Cost of screening, out-of-pocket expenditure & quality of life for diabetes & hypertension in India

Background & objectives: The Government of India has initiated a population based screening (PBS) for noncommunicable diseases (NCDs). A health technology assessment agency in India commissioned a study to assess the cost-effectiveness of screening diabetes and hypertension. The present study was undertaken to estimate the cost of PBS for Type II diabetes and hypertension. Second, out-of-pocket expenditure (OOPE) for outpatient care and health-related quality of life (HRQoL) among diabetes and hypertension patients were estimated. Methods: Economic cost of PBS of diabetes and hypertension was assessed using micro-costing methodology from a health system perspective in two States. A total of 165 outpatients with diabetes, 300 with hypertension and 497 with both were recruited to collect data on OOPE and HRQoL. Results: On coverage of 50 per cent, the PBS of diabetes and hypertension incurred a cost of ? 45.2 per person screened. The mean OOPE on outpatient consultation for a patient with diabetes, hypertension and both diabetes and hypertension was ? 4381 (95% confidence interval [CI]: 3786-4976), ? 1427 (95% CI: 1278-1576) and ? 3932 (95% CI: 3614-4250), respectively. Catastrophic health expenditure was incurred by 20, 1.3 and 14.8 per cent of patients with diabetes, hypertension and both diabetes and hypertension, respectively. The mean HRQoL score of patients with diabetes, hypertension and both was 0.76 (95% CI: 0.72-0.8), 0.89 (95% CI: 0.87-0.91) and 0.68 (95% CI: 0.66-0.7), respectively. Interpretations & conclusions: The findings of our study are useful for assessing cost-effectiveness of screening strategies for diabetes and hypertension.

Objective-structured clinical examination in cardiovascular system for the assessment of internal medicine postgraduates amidst the Covid-19 pandemic

BACKGROUND The Covid-19 pandemic has posed a challenge to organizing a safe clinical assessment for postgraduate degree candidates completing the residency programmes in various specialties. Although minimizing the risk of Covid-19 transmission is a priority, fulfilling the objectives of the assessment is equally important. METHODS We conducted this study in the Department of Internal Medicine at our institute. Instead of physically examining patients, case scenarios that included history, clinical and investigational data of the cardiovascular system (CVS) were presented to the candidates. Performance was scored by both the conventional and the CVS objective-structured clinical examination (CVS-OSCE) method and compared. RESULTS Clinical assessment examination of 27 candidates for the degree of Doctor of Medicine showed that the median cumulative score gained in narrating and analysing various differential diagnoses was lower compared to the mean cumulative score gained in arriving at a single correct diagnosis (50% [interquartile range—IQR 39%–64%] v. 79% [IQR 64%–100%], p<0.01). Most of the candidates agreed that case scenarios were good alternatives to the conventional physical examination amidst the pandemic. CONCLUSION CVS-OSCE-based assessment using structured case scenarios is a feasible and effective alternative for clinical skill assessment in high-stake examinations.

Uric acid as a predictor of endothelial dysfunction in patients with metabolic syndrome

ABSTRACT Objective: We conducted a study to examine the association of endothelial dysfunction and oxidative stress with uric acid levels in patients of metabolic syndrome. Subjects and methods: One hundred and two patients of Metabolic Syndrome (International Diabetes Federation definition) were included in the study. Anthropometric measurements, serum uric acid levels, fasting blood sugar levels and lipid levels, as well as malondialdehyde and reactive nitrogen intermediates were measured after an 8-hour fasting period. Flow mediated vasodilation (FMD) of the brachial artery was measured and endothelial dysfunction was defined as an increase in diameter < 10% post compression. Results: A total of 102 patients were included in the study. Mean uric acid level was 5.49 ± 1.61 mg%. A total of 59 patients in the study had endothelial dysfunction, defined by an abnormal FMD. Patients with an abnormal FMD had higher levels of serum uric acid which was statistically significant (p value = 0.010). Serum RNI and MDA levels were negatively correlated with uric acid, but did not reach statistical significance. Patients with an abnormal FMD had a lower RNI level, but this did not reach statistical significance. Serum MDA levels were significantly higher in patients with an abnormal FMD (p value = 0.038). Conclusions: Uric acid was significantly associated with endothelial dysfunction in patients with metabolic syndrome in our study. It was inversely correlated with serum RNI and MDA levels, but this did not reach statistical significance.

