was analysed to ascertain the gain in the knowledge score. RESULTS: A total of 252 participants were included, of which the majority were from the clinical medicine speciality (85.3%) and had ICU experience of 1-6 months (47.6%). There was a significant improvement in the mean total score of the participants after training from 14/25 to 19/25, with a mean difference (MD) of 5.02 (p < 0.001). Based on ICU experience, in groups I (<1 month), II (1-6 months), and III (>6 months), there was a significant improvement in the total score of the participants after training with MD with 95% confidence interval (CI) limits of 5.27 (4.65-5.90), 4.70 (4.38-5.02), and 5.33 (4.89-5.78), respectively. In the clinical surgery specialty (n = 37), there was a significant improvement in the total score after training from 11/25 to 16.4/25 with an MD (95% CI limits) of 5.38 (4.4-6.3). Similarly, in the clinical medicine group (n = 215), the MD (95% CI limits) score after training was 4.95 (4.71-5.20), from 14.5/25 to 19.5/25. In feedback, more than half of the participants showed interest in joining ICU after training. CONCLUSIONS: Training nonintensivist doctors for 1 day can be useful in improving their knowledge, regardless of their prior ICU experience and speciality.

Diagnostic Accuracy of Screening of Lip and Oral Cavity Cancers or Potentially Malignant Disorders (PMD) by Frontline Workers: A Systematic Review and Meta-Analysis.

BACKGROUND: Oral cancer screening strategies help reduce associated mortality and could be performed by a trained frontline health worker (FHW). The present review aims to assess the diagnostic accuracy of commonly used screening modalities for oral cancer performed by FHW in apparently healthy individuals. METHODS: Electronic databases PubMed, Scopus, Embase, Cochrane Library, and Google Scholar, were searched. The review included studies conducted where apparently healthy adult individuals were screened by the FHW for cancer or PMD of the lip and oral cavity by any of the four commonly used techniques - Conventional Oral Examination (COE), toluidine blue staining (TBS), Oral Cytology (OC), and Chemiluminescent Illumination (CLI). FINDINGS: A total of 2,413 potentially relevant articles were retrieved from the search, among which five studies for COE were included in the review. Four out of those five studies were done before the year 2000. None of the studies fitted the inclusion criteria for TBS, OC, and CLI. Pooled sensitivity of oral screening by COE performed by an FHW (n=5) was 88.8% (95% CI: 71.6-96.1), whereas pooled specificity was 91.9% (95% CI: 78.3-97.3). On subgroup analysis, the pooled sensitivity and specificity of studies where the prevalence of disease was <50% (n=4) was 84.5% (95% CI: 62.6 - 94.7) and 94.1% (95% CI: 82.2 - 98.2), respectively. INTERPRETATION: COE by trained FHW had high pooled sensitivity and specificity for screening of oral cancer and PMDs. The screening techniques TBS, OC, and CLI, were not studied for mass screening by trained FHW. COE by trained FHW could be utilized for oral screening in limited-resource settings. However, the FHW should be sufficiently trained to get the desired benefits of early detection. FUNDING: Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Cancer prevention and control in India can get a boost through primary health care-based approach: A review.

India has a rising burden of cancer with an estimated 70% of the cancers caused by modifiable and preventable risk factors. This review was conducted to document the status, analyse the situation and propose the way forward for cancer prevention in India. A desk review of the online databases and reports from the government websites was conducted. The ongoing initiatives including cancer registries, medical and health education and training, and community-based programmes were analysed. This review was done from July 2019 to February 2021. Cancers of the breast, cervix, and lip and oral cavity are the three most common malignancies, with distinct regional variations in India and account for 34% of the 1.15 million cancer cases diagnosed annually. The major initiatives were focused initially on cancer treatment and prevention was added nearly a decade ago. Even with those, the scope and coverage of cancer prevention and treatment services has remained in hospitals and urban settings. India needs to build upon the ongoing approach which seems to be focused on "tracking the cancer, teaching the future and helping the masses" by implementing non-vertical primary healthcare cancer prevention and control approach. Cancer prevention should be made an integral part of the health interventions, rapidly extended to primary healthcare services and facilities, linked with specialised treatment facilities, as India aims for universal health coverage. The opportunity provided by the Ayushman Bharat Programme launched in 2018 should be leveraged for rapid expansion and effective coverage of cancer prevention and treatment interventions in India.

Role of low dose computed tomography on lung cancer detection and mortality - an updated systematic review and meta-analysis.

Chest low dose computed tomography (LDCT) is reported to be a sensitive tool for the detection of lung cancer at asymptomatic stage, thus reducing mortality. The review assesses the effect of LDCT screening on all-cause mortality, lung cancer mortality and incidence rates. We conducted literature searches of PubMed, SCOPUS, and the Cochrane Library from inception through January 2020 to identify relevant studies assessing the diagnostic accuracy of LDCT for lung cancer. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for reporting this meta-analysis and review. The inclusion criteria were a) Randomized control trials, b) Comparing LDCT to any other form of screening or standard of care, and (c) Primary outcome studied: all-cause mortality, lung cancer-specific mortality, rate of early detection of lung cancer. A total of 11 studies encompassing 97,248 patients were included. When compared with controls (no screening or CXR), LDCT screening was associated with statistically significant reduction in lung cancer mortality (pooled RR 0.86; 95% CI 0.75-0.98); low heterogeneity was observed (I2= 27.86). However, LDCT screening was not associated with statistically significant reduction in all-cause mortality (RR =0.96; 95% CI: 0.92 -1.01). Notably, the LDCT screening was associated with statistically significant increase in lung cancer detection (RR =1.76; 95% CI: 1.14-2.72). LDCT screening has the potential to reduce mortality due to lung cancer among high-risk individuals. LDCT could be considered as a screening modality after careful assessment of other factors like prevalence of TB, proportion of high-risk population, cost, access and availability of LDCT.

