Risk Factors for Unfavorable Glycemic Control Trajectory in Type-2 Diabetes Mellitus: A Community-based Longitudinal Study in Urbanslums of Central India.

BACKGROUND: Diabetes mellitus (DM) is a chronic disease, which requires optimal glycemic control to prevent its ensuing vascular complications. Pathway to optimal glycemic control in T2DM has a complex socio-behavioral construct, especially in vulnerable populations, like slum dwellers, who have reduced health-care access and lower prioritization of health needs. OBJECTIVE: The study aimed to map trajectories of glycemic control amongst individuals with T2DM living in urban slums and identify key determinants associated with unfavourable glycaemic trajectory. METHODS: This study was a community-based longitudinal study conducted in an urban slum of Bhopal in Central India. Adult patients diagnosed with T2DM and on treatment for more than one year were included. All 326 eligible participants underwent a baseline interview, which captured sociodemographic, personal behavior, medication adherence, morbidity profile, treatment modality, anthropometric and biochemical measurements (HbA1c). Another 6-month follow-up interview was conducted to record anthropometric measurements, HbA1c and treatment modality. Four mixed effect logistic regression models (through theory-driven variable selections) were created with glycemic status as dependent variable and usage of insulin was considered as random effect. RESULTS: A total of 231 (70.9%) individuals had unfavorable glycemic control trajectory (UGCT), and only 95 (29.1%) had a favorable trajectory. Individuals with UGCT were more likely to be women, with lower educational status, non-vegetarian food preference, consumed tobacco, had poor drug adherence, and were on insulin. The most parsimonious model identified female gender (2.44,1.33-4.37), tobacco use (3.80,1.92 to 7.54), and non-vegetarian food preference (2.29,1.27 to 4.13) to be associated with UGCT. Individuals with good medication adherence (0.35,0.13 to 0.95) and higher education status (0.37,0.16 to 0.86) were found to be protective in nature. CONCLUSION: Unfavorable glycemic control trajectory seems to be an inescapable consequence in vulnerable settings. The identified predictors through this longitudinal study may offer a cue for recognizing a rational response at societal level and adopting strategy formulation thereof.

Status of Hypertension Control in Urban Slums of Central India: A community Health Worker-Based Two-Year Follow-Up.

Background: Hypertension (HTN) is a leading cause of cardiovascular diseases and its control is poor. There is heterogeneity in levels of blood pressure control among various population subgroups. The present study was conducted within the framework of the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in India. It aims to estimate the proportion of optimal blood pressure control and identify factors associated with uncontrolled HTN consequent to initial screening. Materials and Methods: We assembled a cohort of individuals with HTN confirmed in a baseline screening in sixteen urban slum clusters of Bhopal (2017-2018). Sixteen accredited social health activists were trained from within these slums. Individuals with HTN were linked to primary care providers and followed up for the next two years. Obtaining optimal blood pressure control (defined as SBP <140 and DBP <90 mm of Hg) was a key outcome. Results: Of a total of 6174 individuals, 1571 (25.4%) had HTN, of which 813 were previously known and 758 were newly detected during the baseline survey. Two-year follow-up was completed for 1177 (74.9%). Blood pressure was optimally controlled in 301 (26%) at baseline and in 442 (38%) individuals at two years (an absolute increase of 12%; 95% CI 10.2-13.9). Older age, physical inactivity, higher body mass index, and newly diagnosed HTN were significantly associated with uncontrolled blood pressure. Conclusion: We found about six of every ten individuals with HTN were on treatment, and about four were optimally controlled. These findings provide a benchmark for NPCDCS, in terms of achievable goals within short periods of follow-up.

Case Report: Lepromatous Leprosy Masquerading as Acute Suppurative Lymphadenitis.

Leprosy is a chronic cutaneous infection. It is usually characterized by thickened nerves and maculo-anesthetic patches. Leprosy often has an unusual presentation, which is a diagnostic challenge. In this case report, we present a case of an elderly male who presented with fever and chronic pus-draining axillary, cervical, and inguinal lymph nodes. He also had a weak left foot for the previous 5 months. During his hospital stay, he developed additional papular lesions over his extremities. We performed fine needle aspiration from the lymph nodes and skin biopsy, which were suggestive of lepromatous leprosy. We initiated him on antileprosy medication. On follow-up, he was responsive to therapy. Although skin and nerve involvement in leprosy is common, this case had an atypical presentation of discharging lymph nodes.

Accuracy of Critical Care Ultrasonography Plus Arterial Blood Gas Analysis Based Algorithm in Diagnosing Aetiology of Acute Respiratory Failure.

