Indian Guidelines on Nebulization Therapy.

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

A Community-Based Study on Functional Disability and Its Associated Factors Among Elderly Individuals in a Rural Setting in Northeastern India.

Background Functional disability in older adults is common and adversely impacts the quality of life. Given the paucity of population-based data, the present analysis attempted to determine the prevalence and factors associated with functional disability in basic activities of daily living (ADLs) among the elderly population in a rural setting of Northeastern state of India Methods A total of 430 elderly were recruited in a population-based cross-sectional study among elderly individuals (≥60 years) during the period 2013-2016 in rural areas of the Dibrugarh district of Northeastern India. The Barthel index was used to measure ADL. Anyone with a Barthel index score <100 (or having limitations in one or more ADL items) were considered as having a functional disability. The analysis of variance (ANOVA) test and the binary logistic regression analysis were used to examine the factors associated with functional disability. Results Overall, 43.7% % (Male 42.9%, Female 44.5%) of the participants had a functional disability. Increasing age, being widowed, having no formal education, being underweight (body mass index (BMI)<18.5 kg/m2), and increasing numbers of morbidities were significantly associated with functional disability among the elderly in this study in age and gender-adjusted logistic regression analysis. Being ≥80 years was associated with a three-fold greater risk (OR=31.72, 95% CI=1.3-6.91) of functional disability than the youngest age group (60-69 years). On the other hand, the presence of more than five morbidities was associated with a nearly 20 times increased risk (OR=19.61, 95% CI=9.01-42.68) than those with zero to two morbidities. Conclusion A high proportion of the rural elderly residents of Dibrugarh had a functional disability. The study provides epidemiological evidence of the risk factors of functional disability in this setting. This epidemiological information may be useful for developing prevention strategies to reduce the burden of functional disability.

MycoVarP: Mycobacterium Variant and Drug Resistance Prediction Pipeline for Whole-Genome Sequence Data Analysis.

Whole-genome sequencing (WGS) provides a comprehensive tool to analyze the bacterial genomes for genotype-phenotype correlations, diversity of single-nucleotide variant (SNV), and their evolution and transmission. Several online pipelines and standalone tools are available for WGS analysis of Mycobacterium tuberculosis (Mtb) complex (MTBC). While they facilitate the processing of WGS data with minimal user expertise, they are either too general, providing little insights into bacterium-specific issues such as gene variations, INDEL/synonymous/PE-PPE (IDP family), and drug resistance from sample data, or are limited to specific objectives, such as drug resistance. It is understood that drug resistance and lineage-specific issues require an elaborate prioritization of identified variants to choose the best target for subsequent therapeutic intervention. Mycobacterium variant pipeline (MycoVarP) addresses these specific issues with a flexible battery of user-defined and default filters. It provides an end-to-end solution for WGS analysis of Mtb variants from the raw reads and performs two quality checks, viz, before trimming and after alignments of reads to the reference genome. MycoVarP maps the annotated variants to the drug-susceptible (DS) database and removes the false-positive variants, provides lineage identification, and predicts potential drug resistance. We have re-analyzed the WGS data reported by Advani et al. (2019) using MycoVarP and identified some additional variants not reported so far. We conclude that MycoVarP will help in identifying nonsynonymous, true-positive, drug resistance-associated variants more effectively and comprehensively, including those within the IDP of the PE-PPE/PGRS family, than possible from the currently available pipelines.

Sociodemographic variations in health-related quality of life (HRQOL) among elderly individuals in an urban locality in India.

BACKGROUND: Elderly population is growing rapidly in India. To direct public health actions to improve quality of life among elderly, it is important to understand the sociodemographic factors associated with quality of life. The aim of study was to assess health-related quality of life (HRQOL) among urban elderly in a setting of Assam, India, and to examine how HRQOL varied across different sociodemographic groups among the elderly populations. MATERIALS AND METHODS: A cross-sectional study was carried among elderly aged ≥60 involving 300 participants. Eight domains of HRQOL of participants were measured using RAND SF-36. Analysis of variance test was used to examine sociodemographic differences in HRQOL. RESULTS: The BP domain had highest (71.78 ± 22.25) and GH had lowest mean HRQOL score (48 ± 16.93). Males had significantly higher HRQOL score than females only in BP domain. Age gradients were observed with respect to HRQOl scores in five domains, with youngest age group having the best and oldest age group having the poorest HRQOL. Financially dependent subjects had lower HRQOL in five domains than those who were financially independent. Significant associations between education and HRQOL were found only in physical components of HRQOL, with lowest educated group being the most disadvantaged in terms of HRQOL. Marital status was found to be significantly associated with lower HRQOL scores. CONCLUSION: The study highlights sociodemographic inequalities in HRQOL among urban elderly in an Indian setting. The results may help reducing sociodemographic health inequalities among elderly in this region initiating public health actions paying more attention toward more vulnerable sections of populations.

Association between health related quality of life (HRQOL) and activity of daily living (ADL) among elderly in an urban setting of Assam, India.