Effectiveness of Visual Inspection with Acetic Acid (VIA) Screening on Cervical Cancer Mortality and Incidence - A Systematic Review and Meta-Analysis.

OBJECTIVES: Despite being a cheap, easy, and commonly used technique for screening early development of cervical cancer, collective evidence on the effect of visual inspection with acetic acid (VIA) for reducing cervical cancer mortality and incidence are conflicting. We conducted a systematic review and meta-analysis to determine the effectiveness of VIA screening on cervical cancer mortality and incidence. METHODS: We searched PubMed, Embase, Cochrane library (Cochrane Database of Systematic Reviews & Cochrane Central Register of Controlled Trials), World Health Organization's (WHO) International Clinical Trials Registry Platform, and Google Scholar to identify studies conducted among women with no history of cervical cancer that assessed effectiveness of VIA on the cervical cancer mortality and incidence. Random effects model was used to estimate incident rate ratio and sensitivity analysis was conducted using Bayesian methods. RESULTS: Of the included 4 studies, three were cluster randomized trials from India and one was quasi-experimental study done in Thailand. Duration of follow-up ranged from 7 to 12 years. Based on 3 trials, pooled rate-ratio for cervical cancer mortality and all-cause mortality was 0.68 (95% CI: 0.56-0.81, I2=0%) and 0.91 (0.85-0.97, I2=57%), respectively. Pooled rate-ratio of invasive cervical cancer was 0.94 (95% CI: 0.67 - 1.30, I2=84%). Likewise, there was non-significant reduction in incidence of stage IB, >=stage II, and unknown stage cervical cancer. CONCLUSIONS: VIA screening may lead to reduction in cervical cancer and all-cause mortality in long run. However, the effectiveness of VIA in preventing invasive cervical cancer is inconclusive.

Diagnostic utility of endobronchial ultrasound (EBUS) features in differentiating malignant and benign lymph nodes - A systematic review and meta-analysis.

BACKGROUND: EBUS is being widely used today for echolocation of lymph nodes for FNAC. We present a systematic review and meta-analysis to assess the diagnostic accuracy of EBUS characteristics of lymph nodes in diagnosing malignancy. METHODS: A systematic search of published literature was undertaken using databases like PubMed, Web of Science, Cochrane, Google Scholar and Researchgate. Those studies reporting any endobronchial ultrasonography features of malignant lymph nodes like size, margins, echogenicity, shape, central hilar structure (CHS), coagulation necrosis sign (CNS) or color power doppler index (CPDI) were included for review. Random effects model was used to calculate pooled sensitivity, specificity, positive and negative likelihood ratios (LR), and diagnostic odds ratio (DOR). The review protocol was registered with the International prospective register of systematic reviews (PROSPERO registration no. CRD42019117716). RESULTS: 992 articles were retrieved of which 542 articles were evaluated in detail and finally 29 articles met the inclusion criteria. All EBUS features except CPDI showed a statistically significant area under the SROC curve. CNS showed highest area under the SROC curve [0.81 (SE: 0.09)] with maximum pooled specificity [0.93, 95%CI: 0.92-0.94], maximum pooled LR+ [5.12, 95%CI: 2.56-10.2] and DOR [9.23, 95%CI 3.85-22.15]. Maximum sensitivity was seen for CHS 0.91 [95%CI: 0.90-0.92]. CONCLUSION: EBUS features have the potential to help in more precise location of a malignant lymph node thereby helping in increasing the diagnostic yield. However, high diagnostic accuracy of various EBUS features can currently only be said to supplement tissue diagnosis.

Prevalence and correlates of sexual health disorders among adult men in a rural area of North India: An observational study.

BACKGROUND AND OBJECTIVES: Sexual health disorders are an important but less researched public health issue in India. We aimed to estimate the prevalence of sexual health disorders and their associated factors among adult men in a rural community of Haryana, India. MATERIALS AND METHODS: A community-based cross-sectional study was conducted among adult men aged 18-60 years using a multistage stratified random sampling. Information pertaining to sociodemographic characteristics, lifestyle and sexual practices, and self-reported sexual problems were collected. Sexual health disorders were defined based on International Statistical Classification of Diseases-10 classification of mental and behavioral disorders. Step-wise logistic regression was carried out to identify factors independently associated with sexual disorders. RESULTS: At least one sexual health disorder was reported by 81% of the men. The most commonly reported disorder was self-perceived defect in semen (64.4%), followed by loss of libido (21%), masturbation guilt (20.8%), erectile dysfunction (5%), and premature ejaculation (4.6%). Factors significantly associated with sexual health disorders among all men were being never married (odds ratio = 2.04; 95% confidence interval: 1.51, 2.77), smoking (1.57; 1.16, 2.14), cannabis use (4.20; 1.68, 10.48), diabetes (2.40; 1.22, 4.73), and hypertension (3.17; 1.12, 8.92). INTERPRETATION AND CONCLUSIONS: A high burden of sexual health disorders was identified among the rural men. Wider recognition of this issue is needed among the health-care providers and policymakers.