Reference values for peak expiratory flow in Indian adult population using a European Union scale peak flow meter.

BACKGROUND: Reference values of peak expiratory flow (PEF) in Indian adults have to date been derived locally, using an old (Wright) scale peak flow meter. There are thus no reliable reference values for PEF for Indians and this formed the aim of the study. MATERIALS AND METHODS: A European Union (EU) scale peak flow meter (PFM) was used for the study. A respiratory health and demographic questionnaire was administered to 1000 male and female adults from randomly selected locations in the country in this multi centric study. The locations represented different geographic, ethnic, and socioeconomic backgrounds. Patients were stratified according to height and age. The PEF values were measured using the Breathometer™ (Cipla Ltd., India) with EU scale. Reference equations were derived from multiple regression analysis. RESULTS: A total of 3608 participants were excluded. In 80% of the remaining 6138 healthy adults (M: 3720; F: 2418), the predicted regression equations were derived. Gender, age, and height were the significant determinants of PEF. The equations in L/minute are: Females: PEF = -1.454 (Age) + 2.368 (Height) Males: PEF = -1.807 (Age) + 3.206 (Height). The derived equation was validated by comparing the predicted PEF values with the measured values in the remaining sample of 20% (Mean ΔPEF: M = 1.85 L/minute, CI = -2.76, 6.47; F = 1.64, CI = -2.89, 6.18). An Indian adult with average height and age was found to have approximately 30% lower PEF compared to the corresponding European adult using the Nunn and Gregg equation. CONCLUSION: We derived reference values of PEF for Indian adults using a validated EU scale peak flow meter.

Association between lung function and dyspnoea and its variation in the multinational Burden of Obstructive Lung Disease (BOLD) study.

BACKGROUND: Dyspnoea is a common symptom of respiratory disease. However, data on its prevalence in general populations and its association with lung function are limited and are mainly from high-income countries. The aims of this study were to estimate the prevalence of dyspnoea across several world regions, and to investigate the association of dyspnoea with lung function. METHODS: Dyspnoea was assessed, and lung function measured in 25,806 adult participants of the multinational Burden of Obstructive Lung Disease study. Dyspnoea was defined as ≥2 on the modified Medical Research Council (mMRC) dyspnoea scale. The prevalence of dyspnoea was estimated for each of the study sites and compared across countries and world regions. Multivariable logistic regression was used to assess the association of dyspnoea with lung function in each site. Results were then pooled using random-effects meta-analysis. RESULTS: The prevalence of dyspnoea varied widely across sites without a clear geographical pattern. The mean prevalence of dyspnoea was 13.7 % (SD=8.2 %), ranging from 0 % in Mysore (India) to 28.8 % in Nampicuan-Talugtug (Philippines). Dyspnoea was strongly associated with both spirometry restriction (FVC

Emergence of carbapenem-resistant Acinetobacter in a temperate north Indian State.

This study aims to determine drug sensitivity, metallo-beta-lactamase (MBL) production and elaboration of bla(OXA)-type carbapenemases in Acinetobacter spp. in a temperate climate area in north India with a heavy influx of tourists. Antimicrobial sensitivity of 165 isolates was performed. Imipenem-resistant isolates were subjected to combined disk (CDT) and double-disk diffusion tests (DDT) for MBL detection. Minimum inhibitory concentration (MIC) and MBL production were tested by Etest. A multiplex polymerase chain reaction (PCR) was performed for the detection of genes encoding bla(OXA)-23 like, bla(OXA-24) like, bla(OXA-51) like and bla(OXA-58) like genes. Ninety-nine (60%) isolates were imipenem-resistant (MICs 2-96 microg/mL). Fifty (50.5%) of the 99 carbapenem-resistant isolates were MBL producers by CDT and 26 (26.3%) by DDT. The majority (77%) of the isolates elaborated bla(OXA-23) and bla(OXA-51) like genes. Forty seven of the 50 MBL-positive isolates harboured bla(OXA-23) like and bla(OXA-51) like genes. MBL-producing Acinetobacter has emerged as a major pathogen in Kashmir with elaboration of bla(OXA-23) and bla(OXA-51) related carbapenemases. This poses a significant challenge for healthcare professionals and policy planners, and needs to be addressed immediately. Primary care physicians treating visitors to Kashmir need to be aware of the situation.

