Is telemedicine a holy grail in healthcare policy: clinicians' and patients' perspectives from an Apex Institution in Western India.

BACKGROUND: This study aimed to explore the perception of doctors regarding telemedicine consultations and the level of patient satisfaction with the services received through teleconsultations. METHODS: This cross-sectional study was conducted on clinicians who provided teleconsultations and patients who received teleconsultations in an Apex healthcare institution in Western India. Semi-structured interview schedules were used to record the quantitative and qualitative information. Clinicians' perceptions and patients' satisfaction were assessed using two different 5-point Likert scales. Data were analyzed using SPSS v.23 using non-parametric tests (Kruskal Wallis and Mann-Whitney U). RESULTS: A total of 52 clinicians who delivered teleconsultations and 134 patients who received teleconsultations from those doctors were interviewed in this study. For 69% of doctors, telemedicine was feasible to implement, and for the rest, it was challenging. Doctors believe telemedicine is convenient for patients (77%) and prevents the transmission of infection (94.2%). Difficulty in clinical evaluation (73%), communication (55.7%), network connectivity (34%), diagnosis and investigations (32%), and patients' e-illiteracy (32%) were the most common challenges faced by clinicians. Patients' experiences were positive in terms of ease of registration (82.1%), audio quality (100%), freedom to discuss medicine (94.8%), and comprehension of the diagnoses (88.1%). Patients expressed satisfaction with the length of the teleconsultation (81.4%), the advice and care they received (78.4%), and the manner and communication of the clinicians (78.4%). CONCLUSIONS: Though there were some challenges in the implementation of telemedicine, the clinicians perceived it quite helpful. The majority of the patients were satisfied with teleconsultation services. Difficulty in registration, lack of communication, and a deep-rooted mindset of physical consultations were the primary concerns from the patient side.

Unmasking of systemic lupus erythematosus in a patient with hemophagocytic lymphohistiocytosis- macrophage activation syndrome (HLA-MAS) and diffuse alveolar hemorrhage.

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome caused by macrophages and cytotoxic T cells with aberrant activation. The primary (genetic) form, which is caused by mutations that affect lymphocyte cytotoxicity and immune regulation, is most prevalent in children, whereas the secondary (acquired) form is prevalent in adults. Secondary HLH is commonly caused by infections or cancers, but it can also be caused by autoimmune disorders, in which case it is known as macrophage activation syndrome (MAS; or MAS-HLH). A 25-year-old female presented with a high-grade fever that lasted for two weeks. His laboratory results revealed pancytopenia, neutropenia, hypertriglyceridemia, hypofibrinogenemia, and hyperferritinemia. Based on the clinical presentation and laboratory findings, a provisional diagnosis of HLH has been made. A HLH protocol was utilized to treat the patient. During the course of hospitalization, systemic lupus erythematosus (SLE) was identified as the underlying cause. She improved dramatically after receiving an immunosuppressive regimen of etoposide, cyclosporine, and dexamethasone according to HLH protocol-2004 with individualized modifications. The clinician should be aware that HLH may be the initial manifestation of underlying SLE. Early diagnosis and aggressive, individualized treatment are the key to improving outcomes.

The role of infrared dermal thermometry in the management of neuropathic diabetic foot ulcers.

AIM: This prospective observational study evaluated the role of infrared (IR) dermal thermometry in the management of diabetic foot ulcers. METHODS: Thirty participants with unilateral neuropathic diabetic foot ulcers of University of Texas grade 1 or 2 (stage A) were followed up monthly for 1 year. At each visit, skin temperatures were measured with an IR dermal thermometer at corresponding sites on both feet, using the contralateral feet without ulcers as controls. RESULTS: Average temperature and ulcer temperature in affected feet were significantly higher than in unaffected feet, with a mean difference of 1.2 °C [95% confidence interval (CI) 0.7 to 1.7] and 3.1 °C (95% CI 2.3 to 3.9), respectively. Although the gradient between average temperature of affected foot and that of unaffected foot normalized (mean difference 0.2 °C, 95% CI -0.2 to 0.7) at healing, the temperature gradient between the ulcer and a corresponding site on the unaffected foot decreased but did not normalize (mean difference 2.1 °C, 95% CI 1.2 to 3.1) even at healing, as documented by skin closure, and persisted for up to 1 month after skin closure. A gradient of ≥1 °C between average temperature of affected foot and that of unaffected foot at initial presentation or at any time during ulcer healing was found to predict impaired healing and should alert clinicians to ulcers requiring more attention. An incremental trend in temperature gradient (median difference 2.2 °C; range 0.1-6.3 °C) at a site on the foot was predictive of a recurrent ulcer involving the same site. CONCLUSIONS: IR dermal thermometry may have a role in predicting diabetic foot ulcer healing, in determining the completeness of healing and in guiding the duration of offloading. Serial monitoring of the temperature gradient may predict the development of recurrent diabetic foot ulcers.