Introduction: Lung ultrasound when used in isolation, usually misses out metabolic causes of dyspnoea and differentiating acute exacerbation of COPD from pneumonia and pulmonary embolism is difficult, hence we thought of combining critical care ultrasonography (CCUS) with arterial blood gas analysis (ABG). Aim of the study: The objective of this study was to estimate accuracy of Critical Care Ultrasonography (CCUS) plus Arterial blood gas (ABG) based algorithm in diagnosing aetiology of dyspnoea. Accuracy of traditional Chest X-ray (CxR) based algorithm was also validated in the following setting. Methods: It was a facility based comparative study, where 174 dyspneic patients were subjected to CCUS plus ABG and CxR based algorithms on admission to ICU. The patients were classified into one of five pathophysiological diagnosis 1) Alveolar( Lung-pneumonia)disorder ; 2) Alveolar (Cardiac-pulmonary edema) disorder; 3) Ventilation with Alveolar defect (COPD) disorder ;4) Perfusion disorder; and 5) Metabolic disorder. We calculated diagnostic test properties of CCUS plus ABG and CXR based algorithm in relation to composite diagnosis and correlated these algorithms for each of the defined pathophysiological diagnosis. Results: The sensitivity of CCUS and ABG based algorithm was 0.85 (95% CI-75.03-92.03) for alveolar (lung) ; 0.94 (95% CI-85.15-98.13) for alveolar (cardiac); 0.83 (95% CI-60.78-94.16) for ventilation with alveolar defect; 0.66 (95% CI-30-90.32) for perfusion defect; 0.63 (95% CI-45.25-77.07) for metabolic disorders.Cohn's kappa correlation coefficient of CCUS plus ABG based algorithm in relation to composite diagnosis was 0.7 for alveolar (lung), 0.85 for alveolar (cardiac), 0.78 for ventilation with alveolar defect, 0.79 for perfusion defect and 0.69 for metabolic disorders. Conclusion: CCUS plus ABG algorithm is highly sensitive and it's agreement with composite diagnosis is far superior. It is a first of it's kind study, where authors have attempted combining two point of care tests and creating an algorithmic approach for timely diagnosis and intervention.

Predictors of Mortality among Patients Hospitalized with COVID-19 during the First Wave in India: A Multisite Case-Control Study.

Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India. Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December-March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients (1,137 cases and 1,294 controls) were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age (adjusted odds ratio [aOR]: 46-59 years, 3.4 [95% CI: 1.5-7.7]; 60-74 years, 4.1 [95% CI: 1.7-9.5]; and ≥ 75 years, 11.0 [95% CI: 4.0-30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2-2.9]); malignancy (aOR: 3.1 [95% CI: 1.3-7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2-8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4-3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7-11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6-3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.

Prevalence, Metabolic Profile, and Associated Risk Factors of Non-alcoholic Fatty Liver Disease in an Adult Population of India.

Introduction Non-alcoholic fatty liver disease (NAFLD) is the main cause of chronic liver disease worldwide. NAFLD refers to a group of diseases that includes simple steatosis, nonalcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma. Unfortunately, there aren't many studies on NAFLD conducted in India. The majority of research involved specific populations, such as diabetics, pregnant women with gestational diabetes, and obese or non-obese people. When the current study was being planned, there were few population-based studies available. In almost all of the research, ultrasound was employed to identify NAFLD, and the whole spectrum of NAFLD was not assessed. The full spectrum of NAFLD in India must have been considered, including all stages of steatosis as well as hepatic damage as shown by high alanine aminotransferase levels and fibrosis. The purpose of this study was to determine the prevalence, spectrum, and metabolic determinants of NAFLD as assessed by FibroScan® (FibroScan® expert 630 machine; Echosens, Paris, France) in adults of Central India. Methods This cross-sectional study was conducted among 236 adults aged 18 years and above in three localities of Bhopal, India from March 2022 to October 2022. The study included males and females who provided informed consent and fulfilled inclusion criteria. One research assistant and one staff nurse solicited people to participate in the FibroScan® test during the community screening and shared information about the programme. All participants were subjected to the FibroScan® test. Results A total of 322 healthy adults were approached for possible inclusion in the study. Data from 236 subjects were available for analysis after meeting the inclusion and exclusion criteria. According to this study, 43.6% of the study population had NAFLD as detected by FibroScan®. Out of the total, 12.7% of subjects had steatosis grade 1 (S1), 12.3% of subjects had steatosis grade 2 (S2), and 18.6% of subjects had steatosis grade 3 (S3). High body weight, high waist circumference, high waist-to-hip ratio, high fasting sugar, high serum glutamate pyruvate transaminase (SGPT), high triglyceride levels and high very low-density lipoprotein (VLDL) levels were significantly associated with NAFLD. Conclusion In conclusion, 43.6% of the adult population of Bhopal, India is suffering from NAFLD. NAFLD is a severe burden in the Indian community despite being historically associated with the western world. Obesity, diabetes and dyslipidemia are significantly associated with NAFLD.