COPD exacerbation rates are higher in non-smoker patients in India.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is common among non-smokers exposed to solid fuel combustion at home. Different clinical characteristics in these patients may have significant therapeutic and prognostic implications.METHODS: We used medical record review and a questionnaire among COPD patients at 15 centres across India to capture data on demographic details, different types of exposures and clinical characteristics. Chest radiography and pulmonary function testing were performed in all 1984 cases; C-reactive protein and exhaled breath nitric oxide were measured wherever available.RESULTS: There were 1388 current or ex-smokers and 596 (30.0%) non-smokers who included 259 (43.5%) male and 337 (56.5%) female patients. Sputum production was significantly more common in smokers with COPD (P < 0.05). The frequency of acute symptomatic worsening, emergency visits and hospitalisation were significantly higher (P < 0.05) in non-smokers with COPD; however, intensive care unit admissions were similar in the two groups. There was no significant difference with respect to the use of bronchodilators, inhalational steroids or home nebulisation among smoker and non-smoker patients. The mean predicted forced expiratory volume in 1 sec in smokers (43.1%) was significantly lower than in non-smokers (46.5%).CONCLUSION: Non-smoker COPD, more commonly observed in women exposed to biomass fuels, was characterised by higher rate of exacerbations and higher healthcare resource utilisation.

Frequency, types, severity, preventability and costs of Adverse Drug Reactions at a tertiary care hospital.

INTRODUCTION: Hospital-based adverse drug reaction (ADR) monitoring and reporting studies are conducted to identify, quantify and minimize such risks associated with the use of drugs particularly on long-term basis. Kashmir province of Indian state of Jammu and Kashmir presents a huge market for medicines that runs into millions of rupees. Yet there was no provision to monitor these drugs for their adverse effects prior to this study in any of the leading hospitals of the province. As such the present study, which was first of its kind in the valley, was undertaken to assess the frequency, preventability, category, severity, causality, extension of hospital stay and costs of drug-related adverse effects in Kashmiri patients at a Srinagar-based tertiary care hospital. METHODS: A prospective, observational, cohort study on 5482 patients was undertaken over a 270day period. Adult patients admitted in Internal Medicine in-patient department (IPD), presenting to the Internal Medicine out-patient department (OPD) and those visiting the Accident and Emergency Department of the study hospital were included in the study. Patients belonging to both the sexes were screened and monitored on a daily basis for the occurrence of any ADRs. Definition of ADR given by the World Health Organization (WHO) was used and causality of suspected ADRs was determined using Naranjo's algorithm whereas severity was assessed using modified Hartwig's scale and preventability was determined using Hallas methodology. Costs of ADRs and extension in hospital stay were calculated as per Lagnaou and Nicholas methodology respectively. RESULTS: ADRs accounted for 6.23% of adult Kashmiri patients visiting the tertiary care hospital under study, either for referral or hospitalization, with the majority (81.57%) of these ADRs being preventable; 23.68% of patients had mild ADRs, 69.29% had ADRs of moderate severity, and 7.01% had severe ADRs. Four classes of drugs most frequently suspected in admissions due to ADRs were anti-infective agents (40.92%) including anti-tubercular drugs (13.15%), steroids (14.03%), anti-coagulants (8.77%), and NSAIDs (7.89%). Increasing age and female gender were identified as risk factors. The total cost to the hospital due to hospitalization of patients presenting with ADRs over the 9-month period in the internal medicine IPD was found to be USD 22469 at the time of this study. DISCUSSION/CONCLUSION: The present work is the maiden pharmacovigilance study conducted on Kashmiri patients, especially at a tertiary care teaching hospital that has provided baseline information about the prevalence of ADRs and their distribution among different age groups, genders, organ systems affected, and therapeutic classes of medicines. The data collected will be useful for long term and more extensive ADR monitoring on Kashmiri patients and will also be useful in framing policies toward the rational use of drugs. This study led to the establishment of a full-fledged pharmacovigilance centre and initiation of pharmaceutical care services in the study hospital.

Prevalence of chronic airflow limitation in Kashmir, North India: results from the BOLD study.

BACKGROUND: Data on spirometrically defined chronic airflow limitation (CAL) are scarce in developing countries. OBJECTIVE: To estimate the prevalence of spirometrically defined CAL in Kashmir, North India. METHODS: Using Burden of Obstructive Lung Disease survey methods, we administered questionnaires to randomly selected adults aged ⩾40 years. Post-bronchodilator spirometry was performed to estimate the prevalence of CAL and its relation to potential risk factors. RESULTS: Of 1100 participants initially recruited, 953 (86.9%) responded and 757 completed acceptable spirometry and questionnaires. The prevalence of a forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratio less than the lower limit of normal was 17.3% (4.5) in males and 14.8% (2.1) in females. Risk factors for CAL included higher age, cooking with wood and lower educational status. The prevalence of current smoking was 61% in males and 22% in females; most smoked hookahs. CAL was found equally in non-smoking males and females, and was independently associated with the use of the hookah, family history of respiratory disease and poor education. A self-reported doctor's diagnosis of chronic obstructive pulmonary disease was reported in 8.4/1000 (0.9% of females and 0.8% of males). CONCLUSION: Spirometrically confirmed CAL is highly prevalent in Indian Kashmir, and seems to be related to the high prevalence of smoking, predominantly in the form of hookah smoking.