Vitamin D, body mass composition and metabolic risk factors in healthy young Indians.

BACKGROUND: Studies have linked vitamin D to risk factors for cardiovascular disease. Obesity is a potential confounder in these studies. This study examined the relationship of 25 (OH) cholecalciferol (25[OH] D3) with insulin resistance, blood glucose, and lipid profile in lean male adults. METHOD: We enrolled two hundred and thirty four military recruits before beginning of military training. Demographic and anthropometric data were collected from them. The participants underwent body mass composition analysis by dual energy X ray absorptiometry. Fasting samples were collected for measurement of blood glucose, lipid profile, 25(OH) D3, serum parathormone (PTH) and insulin. RESULTS: Vitamin D deficiency and insufficiency was found in 47.7% (107/224) and 31.6% (71/224) of participants, respectively. Using Pearson's correlation coefficient 25(OH) cholecalciferol and fasting blood glucose (FBG) were inversely correlated (p = 0.023). However, similar relation was not found between 25(OH) D3 and total cholesterol, triglycerides, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, homeostatic model assessment of insulin resistance and levels of PTH. On body composition analysis, there was no correlation of 25(OH) cholecalciferol with body mass index or fat mass index. CONCLUSION: This study showed that in lean young male population, 25(OH) cholecalciferol and FBG are inversely correlated but no association of 25(OH) D3 with other cardiometabolic risk factors could be demonstrated.

The effect of vitamin D supplementation on cardiorespiratory fitness and muscle strength in male adults undergoing basic military training.

BACKGROUND: Vitamin D deficiency (VDD) is ubiquitous in the Indian subcontinent. VDD has been shown to impair muscle functions. However, the association of VDD with cardiorespiratory endurance is uncertain. Hence, we enrolled and supplemented vitamin D in military recruits with VDD with an aim to evaluate effect of supplementation on cardiorespiratory endurance and muscle strength. METHOD: We enrolled 90 military recruits with VDD and randomly allotted them to two groups equally. The group I received cholecalciferol granules 60,000 IU every fortnight for twelve weeks (cases), and the group II was observed as control. Muscle strength and cardiorespiratory endurance was assessed with a battery of tests (standing broad jump, bent arm hang test, 20 m shuttle run) at baseline and repeated at the end of training (nineteen weeks). Blood samples were collected for measurement of serum 25(OH)D and parathyroid hormone. RESULTS: In Group I and Group II, there was significant increase in 25(OH) D levels (25.8 ± 7.1 and 17.3 ± 3.5 ng/ml, respectively), and in VO2 max (9.8 ± 8.8 and 12.7 ± 8.6 ml/kg/min, respectively) compared with the baseline values. However, no significant change was observed in muscle strength after supplementation. There was no difference between the groups in VO2 max and muscle strength at baseline and at the end of training. CONCLUSION: Vitamin D supplementation did not improve muscle strength and cardiorespiratory endurance in military recruits with VDD. A significant rise in 25(OH) D was observed even in those not supplemented with vitamin D.

Identification of Novel PROP1 and POU1F1 Mutations in Patients with Combined Pituitary Hormone Deficiency.