Association of tobacco use with the tobacco-related built environment: an ecological study from urban slums of Bhopal, India.

INTRODUCTION: Tobacco is one of the biggest public health problems and a major risk factor for various non-communicable diseases (NCDs). An important aspect of tobacco control strategy could include modifications in the tobacco-related built environment. This study investigated the association between tobacco shop density and tobacco use prevalence in the urban slums of Bhopal city, India. METHODS: We conducted a cross-sectional survey to obtain the distribution of tobacco-related built environment (tobacco shops) in the neighbourhood (400-m service area) of 32 urban slum clusters of Bhopal. We plotted this distribution using the 'network service area analysis' in ArcMap 10.7.1 software. Then, we used an ecological design to determine the association between tobacco shop density and tobacco use prevalence in these 32 clusters (N = 6214 adult inhabitants). We used multiple linear regression analysis to estimate the regression coefficient (adjusted for socio-demographic variables) between tobacco use and tobacco shop density at the cluster level. RESULTS: The prevalence of tobacco use among all 32 slum clusters ranged from 22.1 to 59.6% (median 40.9% with IQR 31.8-44.2). There were 194 tobacco shops situated in the neighbourhood of all clusters. The median density of tobacco shops was 59.40/km2 (IQR 39.9-108.1/km2) in the neighbourhoods of slum clusters. Tobacco use prevalence was significantly associated with tobacco shop density (estimate or B = 0.071, p value = 0.002) after adjusting for age, literacy, wealth index, and gender ratio. CONCLUSIONS: Tobacco use prevalence is significantly associated with tobacco shop density in the slums of Bhopal city in central India. We need to develop appropriate built environment interventions to control rampant tobacco use.

Assessment of liver fibrosis using non-invasive screening tools in individuals with diabetes mellitus and metabolic syndrome.

Despite its rising prevalence, and its potential to lead to life threatening complications, there are no recommendations in the current guidelines for screening individuals with diabetes mellitus or high BMI for NAFLD(non-alcoholic fatty liver disease)/NASH (non alcoholic steatohepatitis),mainly due to the uncertain performance and feasibility of currently available screening tools. This research was carried out to assess the diagnostic accuracy of non-invasive screening tools in predicting liver fibrosis in individuals with diabetes mellitus and metabolic syndrome. MATERIAL: 140 patients with diabetes mellitus and metabolic syndrome, identified between March 2020 and October 2021 were studied. Liver stiffness measurement by point shear wave elastography was considered the gold standard. 5 non-invasive scores, AST/ALT (aspartate aminotransferase/alanine aminotransferase) Ratio, Aspartate aminotransferase/platelet ratio (APRI)Score, FIB-4 Index, BARD Score and NAFLD Fibrosis Score were determined in all of the study participants. Using receiver operator characteristic (ROC) curve analysis, sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated for each of these scores. The area under the ROC curve (AUROC) was used to calculate the diagnostic accuracy of these scores. OBSERVATION: Out of the140 participants in the study, (83 males (59.29%)), 30 (21.43%) had liver fibrosis as per liver stiffness measurement by point shear wave elastography. The mean age and mean BMI were 54.53±12.42 and 27.37±2.73 respectively in the 'Fibrosis' group and 56.20 ±11.76 and 27.10±4.22 in the 'No fibrosis' group. The major finding of our study was that all these scores had relatively high NPV (>85 %) for predicting liver fibrosis in our cohort. The AST/ALT Ratio had the highest negative predictive value (90.28 %) followed by APRI Score (88.94 %). The AUROC (for FIB-4 Score, NAFLD-Fibrosis Score, APRI Score, AST/ALT Ratio, BARD Score were 0.6669, 0.657, 0.655, 0.637 and 0.599 respectively. FIB-4 Index(p = 0.005) had the highest AUROC, followed by NAFLD-Fibrosis Score(p =0.009) .But, all the scores had relatively low specificity(<60 %), PPV(<35 %) and accuracy(<63 %). CONCLUSION: FIB- 4 Index and NAFLD-Fibrosis Score can be used to reliably exclude liver fibrosis in individuals with diabetes mellitus and metabolic syndrome in the Indian population, but may not be useful in accurately diagnosing liver fibrosis. Utilization of these non-invasive and cost-effective screening tools in routine practice, may have promising results in predicting liver fibrosis in 'at risk' populations.

Exploring the Subclinical Atherosclerotic Load in Patients With Rheumatoid Arthritis: A Cross-Sectional Study.

