Factors associated with unexplained sudden deaths among adults aged 18-45 years in India - A multicentric matched case-control study.

BACKGROUND OBJECTIVES: In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case-control study. METHODS: This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1 st October 2021-31 st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI). RESULTS: Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not. INTERPRETATION CONCLUSIONS: COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death.

Prevalence and antimicrobial resistance of Escherichia coli and Salmonella spp. in animal feed in Colombia / Prevalencia y resistencia a los antimicrobianos de Escherichia coli y Salmonella spp. en los alimentos para animales en Colombia / Prevalência e resistência a antimicrobianos de Escherichia coli e Salmonella spp. em ração animal na Colômbia

ABSTRACT Objective. To determine the prevalence and antimicrobial resistance of Escherichia coli and Salmonella spp. in animal feed samples collected between 2018 and 2021 in Colombia. Methods. This was a laboratory-based cross-sectional study using routine data from the program for inspection, surveillance, and control of animal feed at the Colombian Agriculture Institute. Samples of animal feed for swine, poultry, canine, feline, leporine, piscine, and equine species were processed for detection of E. coli and Salmonella spp. using enrichment and selective culture methods. Isolates were tested for antimicrobial susceptibility using an automated microdilution method. Results. Of 1 748 animal feed samples analyzed, 83 (4.7%) were positive for E. coli and 66 (3.8%) for Salmonella spp. The presence of E. coli and Salmonella spp. was highest in feed for poultry (6.4% and 5.5%) and swine (6.1% and 4.3%). Antimicrobial resistance testing was performed in 27 (33%) E. coli isolates and 26 (39%) Salmonella isolates. Among E. coli, resistance was most frequently observed to ampicillin (44.5%) followed by cefazolin (33.3%), ciprofloxacin (29.6%), ampicillin/sulbactam (26%), and ceftriaxone (11.1%). The highest resistance levels in Salmonella spp. isolates were against cefazolin (7.7%) and piperacillin/tazobactam (7.7%). Conclusions. This is the first study from Colombia reporting on the prevalence and antimicrobial resistance of E. coli and Salmonella spp. in animal feed samples. Its results establish a baseline over a wide geographical distribution in Colombia. It highlights the need to integrate antimicrobial resistance surveillance in animal feed due to the emergence of resistant bacteria in this important stage of the supply chain.

RESUMEN Objetivo. Determinar la prevalencia y resistencia a los antimicrobianos de Escherichia coli y Salmonella spp. en muestras de piensos para animales tomadas entre el 2018 y el 2021 en Colombia. Métodos. Se trata de un estudio transversal realizado en el laboratorio a partir de los datos regulares del programa de inspección, vigilancia y control de alimentos para animales del Instituto Colombiano Agropecuario. Se procesaron muestras de alimentos utilizados en la cría de cerdos, aves de corral, cánidos, félidos, lepóridos, peces y equinos con el fin de detectar E. coli y Salmonella spp. por medio de métodos de enriquecimiento y cultivo selectivo. Se analizó la sensibilidad a los antimicrobianos de las cepas aisladas mediante microdilución automatizada. Resultados. De 1748 muestras de alimentos analizadas, 83 (4,7%) resultaron positivas para E. coli y 66 (3,8%) para Salmonella spp. La presencia de E. coli y Salmonella spp. fue mayor en los alimentos para aves de corral (6,4% y 5,5%) y cerdos (6,1% y 4,3%). Se realizaron pruebas de resistencia a los antimicrobianos en 27 (33%) cepas de E. coli y 26 (39%) de Salmonella. En las cepas de E. coli, se observó una mayor resistencia a la ampicilina (44,5%), seguida de la resistencia a la cefazolina (33,3%), la ciprofloxacina (29,6%), la ampicilina/sulbactam (26%) y la ceftriaxona (11,1%). En el caso de las cepas de Salmonella spp., los niveles de resistencia más elevados fueron para la cefazolina (7,7%) y piperacilina/tazobactam (7,7%). Conclusiones. Este es el primer estudio realizado en Colombia en el que se informa sobre la prevalencia y la resistencia a los antimicrobianos de E. coli y Salmonella spp. en muestras de alimentos para animales. Sus resultados establecen una línea de base para una zona geográfica mucho mayor dentro de Colombia. Se subraya la necesidad de integrar la vigilancia de la resistencia a los antimicrobianos en los alimentos para animales debido a la aparición de bacterias resistentes en esta importante etapa de la cadena de suministro.

