Exploratory analysis of the suitability of data from the civil registration system for estimating excess mortality due to COVID-19 in Faridabad district of India.

Background & objectives: Due to shortcomings in death registration and medical certification, the excess death approach is recommended for COVID-19 mortality burden estimation. In this study the data from the civil registration system (CRS) from one district in India was explored for its suitability in the estimation of excess deaths, both directly and indirectly attributable to COVID-19. Methods: All deaths registered on the CRS portal at the selected registrar's office of Faridabad district in Haryana between January 2016 and September 2021 were included. The deaths registered in 2020 and 2021 were compared to previous years (2016-2019), and excess mortality in both years was estimated by gender and age groups as the difference between the registered deaths and historical average month wise during 2016-2019 using three approaches - mean and 95 per cent confidence interval, FORECAST.ETS function in Microsoft Excel and linear regression. To assess the completeness of registration in the district, 150 deaths were sampled from crematoria and graveyards during 2020 and checked for registration in the CRS portal. Agreement in the cause of death (CoD) in CRS with the International Classification of Diseases-10 codes assigned for a subset of 585 deaths after verbal autopsy was calculated. Results: A total of 7017 deaths were registered in 2020, whereas 6792 deaths were registered till 30 September 2021 which represent a 9 and 44 per cent increase, respectively, from the historical average for that period. The highest increase was seen in the age group >60 yr (19% in 2020 and 56% in 2021). All deaths identified in crematoria and graveyards in 2020 had been registered. Observed peaks of all-cause excess deaths corresponded temporally and in magnitude to infection surges in the district. All three approaches gave overlapping estimates of the ratio of excess mortality to reported COVID-19 deaths of 1.8-4 in 2020 and 10.9-13.9 in 2021. There was poor agreement (κ<0.4) between CoD in CRS and that assigned after physician review for most causes, except tuberculosis and injuries. Interpretation & conclusions: CRS data, despite the limitations, appeared to be appropriate for all-cause excess mortality estimation by age and sex but not by cause. There was an increase in death registration in 2020 and 2021 in the district.

Psychological impact on caregivers of HIV-infected children in Udupi district, Karnataka.

Caregivers of children living with HIV/AIDS (CLWHA) face unique challenges due to disease-related stigma and discrimination, isolation from society, financial constraints, grief and mortality of loved one. A descriptive cross-sectional study was conducted at Udupi ART centre to assess the caregiver burden, psychological distress and their associated factors among the caregivers of CLWHA in Udupi District. The convenience sampling technique was used to collect the data from 171 caregivers and analysed with the help of SPSS version 15.0. Majority of caregivers were female (64.9%) with mean age of 38.1 ± 9.6 years. About 64.3% caregivers were HIV-positive and 63.2% were biological parents of CLWHA. Mild-to-severe caregiver burden on Zarit Burden Inventory (ZBI) was reported among 84.8% of caregivers, and mild-to-severe psychological distress on General Health Questionnaire (GHQ-12) was reported among 49.7% caregivers. Relationship with child was found to be a significant predictor of caregiver burden as compared to other relatives/foster (P < 0.001). Relationship with child (P 0.004), Alcohol use (P 0.008) and Schooling of children (P 0.049) were reported as significant predictors of psychological distress. Study concludes that caregiver burden and psychological distress were high among caregivers of CLWHA. Psychological problems of caregivers need to be addressed and integrated along with the clinical care of HIV-infected children at ART centres.

Prevalence and determinants of delays in care among premature deaths due to acute cardiac conditions and stroke in residents of a district in India.

Background: Lack of timely care is a predictor of poor outcomes in acute cardiovascular emergencies including stroke. We assessed the presence of delay in seeking appropriate care among those who died due to cardiac/stroke emergencies in a community in northern India and identified the reasons and determinants of this delay. Methods: We conducted a social audit among all civil-registered premature (30-69 years) deaths due to acute cardiac event or stroke in the district. The three-delays model was used to qualitatively classify the delays in care-seeking-deciding to seek care, reaching the appropriate health facility (AHF) and initiating definitive treatment. Based on the estimated time from symptom onset to reaching AHF, we classified patients as early (reached within one hour) or delayed arrivers. We used mixed-effect logistic regression with postal code as a random effect to identify determinants of delayed arrival. Findings: Only 10.8% of the deceased reached an AHF within one hour. We noted level-1 delay in 38.4% (60% due to non-recognition of seriousness); level-2 delay in 20% (40% due to going to an inappropriate facility) and level-3 delay in 10.8% (57% due to lack of affordability). Patients with a monthly family income of >270US$ (aOR 0.44; 95% CI 0.21-0.93) were less and those staying farther from AHF (aOR 1.12; 95% CI 1.01-1.25 for each Km) were more likely to have delayed arrival in AHF. Interpretation: A small proportion of patients with cardiac and stroke emergencies reach health facility early with delays at multiple levels. Addressing the reasons for delay could prevent these deaths. Funding: : Indian Council of Medical Research, New Delhi, India.

ABDA Score: A Non-invasive Model to Identify Subjects with Fibrotic Non-alcoholic Steatohepatitis in the Community.