BACKGROUND: Atherosclerosis is the major etiopathogenic factor that decides cardiovascular mortality and morbidity. While inflammation is the putative mechanism for atherosclerosis in various experimental studies, chronic inflammatory state (e.g. in rheumatoid arthritis [RA]) is often neglected as a contributing factor for the development of atherosclerosis. RA patients have two to four times more risk of fatal or non-fatal cardiovascular events, which is not explained by traditional risk factors alone. For example, low-density lipoprotein (LDL) cholesterol levels may not convey the true atherosclerotic risk in RA patients - "the lipid paradox". Thus, for better risk stratification of future cardiovascular events in RA, the traditional parameters like diabetes, hypertension, and dyslipidemia may not suffice. Newer parameters like carotid intimal-medial thickness (CIMT), coronary calcification scores, and C-reactive protein (CRP) may be needed. This study determined subclinical atherosclerotic load in groups of RA and non-RA patients with comparable Framingham risk scores using CIMT values. MATERIALS AND METHODS:  In this hospital-based cross-sectional study, the RA study group had 64 patients with RA (disease duration > 1 year) and 64 controls were patients with at least one traditional risk factor of cardiovascular disease (e.g., hypertension, cigarette smoking, dyslipidemia, and diabetes mellitus). They were all analyzed for CIMT. The aim was to compare if there was a difference in CIMT scores between groups of RA and non-RA patients, with comparable Framingham score cardiovascular risk categories. RESULTS: CIMT was significantly higher in the study population compared to controls, indicating increased subclinical atherosclerotic load in the former. Mean CIMT was higher in all age groups in RA patients when compared to the control population (statistically significant in age groups 40-49 years 0.66 ± 0.07 mm vs 0.64 ± 0.06 mm, P < 0.026 and 50-59 years 0.8 ± 0.05 mm vs 0.76 ± 0.05 mm, P < 0.047). CIMT was significantly higher in the intermediate-risk groups (based on the Framingham risk score) in the RA study population when compared with the same risk categories of the control population. Atherogenic indices such as LDL/high-density lipoprotein (HDL) ratio, atherogenic index, and CIMT were significantly higher in the RA patients with more than five years of disease duration than those with a duration of fewer than five years. CONCLUSION: Subclinical atherosclerotic load is higher in RA versus controls. The mean CIMT was higher in all age groups in RA compared to the controls. CIMT was significantly higher in the intermediate-risk subgroup (by Framingham risk score) when compared between RA and controls. RA subgroup comparisons based on seropositivity/seronegativity, high/normal CRP, and disease activity (low, intermediate, and high) for CIMT were not found to have statistically significant differences. RA group had lower HDL cholesterol and comparable LDL cholesterol values compared to controls.

Preparedness of primary and secondary health facilities in India to address major noncommunicable diseases: results of a National Noncommunicable Disease Monitoring Survey (NNMS).

BACKGROUND: The monitoring framework for evaluating health system response to noncommunicable diseases (NCDs) include indicators to assess availability of affordable basic technologies and essential medicines to treat them in both public and private primary care facilities. The Government of India launched the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) in 2010 to strengthen health systems. We assessed availability of trained human resources, essential medicines and technologies for diabetes, cardiovascular and chronic respiratory diseases as one of the components of the National Noncommunicable Disease Monitoring Survey (NNMS - 2017-18). METHODS: NNMS was a cross-sectional survey. Health facility survey component covered three public [Primary health centre (PHC), Community health centre (CHC) and District hospital (DH)] and one private primary in each of the 600 primary sampling units (PSUs) selected by stratified multistage random sampling to be nationally representative. Survey teams interviewed medical officers, laboratory technicians, and pharmacists using an adapted World Health Organization (WHO) - Service Availability and Readiness Assessment (SARA) tool on handhelds with Open Data Kit (ODK) technology. List of essential medicines and technology was according to WHO - Package of Essential Medicines and Technologies for NCDs (PEN) and NPCDCS guidelines for primary and secondary facilities, respectively. Availability was defined as reported to be generally available within facility premises. RESULTS: Total of 537 public and 512 private primary facilities, 386 CHCs and 334 DHs across India were covered. NPCDCS was being implemented in 72.8% of CHCs and 86.8% of DHs. All essential technologies and medicines available to manage three NCDs in primary care varied between 1.1% (95% CI; 0.3-3.3) in rural public to 9.0% (95% CI; 6.2-13.0) in urban private facilities. In NPCDCS implementing districts, 0.4% of CHCs and 14.5% of the DHs were fully equipped. DHs were well staffed, CHCs had deficits in physiotherapist and specialist positions, whereas PHCs reported shortage of nurse-midwives and health assistants. Training under NPCDCS was uniformly poor across all facilities. CONCLUSION: Both private and public primary care facilities and public secondary facilities are currently not adequately prepared to comprehensively address the burden of NCDs in India.

Baseline risk factor prevalence among adolescents aged 15-17 years old: findings from National Non-communicable Disease Monitoring Survey (NNMS) of India.