Growth hormone deficiency (GHD) results from variations affecting the production and release of growth hormone (GH) and is of 2 types: isolated growth hormone deficiency (IGHD) and combined pituitary hormone deficiency (CPHD). IGHD results from mutations in GH1 and GHRHR while CPHD is associated with defects in transcription factor genes PROP1, POU1F1, and HESX1. The present study reports on screening of POU1F1, PROP1, and HESX1 in CPHD patients and the novel variations identified. Fifty-one CPHD patients from 49 unrelated families clinically diagnosed on the basis of biochemical and imaging investigations along with 100 controls were enrolled. Detailed family history was noted from all participants and 5 ml blood samples drawn were processed for DNA isolation followed by direct sequencing of POU1F1, PROP1, and HESX1genes. Of the 51 patients, 8 were females and 43 were males. Mean height standard deviation score (SDS) and weight SDS were -5.50 and -2.76, respectively. Thirty-six of the 51 patients underwent MRI of which 9 (25%) had normal pituitary structure and morphology while 27 (75%) showed abnormalities. Molecular analysis revealed 10 (20%) patients to have POU1F1 and PROP1 mutations/variations of which 5 were novel and 2 previously reported. No mutations were identified in HESX1. The novel variations identified were absent in the 100 healthy individuals screened and the control database Exome Aggregation Consortium (ExAC). Reported POU1F1 and PROP1 mutation hotspots were absent in our patients. Instead, novel POU1F1 changes were identified suggesting existence of a distinct mutation spectrum in our population.

The relationship between serum 25-hydroxy vitamin D, parathormone and bone mineral density in Indian population.

OBJECTIVES: Vitamin D deficiency (VDD) is a global problem. Not all patients with VDD have clinical manifestations or secondary hyperparathyroidism. We studied the interaction between serum 25-hydroxy vitamin D (25OHD), parathormone (PTH) and bone mineral density (BMD) in Indian adolescents and adults. DESIGN: Population survey. PATIENTS: A total of 1829 adolescents and 1346 adults aged 50 years and above were analysed in this study. MEASUREMENTS: Serum biochemistry, 25OHD, PTH and BMD were estimated. Subjects were grouped according to quartiles of serum PTH. VDD was defined as severe (25OHD ≤ 5 ng/ml), moderate (25OHD ≤ 10 ng/ml) and mild (25OHD ≤ 20 ng/ml) and secondary hyperparathyroidism (SHPT) when serum PTH levels >65 pg/ml. RESULTS: Only 30-40% of subjects with moderate and severe VDD, respectively, had SHPT. BMD decreased from Quartile 1 to Quartile 4 of PTH at all sites among adolescents and adults, with only a marginal decline in serum 25OHD levels between these quartiles. Further, within each PTH quartile, there was no difference in BMD according to categories of VDD. Analysing BMD in the different PTH quartiles, the PTH cut-offs beyond which BMD showed a significant decline, was 35 pg/ml in adolescents and 53 pg/ml in adults. CONCLUSIONS: Less than half of the subjects with VDD have SHPT. BMD levels start to decline at PTH values currently considered to be normal. These data suggest the need to redefine SHPT in different age groups keeping in mind the relationship between PTH and BMD. This may also influence the decision to supplement subjects with VDD.

1,3,4-Trisubstituted pyrazole analogues as promising anti-inflammatory agents.

Twenty-two 1,3,4-trisubstituted pyrazole (3a-d), (4a-d), (5a-d), (6a-l) derivatives were synthesized and structure of newly synthesized compounds were characterized by IR, (1)H NMR, (13)C NMR, and mass spectral analysis. These compounds were screened for the anti-inflammatory activity by carrageenan-induced paw edema method. Compounds 5a, and 5b showed excellent anti-inflammatory activity (⩾84.2% inhibition) and 3a, 3b, and 3c showed good anti-inflammatory activity (⩾64.6% inhibition) compared to that of the standard drug diclofenac (86.72%) when measured 3h after the carrageenan injection. Moreover, the cyclooxygenase (COX) enzyme inhibitor activity of selected compounds, which are the excellent anti-inflammatory activities in carrageenan-induced paw edema model, was investigated in vitro COX inhibition assay. Molecular docking study further helped in supporting the observed activity. In addition compound 5a exhibited considerable cytotoxic activity against MCF-7 cell line with IC50 value 6.5 µM.