RESUMO Objetivo. Determinar a prevalência e a resistência a antimicrobianos de Escherichia coli e Salmonela spp. em amostras de ração animal coletadas entre 2018 e 2021 na Colômbia. Métodos. Estudo transversal de base laboratorial, usando dados de rotina do programa de inspeção, vigilância e controle de ração animal do Instituto Colombiano de Agricultura. Amostras de ração animal para as espécies suína, avícola, canina, felina, leporina, piscina e equina foram processadas para detecção de E. coli e Salmonella spp., usando métodos de enriquecimento e cultura seletiva. Os isolados foram testados quanto à suscetibilidade a antimicrobianos usando um método automatizado de microdiluição. Resultados. Das 1.748 amostras de ração animal analisadas, 83 (4,7%) foram positivas para E. coli e 66 (3,8%) para Salmonella spp. A presença de E. coli e Salmonella spp. foi maior em rações para aves (6,4% e 5,5%) e suínos (6,1% e 4,3%). O teste de resistência a antimicrobianos foi realizado em 27 (33%) isolados de E. coli e 26 (39%) isolados de Salmonella. Em E. coli, a resistência observada com maior frequência foi à ampicilina (44,5%), seguida da cefazolina (33,3%), ciprofloxacino (29,6%), ampicilina/sulbactam (26%) e ceftriaxona (11,1%). Os maiores níveis de resistência em isolados de Salmonella spp. foram contra cefazolina (7,7%) e piperacilina/tazobactam (7,7%). Conclusões. Este é o primeiro estudo da Colômbia a notificar a prevalência e resistência a antimicrobianos de E. coli e Salmonella spp. em amostras de ração animal. Os resultados estabelecem uma linha de base com ampla distribuição geográfica na Colômbia. Destaca-se a necessidade de integrar a vigilância da resistência a antimicrobianos na ração animal, devido ao surgimento de bactérias resistentes nesta importante etapa da cadeia de abastecimento.

Multidrug-resistant Salmonella spp. in fecal samples of pigs with suspected salmonellosis in Antioquia, Colombia, 2019-2021 / Salmonella spp. multirresistentes en muestras fecales de cerdos con presunta salmonelosis en Antioquia, Colombia, 2019-2021 / Salmonella spp. multirresistente em amostras fecais de suínos com suspeita de salmonelose em Antioquia, Colômbia, 2019-2021

ABSTRACT Objectives. To determine the proportion of Salmonella enterica in fecal samples of live pigs with suspected salmonellosis analyzed at the diagnostic unit of the University of Antioquia, Colombia between 2019 and 2021, and examine the serotypes and antimicrobial resistance patterns. Methods. This was a laboratory-based cross-sectional study of routine data on fecal samples received from pig farms in all nine subregions of Antioquia state, Colombia. Salmonella spp. detection at the university is done using enrichment, selective culture, and polymerase chain reaction. Serotypes were identified using the Kauffmann-White scheme and isolates were tested for antimicrobial susceptibility using broth microdilution. Results. Of 653 samples tested, 149 (23%) were positive for S. enterica. Nine serotypes were identified. The most common were Salmonella Typhimurium (56%) and its monophasic variant (35%). Resistance to ampicillin (70%) was most frequently observed, followed by ciprofloxacin (55%), and sulfamethoxazole-trimethoprim (52%). No isolates were resistant to amikacin and gentamicin. Multidrug resistance (resistance to ≥ 3 classes of antibiotics) was observed in 61 (44%) isolates. Multidrug resistance was highest in S. Typhimurium (57%) compared with the other serotypes. Serotype was associated with multidrug resistance (p = 0.01), but age of the pig and sub-region were not. Conclusions. The proportion of Salmonella spp. and the associated high levels of multidrug resistance are of concern and may indicate irrational use of antimicrobials and poor management practices in pig production systems in the region. Strengthened surveillance is needed to monitor and improve farm management practices and the use of antimicrobials in farms in Colombia.