OBJECTIVE: To generate national estimates of key non-communicable disease (NCD) risk factors for adolescents (15-17 years) identified in the National NCD Monitoring Framework and, study the knowledge, attitudes and practices towards NCD risk behaviours among school-going adolescents. DESIGN AND SETTING: A community-based, national, cross-sectional survey conducted during 2017-2018. The survey was coordinated by the Indian Council of Medical Research-National Centre for Disease Informatics and Research with 10 reputed implementing research institutes/organisations across India in urban and rural areas. PARTICIPANTS: A multistage sampling design was adopted covering ages between 15 and 69 years-adolescents (15-17 years) and adults (18-69 years). The sample included 12 000 households drawn from 600 primary sampling units. All available adolescents (15-17 years) from the selected households were included in the survey. MAIN OUTCOME MEASURES: Key NCD risk factors for adolescents (15-17 years)-current tobacco and alcohol use, dietary behaviours, insufficient physical activity, overweight and obesity. RESULTS: Overall, 1402 households and 1531 adolescents completed the survey. Prevalence of current daily use of tobacco was 3.1% (95% CI: 2.0% to 4.7%), 25.2% (95% CI: 22.2% to 28.5%) adolescents showed insufficient levels of physical activity, 6.2% (95% CI: 4.9% to 7.9%) were overweight and 1.8% (95% CI: 1.0% to 2.9%) were obese. Two-thirds reported being imparted health education on NCD risk factors in their schools/colleges. CONCLUSION: The survey provides baseline data on NCD-related key risk factors among 15-17 years in India. These national-level data fill information gaps for this age group and help assess India's progress towards NCD targets set for 2025 comprehensively. Though the prevalence of select risk factors is much lower than in many developed countries, this study offers national evidence for revisiting and framing appropriate policies, strategies for prevention and control of NCDs in younger age groups.

National noncommunicable disease monitoring survey (NNMS) in India: Estimating risk factor prevalence in adult population.

BACKGROUND: The primary objective of National NCD monitoring survey (NNMS) was to generate national-level estimates of key NCD indicators identified in the national NCD monitoring framework. This paper describes survey study protocol and prevalence of risk factors among adults (18-69 years). MATERIALS AND METHODS: NNMS was a national level cross-sectional survey conducted during 2017-18. The estimated sample size was 12,000 households from 600 primary sampling units. One adult (18-69 years) per household was selected using the World Health Organization-KISH grid. The study tools were adapted from WHO-STEPwise approach to NCD risk factor surveillance, IDSP-NCD risk factor survey and WHO-Global adult tobacco survey. Total of 8/10 indicators of adult NCD risk factors according to national NCD disease monitoring framework was studied. This survey for the first time estimated dietary intake of salt intake of population at a national level from spot urine samples. RESULTS: Total of 11139 households and 10659 adults completed the survey. Prevalence of tobacco and alcohol use was 32.8% (95% CI: 30.8-35.0) and 15.9% (95% CI: 14.2-17.7) respectively. More than one-third adults were physically inactive [41.3% (95% CI: 39.4-43.3)], majority [98.4% (95% CI: 97.8-98.8)] consumed less than 5 servings of fruits and / or vegetables per day and mean salt intake was 8 g/day (95% CI: 7.8-8.2). Proportion with raised blood pressure and raised blood glucose were 28.5% (95% CI: 27.0-30.1) and 9.3% (95% CI: 8.3-10.5) respectively. 12.8% (95% CI: 11.2-14.5) of adults (40-69 years) had ten-year CVD risk of ≥30% or with existing CVD. CONCLUSION: NNMS was the first comprehensive national survey providing relevant data to assess India's progress towards targets in National NCD monitoring framework and NCD Action Plan. Established methodology and findings from survey would contribute to plan future state-based surveys and also frame policies for prevention and control of NCDs.

Incident hypertension in urban slums of central India: a prospective cohort study.

BACKGROUND: Numerous studies have highlighted the burden of hypertension by estimating its prevalence. However, information regarding quantum and characteristics of persons whose blood pressure converts to hypertension range from their previous state of prehypertension or normal blood pressure is crucial for any public health programme. We aimed to estimate incidence rate of hypertension and to identify risk factors for the same, so that it is useful for programme implementation. METHODS: We established a cohort of adults residing in urban slums of Bhopal, who were registered in a baseline cardiovascular risk assessment survey, which was performed between November 2017 and March 2018. Blood pressure assessment was done at least three times at baseline for diagnosis of hypertension, which was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on two occasions. Participants who did not have a diagnosis of hypertension were followed up during April-June 2019. RESULTS: Of the 5673 participants assessed at baseline, 4185 did not have hypertension of which 3199 (76.4%) were followed up after a median on 1.25 years (IQR 1.08-1.60) and a total of 170 (5.31%) individuals were detected with incident hypertension. Overall incidence rate of hypertension was 4.1 (95% CI 3.54 to 4.75) per 100 person-years of follow-up. On multivariate analysis, age (relative risk/RR 1.98; 95% CI 1.19 to 3.3, for age >60 years), being in first and second wealth tertile (T-1 RR 1.85; 95% CI 1.17 to 2.91) and being illiterate (RR 1.94; 95% CI 1.31 to 2.86) were significant predictors of incident hypertension. Individuals who had prehypertension at baseline also had a significantly increased risk of developing hypertension (RR 2.72; 95% CI 1.83 to 4.03). CONCLUSIONS: We found that incidence of hypertension in urban slums of central India is higher with increasing age and in men. Illiteracy, lower Wealth Index and prehypertension are other determinants. We also demonstrate feasibility of establishing a cohort within the public health delivery system, driven by efforts of community health workers.