Morphology of plantaris longus with special reference to its clinical importance

Background: Plantaris is small fusiform muscle, with its long, slender tendon. Actually it’s a vestigial muscle inhuman beings hence its rupture does not result in any significant loss of function. Muscle tear associated withbleeding and swelling leads to a posterior compartment syndrome. It can mimic other serious conditions likeDVT, ruptured baker’s cyst and calf neoplasms.The present study aims to find out the various patterns of proximal and distal attachment of plantaris muscle,which will help the clinician deciding in diagnosis and the plastic & orthopaedic surgeons for different types ofreconstructive surgeries.Materials and Methods: Forty-eight limbs from 24 embalmed cadavers of known sex(male) & age (40-75 years)were dissected in the department of anatomy of Lady Harding medical college, New Delhi during 2016-2017.Plantaris muscle identified with its proximal and distal attachment. Length of muscle belly & tendon wererecorded.Result: In the present study out of 48 limbs specimens, Plantaris muscle was absent in 12.5%. Its proximalattachment to lateral supracondylar ridges observed in 29% & with lateral head of gastrocnemius muscle &fibrous capsule in 58.3%. Its distal attachment deep to tendocalcaneus was noted in 25% and superficial totendocalcaneus in 62.4%. Length of muscle belly was 7- 9 cm in 37% and tendon length was 34- 36cm in 37.5%.Conclusion: The Morphological aspects of the attachment of plantaris play a significant role in the Pathologiesassociated with Calf & knee region. Their exact attachment is importance for reconstructive surgeries to therepair of ankle joint injury and flexor tendon replacement in hand.

Urbanization and coronary heart disease: a study of urban-rural differences in northern India.

BACKGROUND: In the West, urbanization has been accompanied by a rise in the rate of coronary heart disease. This trend has gone hand in hand with an increased consumption of processed, energy-dense food and dependence on machines for physical work. To examine whether a similar trend is underway in northern India, the prevalence of and risk factors for coronary heart disease were compared in rural, semi-urban and urban communities. METHODS AND RESULTS: A total of 7,169 adults were interviewed and examined during 1995-2000 in cross-sectional cluster sample surveys from a rural area of Haryana (Raipur Rani block), two semi-urban areas of Punjab (Mandi Gobindgarh and Morinda), and Chandigarh city. The study, which covered people in the age-group of 35+ years, also estimated the lipid, glucose and insulin levels of a sub-sample of 186 persons who did not have coronary heart disease or hypertension. The prevalence of coronary heart disease among males in the villages, towns and city was 1.7%, 2.5% and 7.4%, respectively, and among females, 1.5%, 3.4% and 7.1%,respectively. The age- and sex-adjusted prevalence odds ratio of coronary heart disease, in comparison to the villages, was 1.9 (95% CI; 1.1-3.2) in the towns and 4.9 (95% CI: 2.9-8.2) in the city. Hypertension, diabetes, obesity and physical inactivity were significantly more common in the urban areas, while the rate of tobacco smoking was significantly higher in the rural areas ( p< 0.05). The alcohol consumption rates for the urban and rural communities were similar (p> 0.05). The quantity of the food items commonly consumed, as well as the frequency with which particular items were consumed, varied across the rural, semi-urban and urban areas ( p< 0.05). The urban population had significantly higher levels of lipids and serum insulin than did the rural population, but a lower level of plasma glucose ( p< 0.05). CONCLUSION: The urban way of living is leading to an increase in the prevalence of the well-known risk factors for, as well as the rate of, coronary heart disease. Attempts to preserve the traditional lifestyle are necessary in order to prevent an epidemic of coronary heart disease in the developing countries.

Platelet alloimmunization in multitransfused patients with haemato-oncological disorders.