RESUMEN Objetivos. Determinar la proporción de Salmonella enterica en muestras fecales de cerdos vivos con presunta salmonelosis analizadas en la unidad de diagnóstico de la Universidad de Antioquia (Colombia) entre el 2019 y el 2021, así como examinar los serotipos y los patrones de resistencia a los antimicrobianos. Métodos. Se trata de un estudio transversal de laboratorio sobre datos ordinarios de muestras fecales provenientes de granjas porcinas de las nueve subregiones del departamento de Antioquia (Colombia). La detección de Salmonella spp. en la universidad se realiza mediante el enriquecimiento, el cultivo selectivo y la reacción en cadena de la polimerasa. Se identificaron los serotipos con el esquema de Kauffmann-White y se examinaron las cepas aisladas para determinar la susceptibilidad antimicrobiana mediante microdilución en caldo. Resultados. De las 653 muestras analizadas, 149 (23%) dieron un resultado positivo para S. enterica. Se identificaron nueve serotipos. Los más comunes fueron Salmonella typhimurium (56%) y su variante monofásica (35%). La resistencia a la ampicilina fue la observada con mayor frecuencia (70%), seguida de la resistencia al ciprofloxacino (55%) y al sulfametoxazol-trimetoprima (52%). Ninguna cepa aislada fue resistente a la amikacina y la gentamicina. Se observó resistencia a múltiples fármacos (resistencia a tres o más clases de antibióticos) en 61 cepas (44%). La resistencia a múltiples fármacos fue más elevada en el caso de S. typhimurium (57%) en comparación con los otros serotipos. Se asoció el serotipo con la resistencia a múltiples fármacos (p = 0,01), a diferencia de la edad del cerdo y la subregión. Conclusiones. La proporción de Salmonella spp. y los elevados niveles asociados de resistencia a múltiples fármacos son preocupantes y pueden ser un indicativo de uso irracional de antimicrobianos y malas prácticas de gestión en los sistemas de producción porcina de la región. Es necesario reforzar la vigilancia para dar seguimiento y mejorar las prácticas de gestión agropecuaria y el uso de antimicrobianos en las granjas en Colombia.

RESUMO Objetivos. Determinar a proporção de Salmonella enterica em amostras de fezes de suínos vivos com suspeita de salmonelose analisadas na unidade de diagnóstico da Universidade de Antioquia, Colômbia, entre 2019 e 2021, e examinar seus sorotipos e padrões de resistência a antimicrobianos. Métodos. Estudo transversal, de base laboratorial, utilizando dados de rotina de amostras de fezes recebidas de suinocultores em todas as nove sub-regiões do estado de Antioquia, Colômbia. A detecção de Salmonella spp. na Universidade é feita por enriquecimento, cultura seletiva e reação em cadeia da polimerase. Os sorotipos foram identificados usando o esquema de Kauffmann-White, e os isolados foram testados quanto à suscetibilidade aos antimicrobianos pelo método de microdiluição em caldo. Resultados. Das 653 amostras testadas, 149 (23%) foram positivas para S. enterica. Foram identificados nove sorotipos. Os mais comuns foram Salmonella Typhimurium (56%) e sua variante monofásica (35%). A resistência à ampicilina (70%) foi observada com maior frequência, seguida pela resistência ao ciprofloxacino (55%) e ao sulfametoxazol/trimetoprima (52%). Nenhum isolado apresentou resistência à amicacina ou gentamicina. Multirresistência (resistência a ≥ 3 classes de antibióticos) foi observada em 61 isolados (44%). A multirresistência foi mais comum em S. Typhimurium (57%), em comparação aos outros sorotipos. Foi constatada associação da multirresistência com sorotipos (p = 0,01), mas não com idade do suíno ou sub-região. Conclusões. A proporção de Salmonella spp. e os níveis elevados associados de multirresistência a antimicrobianos aqui constatados são preocupantes, e podem indicar uso irracional de antimicrobianos e práticas inadequadas de manejo nos sistemas de suinocultura da região. É preciso fortalecer a vigilância para monitorar e melhorar as práticas de manejo agrícola e o uso de antimicrobianos em fazendas na Colômbia.

Hypertension and its association with body mass index among the Indian population. Findings from a nationwide survey (NFHS-4), 2015-16.