Determinants of behavioural and biological risk factors for cardiovascular diseases from state level STEPS survey (2017-19) in Madhya Pradesh.

BACKGROUND: National and statewide assessment of cardiovascular risk factors needs to be conducted periodically in order to inform public health policy and prioritise allocation of funds, especially in LMICs. Although there have been studies from India which have explored the determinants of cardiovascular risk factors, they have mostly been from high epidemiological transition states. The present study assessed the determinants of cardiovascular (CVD) risk factors in a low epidemiological transition state (Madhya Pradesh) using the WHO STEPwise approach to surveillance (STEPS). METHODS: A total of 5,680 persons aged 18-69 years were selected from the state of Madhya Pradesh through multi-stage cluster random sampling. Key CVD risk factors we sought to evaluate were from behavioural (tobacco, alcohol, physical activity, diet) and biological domains (overweight or obese, Hypertension, Diabetes, and Raised serum cholesterol). Key socio-demographic factors of interest were the caste and tribe groups, and rural vs urban location, in addition to known influencers of CVD risk such as age, gender and education level. RESULTS: Those belonging to the scheduled tribes were more at risk of consuming tobacco (OR 2.13 (95% CI [1.52-2.98]), and a diet with less than five servings of fruits and vegetables (OR 2.78 (95% CI [1.06-7.24]), but had had the least risk of physical inactivity (OR 0.31 (95% CI [0.02-0.54]). Residence in a rural area also reduced the odds of physical inactivity (OR 0.65 (95% CI [0.46-0.92])). Lack of formal education was a risk factor for both tobacco consumption and alcohol intake (OR 1.40 (95% CI [1.08-1.82]) for tobacco use; 1.68 (95% CI [1.14-2.49]) for alcohol intake). Those belonging to schedules tribes had much lower risk of being obese (OR 0.25; 95% CI [0.17-0.37]), but were at similar risk of all other clinical CVD risk factors as compared to other caste groups. CONCLUSION: In the current study we explored socio-demographic determinants of behavioural and biological CVD risks, and found that in Madhya Pradesh, belonging to a scheduled tribe or living in a rural location, protects against being physically inactive or being overweight or obese. Increasing age confers a greater CVD-risk in all domains. Being a male, and lack of formal education confers a greater risk for behavioural domains, but not for most clinical risk domains. Future efforts at curbing CVDs should be therefore two pronged -a population-based strategy targeting biological risk factors, and a more focussed approach directed at those displaying risky behaviour.

Descriptive profile of risk factors for cardiovascular diseases using WHO STEP wise approach in Madhya Pradesh.

BACKGROUND: Periodic information on risk factor distribution is critical for public health response for reduction in non-communicable disease (NCDs). For this purpose, the WHO has developed STEPs wise approach. State representative population-based STEPS survey was last conducted in 2007-08 in seven states of In India. Since then no such work has been reported from low ETL states. This survey was carried out to assess the prevalence of risk factors associated with NCDs and the prevalence of NCDs in the low ETL state of Madhya Pradesh using the WHO STEPs approach. METHODS: A total of 5680 persons aged 18-69 years were selected from the state of Madhya Pradesh using multi-stage cluster random sampling. Using the WHO STEPs approach, details were collected on demographics, STEP 1 variables (tobacco consumption, alcohol consumption, physical activity, diet), STEP 2 variables (weight, height, waist circumference, blood pressure) and STEP 3 variables (fasting blood glucose, blood cholesterol). RESULTS: We found that 9.4% individuals smoked tobacco, 15.3% were overweight/obese, 22.3% had hypertension, and 6.8% have diabetes mellitus. As compared to women, men were less likely to be overweight or obese, but more likely to smoke tobacco, and have diabetes mellitus. Hypertension was also more common in men. Overall, about a fourth of all adults had three or more risk factors for cardiovascular disease. CONCLUSION: The survey shows that a large section of the population from Madhya Pradesh is either suffering from NCDs or have risk factors which predispose them to acquire NCDs. This state representative survey provides benchmarking information for behavioural and biological risk factor distribution for recently scaled up National Programme for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS).