Primary gradient defect distal renal tubular acidosis presenting as hypokalaemic periodic paralysis.

A 45 year old man presented with recurrent hypokalaemic paralysis. Laboratory investigations revealed renal tubular acidosis as the cause of the hypokalaemia, and dynamic tubular studies suggested a gradient defect as the underlying cause. The patient had associated dextrocardia. To our knowledge, this is the first report of this condition.

Performance of rapid influenza diagnostic tests (QuickVue) for influenza A and B Infection in India.

BACKGROUND: Rapid point-of-care (POC) tests provide an economical alternative for rapid diagnosis and treatment of influenza, especially in public health emergency situations. OBJECTIVES: To test the performance of a rapid influenza diagnostic test, QuickVue (Quidel) as a POC test against a real-time polymerase chain reaction (RT-PCR) assay for detection of influenza A and B in a developing country setting. STUDY DESIGN: In a prospective observational design, 600 patients with influenza-like illness (ILI) or with severe acute respiratory illness (SARI) who were referred to the Influenza Clinic of a tertiary care hospital in Srinagar, India from September 2012 to April 2013, were enrolled for diagnostic testing for influenza using QuickVue or RT-PCR. All influenza A-positive patients by RT-PCR were further subtyped using primers and probes for A/H1pdm09 and A/H3. RESULTS: Of the 600 patients, 186 tested positive for influenza A or B by RT-PCR (90 A/H1N1pdm09, 7 A/H3 and 89 influenza B), whereas only 43 tested positive for influenza (influenza A=22 and influenza B=21) by QuickVue. Thus, the sensitivity of the QuickVue was only 23% (95% confidence interval, CI: 17.3-29.8) and specificity was 100% (95% CI: 99.1-100) with a positive predictive value (PPV) of 100% (95% CI 91.8-100) and a negative predictive value (NPV) of 74.3% (95% CI: 70.5-77.9) as compared to RT-PCR. CONCLUSIONS: The high specificity of QuickVue suggest that this POC test can be a useful tool for patient management or triaging during a public health crisis but a low sensitivity suggests that a negative test result need to be further tested using RT-PCR.

Gaps in using bronchodilators, inhaled corticosteroids and influenza vaccine among 23 high- and low-income sites.

BACKGROUND: Increasing access to essential respiratory medicines and influenza vaccination has been a priority for over three decades. Their use remains low in low- and middle-income countries (LMICs), where little is known about factors influencing use, or about the use of influenza vaccination for preventing respiratory exacerbations. METHODS: We estimated rates of regular use of bronchodilators, inhaled corticosteroids and influenza vaccine, and predictors for use among 19 000 adults in 23 high-income countries (HICs) and LMIC sites. RESULTS: Bronchodilators, inhaled corticosteroids and influenza vaccine were used significantly more in HICs than in LMICs, after adjusting for similar clinical needs. Although they are used more commonly by people with symptomatic or severe respiratory disease, the gap between HICs and LMICs is not explained by the prevalence of chronic obstructive pulmonary disease or doctor-diagnosed asthma. Site-specific factors are likely to influence use differently. The gross national income per capita for the country is a strong predictor for use of these treatments, suggesting that economics influence under-treatment. CONCLUSION: We still need a better understanding of determinants for the low use of essential respiratory medicines and influenza vaccine in low-income settings. Identifying and addressing these more systematically could improve the access and use of effective treatments.

CT in pulmonary hydatid disease: unusual appearances.