Background: Globally, hypertension (HTN) and obesity are two cardinal causes of morbidity and mortality. The Asian population shows comorbidities associated with obesity at a much lower body mass index (BMI) than the western population. Aim: The primary objective of the present study was to evaluate the association between BMI and HTN among the adult population. Material and Methods: We did a cross-sectional secondary data analysis of the NFHS-4 datasets, conducted during 2015-16. We included the adult population, that is, ≥19 years of age (93,040 men and 5,46,066 women), and excluded adolescents and pregnant women from our analysis. HTN was the primary dependent variable, while BMI was the primary predictor variable. Other covariates included age, education, place of residence, wealth index, use of alcohol and tobacco, and diabetes. Weighted analysis was done to depict our results. Results: Around 18.7% of men and 13.5% of women were hypertensive, of which 53.86% of males and 38.7% females were either overweight or obese. The odds of living with HTN among obese men and women increased with age, wealth, use of alcohol and tobacco, and comorbidities such as diabetes. The prevalence of HTN was higher even among the underweight adults living with diabetes and those consuming alcohol and tobacco. Conclusion: We reaffirm the significant association between BMI and HTN among adults. The use of the Asian classification of BMI for India and its neighboring countries to assess the burden of obesity would help in planning better interventions. A community-based targeted approach would help in controlling and reducing the prevalence of HTN.

Screening adults with tuberculosis for severe illness at notification: programme experience from Gujarat, India.

BACKGROUND: National tuberculosis (TB) programmes in high-burden countries do not systematically assess severity at diagnosis followed by referral for inpatient care. Due to limited capacity, comprehensive assessment of all TB patients is not practical. In three districts of Gujarat (West India) in June 2021, we determined the feasibility of screening for severe illness by paramedical staff of public facilities and the burden of 'high risk for severe illness' at notification among adults (≥15 y of age) with TB. METHODS: In this cross-sectional study, the screening criteria for high risk for severe illness was the presence of any one of the following: body mass index (BMI) ≤14.0 kg/m2, BMI ≤16.0 kg/m2 with bilateral leg swelling, respiratory rate >24/min, oxygen saturation <94% or inability to stand without support. We summarized the feasibility indicators and burden using proportion (95% confidence interval [CI]) and median, as applicable. RESULTS: Of 626 notified adults, 87% were screened. The median time interval for screening was 3 d from notification and all indicators were collected in 97% of patients. The burden of high risk for severe illness was high, at 41.6% (95% CI 37.5 to 45.8). CONCLUSIONS: High burden and feasibility (high coverage, acceptable time interval and minimal missing data) makes a strong case for routine screening of severe illness.

Gender-specific factors associated with hypertension among women of childbearing age: Findings from a nationwide survey in India.

Background: The association of conventional (modifiable and non-modifiable) risk factors for hypertension has already been established in the literature. However, there are other putative risk factors specific to women (early menarche, age at first childbirth, women empowerment, number of children born, hysterectomy, etc.) in the development of hypertension. This study is the first study to highlight the potential association of gender-specific factors along with other conventional risk factors and hypertension, using a nationwide sample. Methods: The study is a secondary analysis of the data collected from the National Family Health Survey-4 (NFHS-4), a nationally representative sample of 699,686 women of reproductive age in India. The interview schedule included data on general background characteristics, marriage, reproductive history, hysterectomy, knowledge, and utilization of family planning services, maternal and child care, women empowerment, non-communicable diseases, and domestic violence. The blood pressure was measured by direct observation by the study investigators using a digital blood pressure monitor. To account for disproportionate sampling and non-response, a weighted statistical analysis was performed. Logistic regression analysis was done to study the strength of the association between the risk factors and hypertension (computation of unadjusted and adjusted odds ratio). Results: The prevalence of hypertension was 11.8% among women. Among the conventional factors, older age, higher body mass index (BMI), tobacco use, and alcohol use had higher odds for hypertension, while higher education, higher socio-economic position, and living in urban areas had lower odds. Among the gender-specific factors, younger age at first childbirth, early menarche, oral contraceptive pill use [adjusted OR: 1.23; (1.18-1.28)], and hysterectomy [adjusted OR: 1.10; (1.05-1.69)] were found to be risk factors for hypertension. Domestic violence was significantly associated with hypertension [unadjusted OR: 1.11; (1.02-1.20)]. Empowered women had lower odds of hypertension [adjusted OR: 0.93; (0.95-1.03)]. Conclusion: Significant association of these gender-specific factors among women necessitates the need for taking into account these factors while screening for hypertension among women and thus, designing a tailored model better suited to them for risk assessment.

Pharmacy based surveillance for identifying missing tuberculosis cases: A mixed methods study from South India.