Practice patterns in the management of congestive heart failure and post-discharge quality of life: A hospital-based cross-sectional study.

OBJECTIVE: The objective of the study is to identify the etiology, risk factors, frequency of major and minor components of the Framingham criteria for heart failure, discharge medications, mortality, and quality of life after discharge from the hospital, for patients who were admitted to the in-patient unit of a tertiary care hospital in central India, with a diagnosis of congestive heart failure (CHF). METHODS: This hospital-based cross-sectional study involved retrospective chart review of patients who were admitted to the in-patient unit with a diagnosis of CHF. These patients were then attempted to reach via their telephone numbers listed in the medical records and their current quality of life was assessed using Euro-QoL 5D questionnaire. RESULTS: In the 69 patients who were admitted to the hospital with congestive cardiac failure during the pre-defined period, ischemic heart disease was the most common etiology and smoking was the most common risk factor for the development of CHF. The most common findings based on Framingham criteria were dyspnea on mild exertion, rales and bilateral ankle edema. It was determined that one-fourth of the individuals were non-compliant to the medical treatment and more than half of the patients had a poor health score. CONCLUSION: Smoking remains to be a major risk factor for patients to develop ischemic heart disease and subsequent CHF. Patients with congestive cardiac failure also had severe deterioration in their quality of life after discharge from the hospital, implying the need for improving efforts toward prevention and better management.

Cardiovascular risk factor reduction by community health workers in rural India: A cluster randomized trial.

BACKGROUND: There is a need to identify and test low-cost approaches for cardiovascular disease (CVD) risk reduction that can enable health systems to achieve such a strategy. OBJECTIVE: Community health workers (CHWs) are an integral part of health-care delivery system in lower income countries. Our aim was to assess impact of CHW based interventions in reducing CVD risk factors in rural households in India. METHODS: We performed an open-label cluster-randomized trial in 28 villages in 3 states of India with the household as a unit of randomization. Households with individuals at intermediate to high CVD risk were randomized to intervention and control groups. In the intervention group, trained CHWs delivered risk-reduction advice and monitored risk factors during 6 household visits over 12 months. Households in the non-intervention group received usual care. Primary outcomes were a reduction in systolic BP (SBP) and adherence to prescribed BP lowering drugs. RESULTS: We randomized 2312 households (3261 participants at intermediate or high risk) to intervention (1172 households) and control (1140 households). At baseline prevalence of tobacco use (48.5%) and hypertension (34.7%) were high. At 12 months, there was significant decline in SBP (mmHg) from baseline in both groups- controls 130.3 ±â€¯21 to 128.3 ±â€¯15; intervention 130.3 ±â€¯21 to 127.6 ±â€¯15 (P < .01 for before and after comparison) but there was no difference between the 2 groups at 12 months (P = .18). Adherence to antihypertensive drugs was greater in intervention vs control households (74.9% vs 61.4%, P = .001). CONCLUSION: A 12-month CHW-led intervention at household level improved adherence to prescribed drugs, but did not impact SBP. To be more impactful, a more comprehensive solution that addresses escalation and access to useful therapies is needed.

Lung Ultrasound and Blood Gas-Based Classification of Critically Ill Patients with Dyspnea: A Pathophysiologic Approach.

INTRODUCTION: The objective of this study was to classify dyspneic patients and to evaluate outcome variables on the basis of lung ultrasound (LUS) and arterial blood gas (ABG) findings. METHODS: We performed a retrospective chart-based review in which we included patients with dyspnea admitted to our intensive care unit (ICU) between March 2015 and August 2016. On the basis of LUS (presence of A-lines/B-lines) and ABG (hypoxia/hypercarbia), patients were classified into six groups: (i) metabolic defect (dry lung, no hypoxia); (ii) perfusion defect (dry lung, hypoxia); (iii) ventilation defect (dry lung, hypoxia, and hypercarbia); (iv) ventilation and alveolar defect (wet lung, hypoxia, and hypercarbia); (v) alveolar defect-consolidation ([wet lung] hypoxia, no echocardiographic [ECG] abnormality); (vi) alveolar defect-pulmonary edema (wet lung [usually bilateral], hypoxia, ECG abnormality). The patient's demographic data, sequential organ failure assessment (SOFA) score, need for intubation, vasopressors, form of mechanical ventilation, ICU outcome, and length of stay were noted. RESULTS: A total of 244 out of 435 patients were eligible for inclusion in the study. The median age was 56 years. 132 patients (54.1%) required mechanical ventilation, and median SOFA score was 7. Noninvasive ventilation was required in 87.5% of patients with ventilation defect as compared to 9.2% with alveolar defect-consolidation (P < 0.0001). We had 21.7% mortality in patients with alveolar defect-consolidation, 10.8% mortality in patients with metabolic defect, and 8.7% mortality in patients with alveolar defect-pulmonary edema (P < 0.0001). CONCLUSION: This classification gives an organized approach in managing patients with dyspnea. It predicts that patients with alveolar defect-consolidation are most sick of all the groups and need immediate intervention.