Background: Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NASH) are prevalent in the community, especially among those with metabolic syndrome. Patients with fibrotic NASH are at increased risk of liver-related-events. Currently available non-invasive tests have not been utilized for screening for fibrotic NASH among the community. We aimed to develop a screening tool for fibrotic NASH among community members. Methods: We included two large cohorts aimed at assessing cardiovascular disease among community members. Fibrotic NASH was defined using the FibroScan-aspartate aminotransferase score of ≥0.67 that identifies ≥F2 fibrosis and a non-alcoholic fatty liver disease activity score ≥4 with a specificity of 90%. Metabolic parameters, biochemical tests and anthropometry were used to develop a multivariate model. Results: The derivation cohort (n = 1660) included a population with a median age 45 years, 42.5% males, metabolic syndrome in 66% and 2.7% (n = 45) with fibrotic NASH. Multivariate analysis identified the four significant variables (Age, body mass index , Diabetes and alanine aminotransferas levels) used to derive an ABDA score. The score had high diagnostic accuracy (the area under receiver-operating characteristic curve, 0.952) with adequate internal validity. An ABDA score ≥-3.52 identified fibrotic NASH in the derivation cohort with a sensitivity and specificity of 88.9% and 88.3%. The score was validated in a second cohort (n = 357) that included 21 patients (5.9%) with fibrotic NASH, where it demonstrated a high area under receiver-operating characteristic curve (0.948), sensitivity (81%) and specificity (89.3%). Conclusions: ABDA score utilizes four easily available parameters to identify fibrotic NASH with high accuracy in the community.

Rural-Urban differentials in prevalence, spectrum and determinants of Non-alcoholic Fatty Liver Disease in North Indian population.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is a spectrum of disease ranging from simple steatosis, non-alcoholic steatohepatitis (NASH), through to advanced fibrosis and cirrhosis. We assessed the prevalence, spectrum, and determinants of NAFLD among adults in urban and rural North India. METHODS: A representative sample of adults aged 30-60 years were recruited from urban Delhi and rural Ballabhgarh during 2017-2019. Participants underwent abdominal ultrasonography (USG) and vibration controlled transient elastography (VCTE) with FibroScan to assess fatty liver and fibrosis, respectively. We estimated the age- and sex-standardised prevalence of NAFLD and its spectrum. The factors associated with 'ultrasound-diagnosed NAFLD' were identified using multivariate logistic regression. RESULTS: A total of 828 urban (mean ± SD age: 45.5 ± 8.0 years; women: 52.7%) and 832 rural (mean ± SD age: 45.1 ± 7.9 years; women: 62.4%) participants were recruited. The age- and sex-standardized prevalence of ultrasound-diagnosed NAFLD was 65.7% (95%CI: 60.3-71.2) in the urban and 61.1% (55.8-66.5) in the rural areas, respectively. The prevalence of NAFLD with elevated alanine transaminase (≥40IU/L) was 23.2% (19.8-26.6), and 22.5% (19.0-26.0) and any fibrosis by liver stiffness measurement on transient elastography (≥6.9 kPa) was 16.5% (13.8-19.8) and 5.2% (3.8-6.7) in urban and rural participants, respectively. In both urban and rural areas, diabetes, central obesity and insulin resistance were significantly associated with NAFLD. CONCLUSION: NAFLD prevalence was high among rural and urban North Indian adults, including fibrosis or raised hepatic enzymes. The strong association of metabolic determinants confirms its linkage with metabolic syndrome.

Change in prevalence of Coronary Heart Disease and its risk between 1991-94 to 2010-12 among rural and urban population of National Capital Region, Delhi.

OBJECTIVES: We aimed to measure the change in prevalence of Coronary Heart Disease (CHD) and Cardiovascular Diseases (CVDs) risk among those aged 35-64 years in urban and rural areas of National Capital Region (NCR) of Delhi, between 1991-1994 (survey 1) and 2010-2012 (survey 2). METHODS: Both surveys used similar sampling methodology and mean ages of participants were similar. A total of 3048 and 2052 subjects were studied in urban Delhi and 2487 and 1917 participants recruited from rural Ballabgarh in survey 1 and in survey 2 respectively. CHD was diagnosed based on a Minnesota coded ECG and Rose angina questionnaire. Data on behavioural, physical, clinical and biochemical parameters were collected using standard methods. CVD Risk of participants was calculated using the gender specific Framingham risk equation. RESULTS: The age and sex standardised prevalence of CHD in urban Delhi increased from 10.3% (95% CI: 9.2-11.4) to 14.1% (95% CI: 12.6-15.6) between the two surveys as compared to an increase from 6.0% (95% CI: 5.0-6.9) to 7.4% (95% CI: 6.3-8.6) in rural Ballabgarh. The highest increase in the prevalence of CHD was reported among urban women (10.1% to 16.6%).The proportion of population with high 10-year CVD risk increased to 4.1% from 1.2% in rural areas as compared to 4.8% from 2.5% in urban areas. CONCLUSIONS: The CHD and CVD risk has increased over 20 years period in and around Delhi and the increase was more in rural population and women, traditionally considered to be at low risk.

Surgical management of periapical lesion with dens in dente.

The management of one case of dens in Dente (Dens invaginatus) in maxillary lateral incisor with history of trauma to maxillary central incisor with periradicular lesion is reported. The patient presented with pain and fracture of anterior tooth. Despite of complex anatomy and diagnosis of dens invaginatus, surgical root canal (Apicoectomy) was performed successfully. Further more essential clinical considerations and treatment options are suggested. Early diagnosis and management are important to avoid complications.