Normative data of body fat mass and its distribution as assessed by DXA in Indian adult population.

Dual-energy X-ray absorptiometry (DXA) assessment of body fat mass is precise and highly correlated with under water weighing. In view of ethnic differences, we undertook this study to prepare normative data for body fat mass in apparently healthy adult Indians and correlate it with body mass index (BMI). This cross-sectional population-based study included 2347 subjects (male: 924; female: 1423) aged >20 yr who participated in a general health examination. They were evaluated for anthropometry and body fat mass by DXA. All subjects were categorized as overweight and obese based on standard BMI criteria. Mean age and BMI were 49.1 ± 18.2yr and 25.0 ± 4.7kg/m(2), respectively. Mean percent total and regional fat (trunk, arm, and leg) reached maximum in the age group of 30-40yr in males and 50-60yr in females. Females had significantly higher total and regional fat mass compared with males. Fat mass was positively correlated with age (r = 0.224; p < 0.00001) and BMI (r = 0.668; p < 0.00001). Prevalence of overweight and obesity was seen in 2119 (46.1%) and 536 (13.8%), respectively, according to World Health Organization definition and 64.0% and 31.1%, respectively, as per Indian guidelines. Percent total body fat mass (PTBFM) of 25% in males and 30% in females corresponds to BMI of 22.0kg/m(2) with sensitivity of >80% and specificity of >70% in receiver operating characteristic curve analysis. Body fat mass in Indians is higher than that in Western populations for a given age and BMI. PTBFM of 25% in males and 30% in females corresponds to BMI of 22kg/m(2) in Indians.

Impact of body mass index on thyroid functions in Indian children.

OBJECTIVE: There is controversy about the relation of thyroid functions and body mass index. The present study was aimed to assess the relationship between thyroid function and body mass index in Indian school children. DESIGN: Population survey. PATIENTS: Data were collected from 25 schools in 19 cities across five different geographical zones of India. Children, who consented, were evaluated for anthropometry and blood tests. Children were categorized as overweight and obese based on standard BMI criteria. MEASUREMENTS: Serum samples were analysed for free T3, free T4, TSH and anti-TPO antibodies. RESULTS: A total of 13,691 children in the age group of 5-18 years formed the study population. The mean age and mean BMI were 11·9 ± 3·0 years and 18·48 ± 3·89 kg/m² respectively. Among these, 2119 (15·5%) children were overweight and 536 (3·9%) were obese. Subclinical hypothyroidism was present in 943 (6·9%) children.FT3 and TSH levels increased and FT4 levels decreased with increasing BMI in euthyroid boys and girls. Prevalence of SCH was significantly higher in obese/overweight children (9·0%, vs 6·5%; P = 0·034) as compared with normal BMI children. CONCLUSIONS: Serum FT3 and TSH were positively while FT4 was negatively associated with BMI in apparently healthy euthyroid children.

Impact of vitamin D fortified milk supplementation on vitamin D status of healthy school children aged 10-14 years.

UNLABELLED: Vitamin D deficiency is a major public health problem, needing immediate attention. We studied the effect of vitamin D fortification of milk in school children. Our results show that fortification of milk is safe and effective strategy to deal with widespread vitamin D deficiency. INTRODUCTION: Vitamin D deficiency among school children and adolescents is a well-documented major public health problem, needing immediate attention. To assess the effect of vitamin D fortified milk on serum 25 hydroxy vitamin D [S.25(OH)D] levels, we carried out a prospective double-blind randomized control trial in apparently healthy school children, aged 10-14 years. METHODS: Of 776 subjects recruited out of 796 who consented, 713 (boys-300; girls-413) completed the study. Subjects were randomized into three groups. Group A (n = 237) received 200 ml of unfortified milk per day while group B (n = 243) and group C (n = 233) received 200 ml of milk fortified with 600 IU (15 µg) and 1,000 IU (25 µg) of vitamin D per day for 12 weeks. Serum calcium, phosphate, alkaline phosphatase, S.25(OH)D, and urinary calcium/creatinine ratio were estimated at baseline and after supplementation. RESULTS: Hypovitaminosis D [25(OH)D < 20 ng/ml] was observed in 92.3 % subjects with mean S.25(OH)D level of 11.69 ± 5.36 ng/ml. There was no significant difference in S.25(OH)D levels among the three groups at baseline. The mean percentage change in S.25(OH)D level in groups B (137.97 %) and C (177.29 %.) were significantly greater than group A (-5.25 %). The percentage of subjects having S.25(OH)D levels >20 ng/ml following supplementation were 5.9 % in group A, 69.95 % in group B, and 81.11 % in group C in comparison to 6.32 %, 4.9 % and 12 %, respectively, at baseline. CONCLUSION: Fortification of milk with vitamin D is an effective and safe strategy in improving S.25(OH)D levels in children aged 10-14 years.