BACKGROUND: No Indian studies have assessed the implementation of recent policy on pharmacy based surveillance and its contribution in TB notification. So, this study was conducted with objectives to describe: a) pharmacy based TB surveillance and TB notification, and b) experiences of pharmacy based surveillance implementation from the programme managers and pharmacists perspective. METHODS: A mixed methods study-quantitative (cross-sectional) and qualitative (in-depth interviews) in two selected districts Dharmapuri and Salem districts of Tamil Nadu State, India. RESULTS: In 2018, 45 (11%) of 397 pharmacies in Dharmapuri and 90 (6%) of 1457 pharmacies in Salem districts reported sale of anti-TB drugs to 1307 and 1673 persons respectively. Upon validation through direct patient contact 942 (72%) persons in Dharmapuri and 863 (52%) persons were identified as previously 'un-notified' TB patients. These patients constituted 20% and 29% of the total TB cases notified in Dharmapuri and Salem respectively. The enablers for implementing this activity were: understanding the importance of notification, availability of resources (manpower, computers) to record, report and validate the patient data, repeated trainings and partnerships. The barriers were: patients' hesitancy to share their details to pharmacists (confidentiality), cumbersome recording and reporting process, difficulties in recording patient details during high workload busy business hours. CONCLUSION: This process contributed about one-fourth of the TB patients notified in these districts. Its implementation needs to be strengthened and should be scaled up in other parts of the country.

Pain Management in Children With Cancer Using World Health Organization Guidelines at a Tertiary Cancer Center in Rural India.

Management of cancer pain among children is a difficult process due to the way they perceive pain, their dependence on parents, complexity of assessment, and limited availability of safe analgesics. Pain among children with cancer is still a less explored problem in India. This descriptive study was carried out in a tertiary cancer center to explore the characteristics of pain and its management among the children with cancer. We analyzed children diagnosed with hematologic malignancies, aged 4-18 years, admitted between January 2013 and December 2017. This retrospective cohort study involved the review of patient records available at the medical records department. During the study period, there were 290 admission episodes, of which 93 (32.1%) episodes were associated with pain. Of these 93 episodes, 14 (15%) were primarily for pain management. Step I analgesic was utilized in the majority (83%) of the admission episodes involving younger age group (4-9 years) children, whereas for the older age group (10-18 years) Step 2 analgesic (tramadol) was utilized in 29 (58%) episodes, and this was found to be statistically significant (P < .001). Only in 9 (9.7%) episodes Step 3 analgesic was utilized. A significant proportion of children with hematologic malignancies had pain episodes, and these episodes in older age group children were managed with weak opioids.

Tuberculosis screening among pregnant women attending a tertiary care hospital in Puducherry, South India: is it worth the effort?

BACKGROUND: The national tuberculosis (TB) programme in India recommends screening all pregnant women for TB, but this is rarely implemented. We carried out systematic TB screening among women attending the antenatal clinic of a tertiary care hospital in Puducherry, South India, during February to April 2018. OBJECTIVE: To assess the number screened and number (proportion) with presumptive and active TB, and understand potential implementation from the healthcare providers' perspective. METHODS: We conducted a mixed-methods study. The quantitative phase was a cross-sectional study including 4203 pregnant women. Data were captured using a structured proforma. Any of the following symptoms constituted 'presumptive TB': any cough, haemoptysis, fever, weight loss, night sweats, neck swellings, joint pains, neck stiffness and disorientation. Those screening positive were referred for investigations and evaluation by a chest physician. The qualitative phase involved seven one-to-one interviews with healthcare providers. Manual thematic analysis was performed to generate themes. RESULTS: Among 4203 women (two HIV-positive) screened, 77 (1.8%) had presumptive TB. Cough was the predominant symptom (n = 75). Only 12 women could produce a sputum sample, of whom one (0.02%) was diagnosed with active TB by the Xpert MTB/RIF assay. Challenges cited by healthcare providers were lack of awareness among clients and providers, high case load, lack of dedicated staff, perception that TB screening is a low-yield, low-priority activity and losses in the referral process. Suggested solutions were providing dedicated staff and space for screening, educating women to self-report using posters and videos, and creating a one-stop care provision. CONCLUSIONS: The TB yield among pregnant women was very low, calling into question the value of systematic screening in a low-HIV setting. However, the findings may not be generalizable. Evidence is urgently needed from primary and secondary care facilities. The challenges and solutions identified may help in optimizing the screening process.