BACKGROUND: We studied the incidence of platelet alloimmunization in multitransfused patients with haemato-oncological disorders and determined the factors influencing alloimmunization. We also assessed the effect of alloimmunization on response to platelet transfusion. METHODS: Fifty patients with haemato-oncological disorders who received multiple transfusions were included. The patients were tested for antibodies before they received any transfusion and then after 3-4 weeks of transfusion. Lymphocytotoxicity and platelet immunofluorescence suspension tests were used to detect antiplatelet antibodies. Symptomatic improvement was used to assess the response to platelet transfusions. RESULTS: Thirty patients were positive by the lymphocytotoxicity test, giving an incidence of 60% for anti-HLA antibodies. The panel reactivity of the antibodies ranged from 3% to 100%. Nineteen patients were positive by the platelet immunofluorescence suspension test, 16 of whom were also positive by the lymphocytotoxicity test. The overall incidence of antiplatelet antibodies was 66%. The number of transfusions received and the underlying haemato-oncological disorder were not risk factors for the development of antibodies. Patients with a past history of transfusions and those with a positive obstetric history had a significantly higher incidence of antibodies. The response to transfusion therapy was poor in patients with antibodies, as 71.4% of patients with antibodies were nonresponsive compared to only 26.6% of antibody-negative patients. CONCLUSION: A high percentage of multitransfused patients developed antiplatelet antibodies. Previous sensitization was an important risk factor for the development of antibodies. Patients with high panel reactivity (HLA) showed non-responsiveness to platelet transfusions. Testing for the presence of antiplatelet antibodies and provision of compatible platelets should be important components in the management of patients with platelet transfusion refractoriness.

Cryptococcal meningitis in acute lymphoblastic leukemia.

The occurrence of cryptococcal meningitis in acute lymphoblastic leukemia (ALL), despite being immunosuppresed state is uncommon. We report a 28-year gentleman in the maintenance treatment phase of ALL developing cryptococcal meningitis. The diagnosis was made by positive India ink staining and detection of cryptola antigen by latex agglutination. The patient was successfully treated with amphotericin B. The rarity of this condition in ALL is briefly discussed.

Prevalence of anemia in adult rural population of north India.

OBJECTIVES: To find the prevalence of anemia in adult males and non-pregnant females of rural north Indian population. METHODS: During an epidemiological survey on hypertension in rural population of north India (n=2559), a random sample of 215 individuals underwent blood investigations including hemoglobin estimation. RESULTS: The overall prevalence of anemia in 16-70 years of age group was 47.9% (n=215), being 50% (n= 136) among females and 44.3% (n=78) among males. Low socioeconomic status, illiteracy and lower body mass index, were associated with higher prevalence of anemia. CONCLUSIONS: The finding of higher prevalence of anemia in adult males need further investigation and corroboration in other studies. The intervention for anemia should be directed on the community as a whole.

Isolated lipid abnormalities in rural and urban normotensive and hypertensive north-west Indians.

BACKGROUND: Lipid abnormalities are common in patients with hypertension. The prevalence of isolated lipid abnormalities is not known in normotensive and hypertensive population of north-west India. METHODS: We studied the prevalence of isolated low high density lipoprotein cholesterol (IL-HDLC), isolated high low density lipoprotein cholesterol (IH-LDLC) and isolated high triglycerides (IH-TG) abnormalities among rural and urban normotensive and hypertensives of north-west India. RESULTS: The prevalence of lipid abnormalities was 47.6% and 51.4% in rural normotensives and hypertensives and 43.8% and 46.8% in urban normotensives and hypertensives respectively. The prevalence of IL-HDLC varied from 3.8% to 23.7% among hypertensives and 19.4% to 30.4% among normotensives. The prevalence of IH-TG abnormalities was 11.8% to 18.8% among hypertensives and 7.0% to 15.4% among hypertensives. The prevalence of isolated high LDLC abnormalities was low (0.8-9.2%). There was no significant difference in these abnormalities in relation to age and sex except IH-LDLC in male hypertensives. CONCLUSION: Isolated low HDLC and isolated high TG were the commonest isolated lipid abnormalities among rural and urban population of north-west India whereas isolated high LDLC was uncommon.