Glutamic acid decarboxylase (anti-GAD) & tissue transglutaminase (anti-TTG) antibodies in patients with thyroid autoimmunity.

BACKGROUND & OBJECTIVES: Several autoimmune disorders have been reported to be associated with autoimmune thyroiditis and may coexist with other organ-specific autoantibodies. The aim of the present study was to evaluate the presence of tissue transglutaminase (anti-TTG) and glutamic acid decarboxylase (anti-GAD) antibodies in patients suffering from autoimmune thyroiditis as diagnosed by anti-thyroid peroxidase (anti-TPO) antibodies, which may indicate high risk for developing celiac disease or type 1 diabetes mellitus. METHODS: Five thousand children and 2800 adults were screening as part of a general health examination done on a voluntary basis in four different parts of Delhi. A total of 577 subjects positive for anti-TPO antibody constituted the cases. Equal number of age and sex matched anti-TPO antibody negative controls were randomly selected from the same cohort to form paired case control study. The cases and controls were further divided into two groups as follows: group-1 (children and adolescent <18 yr), group-2 (adults >18 yr). Serum samples of cases and controls were analysed for thyroid function test (FT3, FT4, and TSH), anti-TTG and anti-GAD antibodies. RESULTS: A total of 1154 subjects (577 cases and 577 controls) were included in this study. Hypothyroidism was present in 40.2 per cent (232) cases compared to only 4.7 per cent (27) in controls (P<0.001). Anti-TTG and anti-GAD antibodies were present in 6.9 and 12.5 per cent subjects among cases compared to 3.5 per cent (P=0.015) and 4.3 per cent (P=0.001) in controls, respectively. Only anti-GAD antibody were significantly positive in cases among children and adolescents (P =0.0044) and adult (P=0.001) compared to controls. Levels of anti-TTG and anti-GAD antibodies increased with increasing titre of anti-TPO antibody. INTERPRETATION & CONCLUSIONS: Our findings showed high positivity of anti-GAD and anti-TTG antibodies among subjects with thyroid autoimmunity. It is, therefore, important to have high clinical index of suspicion for celiac disease or type 1 diabetes mellitus in patients with autoimmune thyroiditis.

Efficacy of vitamin D loading doses on serum 25-hydroxy vitamin D levels in school going adolescents: an open label non-randomized prospective trial.

AIM: Vitamin D deficiency (VDD) among adolescents is a major health problem in India. The aim of this study was to assess the efficacy of therapeutic/loading doses of vitamin D supplementation on serum 25-hydroxy vitamin D (25OHD) levels in vitamin D deficient adolescents. METHODS: A total of 482 out of the 511 subjects recruited for the study were divided into three groups, each group receiving 60,000 IU of vitamin D3 weekly for 4, 6 and 8 weeks followed by 600 IU daily for 12 weeks, respectively. Clinical evaluation was followed by estimation of biochemical markers and serum 25OHD levels. RESULTS: VDD was observed in 94.8% of adolescents. All three vitamin D loading doses were equally efficacious in achieving vitamin D sufficiency >75 nmol/L (>30 ng/mL) in more than 90% subjects in the three groups. Mean 25OHD levels in groups 2 and 3 following maintenance therapy were 67.5±16.5 nmol/L (27.0±6.6 ng/mL) and 70.0±21.8 nmol/L (28.0±8.7 ng/mL), respectively. CONCLUSION: Supplementing 60,000 IU of vitamin D3 per week for 4-8 weeks, followed by 600 IU daily through fortified milk, is an effective strategy for achieving vitamin D sufficiency in Indian adolescents.