OBJECTIVE: To study the CT features of pulmonary hydatid disease. PATIENTS: Thirty-two consecutive patients with surgically proven pulmonary hydatid cysts. SETTING: SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India, a tertiary-care referral center. INTERVENTIONS: CT of the chest was obtained in all cases on Somatom DR double rotate CT scanner (Siemens; Erlangen, Germany). RESULTS: Forty cysts of different size and shapes were encountered, 34 of them being ruptured. CT density of the cysts varied from - 42 to 160 Hounsfield units (HU; median, 15.5 HU). Apart from the classically described features of pulmonary hydatid disease, a crescent-shaped rim of air at the lower end of the cyst (inverse crescent sign) was seen in three cysts, and a bleb of air in the wall of two as-yet unruptured cysts (signet ring sign). Thick wall (>10 mm) was observed in four cysts, and each of them had associated evidence of infection. CONCLUSIONS: Inverse crescent sign, signet ring sign, high CT density, and thick wall should be recognized as features of pulmonary hydatid cysts on CT.

HLA antigen pattern of Kashmiri patients with rheumatic heart disease.

The distribution of HLA class-I (A, B and C), and class II (DR and DQ) antigens was studied in 50 randomly selected Kashmiri Muslim patients with established rheumatic heart disease and compared with that of 50 controls of similar ethnicity. A significant increase in the frequency of HLA-DR4 (P < 0.005, RR 3.27) and a significant decrease in the frequency of HLA-B5 (P < 0.001, RR 0.19) were found in the patient group. Though HLA-DQ3 showed a significant increase (P < 0.005, RR 2.52) and HLA-DR7 a significant decrease (P < 0.05, RR 0.42) in the patient group, the corrected P value was not significant. The findings suggest that susceptibility to RHD in the studied population is HLA-related, with HLA-DR4 influencing its occurrence and HLA-B5 conferring protection against the same.

Lead exposure in papier mâché workers.

Lead exposure was assessed in a random cohort of 70 male papier mâché workers and compared with 35 age and sex matched controls. Blood-lead levels in workers were significantly higher than in controls (Mean 68.07 +/- 44.64 ug/dl vs 25.52 +/- 16.56 ug/dl respectively; P < 0.001). Urinary lead was also higher in workers (128.53 +/- 52.61 ug/l) compared to controls (91.18 +/- 27.06, P < 0.001), but excretion of urinary coproporphyrin in the two groups was not significantly different (102.78 +/- 153.42 vs 70.03 +/- 27.06 ug/l, P > 0.05). Blood levels bore a significant correlation with age but did not bear any correlation with the duration of exposure. Various modes of exposure to lead included hand mixing of paints, skin application of the paint to match shades and making point of the brush using lips and the tongue.

Hypocomplementemic urticarial vasculitis and lower cranial nerve palsies.

A 55 years post menopausal lady presented with puffiness of face, and a pruritic urticarial rash over face and upper trunk of one week duration with accompanying dysphagia. Clinical examination revealed an urticarial rash over face and upper trunk, two small ulcers over floor of mouth and evidence of bilateral VIII, IX and Xth cranial nerve palsies. Hypocomplementemia, negative immune profile and evidence of vasculitis on skin biopsy suggested a diagnosis of hypocomplementemic urticarial vasculitis. The patient responded to a course of steroids.

Mepacrine therapy in niclosamide resistant taeniasis.

OBJECTIVE: To evaluate the efficacy of mepacrine (quinacrine) in patients with niclosamide resistant Taenia saginata infection. METHODS: Eighty six cases with niclosamide resistant Taenia saginata (unresponsive to 2-8 courses of niclosamide) were treated with quinacrine (1 g) administered orally or via a nasogastric tube, and followed at 2, 4, 8 and 12 weeks for recurrence of passage of proglottids and presence of Taenia eggs in the stool examinations. Pre and post-therapy egg counts were obtained and egg viability was tested by staining with methylene blue. RESULTS: Eighty-one (94.2%) patients responded promptly with passage of the worm within 4-72 hours. The egg counts showed a drastic fall in 79 cases and a fall in viability from a median of 100% to 0% was observed. Only one patient demonstrated a relapse at 4 weeks. Gastrointestinal side effects occurred in 9 cases but were controlled easily by symptomatic therapy. CONCLUSION: We conclude that quinacrine is a safe, inexpensive, effective and generally well tolerated drug for the treatment of niclosamide resistant Taenia saginata infestations.

The foam mattress-back syndrome.