BACKGROUND: Ensuring better quality of life to an increasing number of elderly people is emerging as a stiff public health challenge in India. There is paucity of data on impact of functional health on health-related quality of life (HRQOL) in India. OBJECTIVES: The aim of this study is to explore the functional status and its association with different dimensions of HRQOL among elderly individuals in an urban setting of Assam, India. MATERIALS AND METHODS: A total of 300 elderly were recruited in a cross-sectional study from the city of Dibrugarh, Assam, India. Eight domains of HRQOL of participants were assessed using short form 36 (SF-36). Functional status was assessed by using Barthel activity of daily living (ADL) tool. ANOVA test and binary logistic regression analysis was performed to examine the relationship between ADL status and HRQOL. RESULTS: In all, 34.7% (n = 104) of participants had limitations in one or more ADL items. We also observed a strong graded relationship between ADL and HRQOL scores. Those who scored perfect 100 ADL score also scored highest in all eight HRQOL scales, whereas those with least ADL score scored lowest in all the HRQOL scales. In age- and sex-adjusted logistic regression analysis, the probability of poor health increased with decreasing level of ADL scores. CONCLUSION: Findings of the study suggest that decline in ADL can negatively impact different dimensions of HRQOL among elderly individuals. The findings indicate that there is need to pay proper attention for restoring functional health at later life in order to improve quality of life among elderly in India.

Assessment of Diagnostic Reference Level in Radiography of Neonatal Chest Anteroposterior Examination: A Hospital-based Study.

Radiological imaging is an important modality of today's overall practicum. Imaging can begin as early as the 1st day of life. Neonates are 3-4 times more sensitive to radiation than adults. The purpose of the work was to assess the diagnostic reference level (DRL), the radiation organ dose, and effective organ dose for both sexes from chest anteroposterior radiograph, which is the most common radiographic examination performed at the Neonatal Intensive Care Unit (NICU). The entrance air kerma was measured using a solid-state PIN type detector, and the value was used as the input factor to PCXMC-2.0 software to calculate the entrance surface air kerma (ESAK), patient-specific organ dose, and effective dose originated from chest anteroposterior examinations of neonates at NICU. The mean value of ESAK is taken as a diagnostic reference level (DRL) for neonates (both male and female). The mean ESAK value of male neonates is (79.6 ± 1.4) µGy and for female is (79.9 ± 1.9) µGy, and the institutional diagnostic reference level (DRL) is 80.35 µGy for male and 81.2 µGy for female (i.e., third quartile value). A statistical dependency (correlation) between neonates body mass index (BMI) and ESAK was defined for both the sexes. Significant positive correlation was found between ESAK per patient with respect to BMI of both male (R = 0.83, P = 0.00001) and female (R = 0.72, P = 0.00055) neonates. The results for neonatal dose in NICU were compatible with the literature. The result presented will serve as baseline data for the selection of technical parameters in neonatal chest anteroposterior X-ray examination.

Retinoic acid syndrome in a elderly male with psoriasis- A case report.

The retinoic acid derivatives are used for disorders of keratinization such as psoriasis. Retinoic acid syndrome is a cytokine release syndrome, commonly encountered in patients with acute promyelocytic leukaemia (APL). It is very rarely described in psoriasis seconday to use of retoind derivatives. Here we report a case of elderly male with psoriasis presenting with acitretin induced retinoic acid syndrome.

Clinical and radiological spectrum of intracranial tuberculosis: A hospital based study in Northeast India.

Central nervous system tuberculosis (TB) is the most severe extra pulmonary TB having a high mortality and morbidity. OBJECTIVE: To study the various clinical, biochemical, and radiological spectrum of intracranial TB. MATERIALS AND METHOD: Ninety-three patients were enrolled in this prospective study after ethical clearance and consent from August 2013 to May 2015. The entire clinical course with complications and predictors of mortality were assessed. RESULTS: 36 females (38.7%) and 57 males (61.3%) were included whose mean age of presentation was 32.3±17.05 years. Alcohol was the most common risk factor seen in 19.4%. Headache (90.3%) was the most common symptom. Co-infection with human immunodeficiency virus, cryptococcal, and toxoplasmosis were seen in 11, 3, and 2 patients, respectively. Cerebrospinal fluid analysis showed acid-fast bacilli in 1 patient; polymerase chain reaction for TB and BACTEC was positive in one and three patients, respectively. Neuroimaging showed basal exudates (21.7%), tuberculoma (28.6%), brain edema (27%), hydrocephalus (32.9%), infarct (21%), and abscess (2.9%). Complications were noted such as brain edema (24.7%), vasculitis (26.9%), hydrocephalus (17.2%), hyponatremia (11.8%), drug-induced hepatitis (4.3%), and drug rash in 5 patients (5.4%). A total of 25 patients (26.9%) died and 38 patients (40.9%) developed neurological sequelae like hemiparesis, paraparesis, visual loss, and hearing loss. Logistic regression showed that a Glasgow scale of <10, British Medical Research Council stage 3, and vasculitis were associated with poor outcome. CONCLUSION: Lack of sensitive diagnostic method and criteria makes central nervous system TB a challenge where early diagnosis and prompt management is required.