A cat has 9 lives: The dilemma of diagnosing non hodgkin's lymphoma in intensive care unit.

Non hodgkins lymphoma is a common haematological malignancy characterized by abnormal clonal proliferation of T-cells, B-cells or both. The incidence of non hodgkins lymphoma is rapidly rising. The diagnosis and management of NHL presents as a challenge in developing countries like India due to high prevalence of tuberculosis, cost and poor patient compliance. We describe an unusual case of a patient who presented as a diagnostic dilemma and took 8 diagnosis before finally being confirmed as a case of NHL. A suspicion for NHL should always be kept in mind in a patient presenting with pneumonia, bilateral pulmonary infiltrates and eosinophilia.

Community health worker-based intervention for adherence to drugs and lifestyle change after acute coronary syndrome: a multicentre, open, randomised controlled trial.

BACKGROUND: Adherence to drugs and healthy lifestyles is low after acute coronary syndrome. We assessed whether trained community health workers could improve adherence to drugs, lifestyle changes, and clinical risk markers in patients with acute coronary syndrome in India. METHODS: In this study done at 14 hospitals in India we randomly assigned (1:1) patients with acute coronary syndrome 1 or 2 days before discharge from hospital to a community health worker-based intervention group or a standard care group. Patients were randomly assigned with a telephone randomisation service. In the intervention group, during four in-hospital and two home visits, community health workers used unstructured discussions, visual methods, and patient diaries to educate patients on healthy lifestyle and drugs, and measures to enhance adherence. The primary outcome was adherence to proven secondary prevention drugs (antiplatelet drugs, ß blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins) estimated using a Composite Medication Adherence Scale at 1 year. The secondary outcomes were difference in lifestyle factors (diet, exercise, and tobacco and alcohol use), and clinical risk markers (blood pressure, bodyweight, BMI, heart rate, and lipids). All analyses were by intention to treat. This trial is registered with the Clinical Trial Registry of India, number REF/2013/03/004737, and ClinicalTrials.gov, number NCT01207700. RESULTS: Between Aug 23, 2011, and June 25, 2012, 806 participants were randomly assigned (405 to a community health worker-based intervention group and 401 to a standard care group). At 1 year, 40 patients had died and 15 had discontinued or been lost to follow-up, so 750 (93%) were included in the analyses (375 in each group). Secondary prevention drugs prescribed at discharge were 98% (786/803) for any antiplatelet drug, 79% (638/803) for dual antiplatelet drugs, 69% (555/803) for ß blockers, 69% (552/803) for angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and 95% (762/803) for statins. At one year, overall adherence (≥80%) to prescribed evidence-based drugs was higher in the intervention group than in the control group (97% vs 92%, odds ratio [OR] 2·62, 95% CI 1·32-5·19; p=0·006). For individual drugs, we recorded significant differences for angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (97% [233/240] in the intervention group vs 93% [223/240] in the control group; p=0·036) and statins (97% [346/356] vs 93% [321/345]; p=0·011). The intervention group had significantly greater adherence to smoking cessation (85% [110/129] vs 52% [71/138], OR 5·46, 95% CI 3·03-9·86; p<0·0001), regular physical activity (89% [333/375] vs 60% [226/375], OR 5·23, 95% CI 3·57-7·66; p<0·0001), and healthy diet (score 5·0 vs 3·0, OR 2·47, 95% CI 1·88-3·25; p<0·0001). More patients in the intervention group had stopped alcohol use at 1 year (87% [64/74] vs 46% [46/67], OR 2·92, 95% CI 1·26-6·79; p =0·010). At 1 year, the mean systolic blood pressure (124·4 mm Hg [SD 13·5] vs 128·0 mm Hg [15·9]; p=0·002), weight (65·0 kg [11·0] vs 66·5 kg [11·5]; p<0·0001), cholesterol (157·0 [40·2] vs 166·9 [48·4]; p=0·184), LDL (81·0 [20·6] vs 87·3 [29·9]; p=0·191), HDL (42·0 [11·4] vs 38·2 [6·5]; p=0·042), and BMI (24·4 kg/m(2) [SD 3·7] vs 25·0 kg/m(2) [3·8]; p<0·0001) were lower in the intervention group than in the control group. However, we noted no significant difference in diastolic blood pressure and heart rate. INTERPRETATION: A community health worker-based personalised intervention strategy in patients with acute coronary syndrome improved adherence to evidence-based drugs and healthy lifestyles, and resulted in an improvement in clinical risk markers. Integration of trained community health workers can improve secondary prevention in coronary artery disease. FUNDING: US National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, Department of Health and Human Services, and the UnitedHealth group, USA.