BACKGROUND: Many medical residents used to sleeping on cotton mattresses at home complain of mild to moderate back pain after sleeping on foam mattresses provided in the hospital and hostel rooms. OBJECTIVE: To determine the relationship of sleeping on foam mattress with the appearance of back pain in a 500 bedded multispecialty tertiary care hospital. METHODS: One hundred medical residents were interviewed for the appearance of backache after sleeping on 10 cm thick foam mattress provided to them in the hostels. Pain was scored over a visual analog scale of 10 cm. Effect of sleeping on a regular cotton mattress was assessed. RESULTS: Sixty-three (5 female residents) developed back pain on the morning of a night of sleep over the foam mattress. The pain was mostly of lower back and was not associated with any objective neurodeficit. Four residents on account of the backache reported thirteen episodes of absenteeism. Sixty-one residents had a relief of the pain on going home where they would sleep on regular cotton mattresses, only to recur after sleeping again on the foam mattress in the hospital/hostel. CONCLUSION: Sleeping on foam mattress is associated with the appearance of backache in medical residents which is reproducible and gets relieved after using regular cotton mattresses.

Relapsing polychondritis in an elderly male.

A 65 years patient presented with left ear swelling, swelling of the nasal bridge with congestion of the eyes. Clinically there was evidence of left auricular chondritis, nasal chondritis and conjunctivitis with a history of multiple similar episodes in the past, features suggestive of relapsing polychondritis. The patient improved with oral prednisolone.

Evaluation of social marketing of oral rehydration therapy.

Attempts, at social marketing of oral rehydration therapy (ORT) through television, in changing the knowledge and practice of mothers with regard to its use was assessed. One hundred and eighty seven consecutive mothers (38 excluded due to non use of ORT) were administered a preplanned questionnaire to assess their socio-economic profile, educational status, concept of diarrhea and correct use of ORT. Fifty nine mothers who watched these programmes on TV regularly formed the study group. These were compared with 90 mothers who had gained such knowledge from non-television sources. The correct application of knowledge of ORT was significantly better in study group compared with control group. The educational status of mothers had a positive impact on motivation to use ORT at home in the study group. Mass media campaigns through "TV spots" is an effective way of improving knowledge of mothers on ORT in a developing country.

PIP: Researchers interviewed 149 mothers from the slums of East Delhi, India who knew about oral rehydration therapy (ORT) to evaluate the effectiveness of the Ministry of Health's mass media campaign to promote ORT use during diarrheal episodes. As of September 1991, India has distributed oral rehydration solution (ORS) packets free of charge. The Ministry of Health has conducted the campaign since 1989. They compared the 59 mothers who watched the television (TV) ads with celebrities delivering simple and clear images to the 90 mothers who had received ORT messages from other sources such as health workers. Mothers who watched the TV ads were considerably more likely to know how to correctly prepare ORS than those who learned about ORT from other sources (62.7% vs. 37.7%; p.01). No significant difference in use of ORT at home between the 2 groups existed, however (69.49% and 53.33%, respectively). Yet when the mothers were divided by educational status, they learned that TV ads were more likely to teach educated mothers how to correctly prepare and to use ORT at home than health staff (81.5% vs. 35.5% and 81.5% vs. 41.9%, respectively; p.01). Most mothers (88.13% and 81.11%, respectively) in both groups still fed their child during diarrheal episodes. TV ads and health staff were equally effective for both educated and uneducated women. These results showed that social marketing of ORS packets via the TV ads was successful in increasing ORT acceptability, knowledge, use, and especially among educated mothers. Similar studies in Bangladesh showed that education incites changes in attitude and behavior of mothers which makes them more receptive of new knowledge and modern medicine. Another possibility for the education difference may be that TV was better able to interest educated mothers than health staff.

Multi drug resistant Salmonella typhi infection: clinical profile and therapy.

Multiple drug resistant Salmonella typhi infection was observed in thirty five recent cases among forty eight children with bacteriologically proven enteric fever. Incidence of complications such as shock, myocarditis, encephalopathy and paralytic ileus was higher among these. A combination of cephalexin and gentamicin was successfully used in the management of these children.

Continuous octreotide infusion for treatment of upper gastrointestinal bleeding due to portal hypertension in children: An observational study from pediatric intensive care unit.

Evaluate the usage of octreotide for the control of acute upper gastrointestinal bleeding in children with portal hypertension. A retrospective electronic database analysis of these children was performed over a period of five years. Setting was a tertiary pediatric intensive care. Case notes of 18 encounters in 13 children were reviewed. A loading dose (1.27 ± 0.76 µg/kg) was administered in seven, with median starting dose of 1.44 ± 1.19 µg/kg/h in all other episodes. The mean maximum dose was 1.68 ± 1.38 µg/kg/h. Re-bleeding occurred in one third; hemostasis was eventually achieved in all. Octreotide infusion appears to be safe and effective in controlling pediatric upper gastrointestinal bleeding due to portal hypertension. We also recommend its use in community and rural hospital settings prior to transfer of such patients to a tertiary care center.