Intramuscular ACTH stimulation test for assessment of adrenal function.

OBJECTIVES: Adrenal insufficiency is often diagnosed by short synacthen test using intravenous Injection Synacthene, which is not marketed in India officially. To overcome this problem this study was planned to validate and use Acton Prolongatum (Ferring pharmaceuticals) as intramuscular ACTH stimulation test for evaluation of adrenal function. METHODS: This study was planned in two groups. First group called validation group, was studied for validation of intramuscular ACTH test and second group called study group, was evaluated for efficacy of intramuscular ACTH test to detect adrenal insufficiency. Twenty five units of ACTH (Acton Prolongatum) was injected intramuscularly and blood sample was collected after 60 minutes for estimation of cortisol. All subjects with one hour post ACTH cortisol < 18.0 microg/dl were diagnosed as having adrenal insufficiency. RESULTS: This study was carried out in 61 subjects in validation group and 89 patients in study group. Basal and post ACTH serum cortisol were within normal range in healthy adults, patients with diabetes mellitus and primary hypothyroidism in validation group. Basal cortisol ranged from 4.67-18.39 microg/dl and post ACTH serum cortisol ranged from 20.01-44.95 microg/dl in these groups. Patients with known adrenal insufficiency had significantly low basal cortisol level than controls (2.86 +/- 2.66 vs. 10.35 +/- 4.37 microg/dl, p < 0.001), and post ACTH serum cortisol was < 18.0 microg/dl in all. Among study group 37 patients (41.6%) were diagnosed as adrenal insufficiency using post ACTH cortisol levels. Basal cortisol (< 3.0 microg/dl) could detect only 60% of these patients. Basal cortisol level has sensitivity of 60% and specificity of 100% to detect AI when compared to ACTH stimulated cortisol levels. CONCLUSION: Intramuscular ACTH test using Acton Prolongatum is effective in evaluation of adrenal function in all suspected cases of primary or secondary adrenal insufficiency. Basal cortisol has poor sensitivity to diagnose AI.

Cryptorchidism due to chromosome 5q inversion duplication.

We present a 15 year old boy who was born out of a non consanguineous marriage, and presented with bilateral cryptorchidism, mental retardation, facial dysmorphism, hypergonadotrophic hypogonadism with failure of anatomical and biochemical localisation of testes. Karyotype analysis showed 46 XY with inverted duplication on chromosome 5q22-31.

Comparison between abdominal CT findings in intensive care unit (ICU) and non-ICU patients with Covid-19: experience from a tertiary care hospital.

Background: 16-66% of COVID-19 positive patients may have abdominal symptoms and findings in abdominal CT. The yield of abdominal CT scan in patients having abdominal complaints is not known. Objectives: The aim of this study was to explore the various abdominal imaging manifestations of COVID-19 and COVID-19 associated Mucormycosis (CAM) and to identify the relevant clinical and laboratory features associated with severity of the symptoms. Methods: A retrospective single centre observational study was performed at a tertiary care hospital in Northwest India. All consecutive patients who had COVID positive RT-PCR report and had undergone abdominal Computed Tomography scan from March 2020 to November 2021 for various abdominal complaints were included. Demographic data, CT images and reports and all relevant lab parameters were collected. Results: Out of 75 patients, positive abdominal findings were seen in 65 patients. Hepatobiliary findings were seen in 41.3% (31 of 75; OR=1.9) and bowel abnormalities were found in 37.3% (28 of 75; OR=2.1) of COVID-19 patients. 7 patients who had renal infarcts or bowel ischemia were found to have COVID-19 associated Mucormycosis on histopathology. Conclusion: Chest CT severity score was positively correlated with most of the abdominal manifestations in patients requiring ICU admission. Elevated D-dimer levels were significantly associated with abdominal symptoms.