Effectiveness of Novel Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Atrial fibrillation (AF) is a common cardiac arrhythmia associated with an increased risk of stroke and systemic embolism (SE). Anticoagulation therapy, particularly with vitamin K antagonists (VKA) or novel oral anticoagulants (NOACs), is essential for stroke prevention in patients with AF. However, the comparative effectiveness of NOACs and warfarin remains debatable. Of the 34 studies included, 14 studies involving 166,845 patients were included in the meta-analysis and 20 studies were included in the systematic review. Our findings indicate that NOACs were associated with a significantly lesser risk of stroke/SE with a relative risk (RR) of 0.84 and p=0.0005, and all-cause mortality RR=0.88 and p=0.006. There were no significant differences between major bleeding events with an RR of 0.87 and p=0.22, and serious adverse events (SAE) with RR=1.01 and p=0.35, compared to warfarin in patients with AF. Our meta-analysis demonstrates strong evidence for the superiority in reducing stroke/SE and all-cause mortality of NOACs compared to warfarin. However, no significant differences were identified in the bleeding outcomes or SAEs between the two groups.

Anaesthetic Management of a Child with Parapharyngeal Abscess.

Airway management in a case of parapharyngeal abscess is challenging as there can be airway obstruction during anaesthetic induction. We describe airway management in 13-yr-old child with parapharyngeal abscess scheduled for incision and drainage. Informed consent was taken for publishing this case report.

The Clinical and Endoscopic Profiles of Patients With Upper Gastrointestinal Bleeding (UGIB) and the Role of the Rockall Scoring System in Predicting Adverse Outcomes.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is one of the common emergencies seen by physicians. Upper gastrointestinal (UGI) endoscopy remains a crucial tool in the identification of UGIB. OBJECTIVE: The aim of the present study was to determine the clinical and endoscopic profiles of UGIB in an adult population. METHODS: This prospective, cross-sectional study was conducted in Dayanand Medical College and Hospital (DMCH), Ludhiana, where 75 patients aged 18 years and above admitted to the hospital with a history of UGIB from July 1 to December 31, 2018, were enrolled in the study. After obtaining the demographic data, all patients underwent clinical examination, laboratory investigations, and video endoscopy. The Rockall scoring system was used to assess their prognosis. RESULTS: The mean age of the study population was 52.19±6.65 years. The majority (33%) were in the age group of 51-60 years. Of the study population, 82.7% were male and 17.3% were female. Chronic alcohol intake was found to be the most common risk factor, followed by drug intake. On upper gastrointestinal endoscopy, esophageal varices (65.3%) were the most common finding, followed by peptic ulcer disease (25.2%), gastric erosions (2.6%), gastroduodenitis (1.3%), Mallory-Weiss tear (1.3%), carcinoma stomach (1.3%), Camron's lesion (1.3%), and Dieulafoy's lesion (1.3%). Mortality attributed to UGIB was found to be 8%. CONCLUSION: The present study reported portal hypertension as the most common cause of UGIB, while the most common endoscopic lesions reported were esophageal varices. The factors associated with poor prognosis were age >60 years, shock, respiratory failure, low hemoglobin, low platelet count, deranged international normalized ratio (INR), variceal bleed, renal failure, rebleed, Rockall score ≥ 8, and late endoscopy (>24 hours of admission). Urgent appropriate hospital management definitely helps to reduce morbidity and mortality in patients with UGIB.

White Coat Effect: Is It Because of the Hospital Setting, or Is It Physician-Induced?

INTRODUCTION: White coat hypertension (WCH) patients are those individuals who have high blood pressure (BP) in the medical environment but are normal during their daily activities. White coat hypertensive patients with normal daytime ambulatory blood pressure monitoring (ABPM) rapidly progress to sustained hypertension. WCH is mainly treated with non-pharmacological methods. Alpha-1 agonists and beta blockers are logical treatment choices for patients with fixed hypertension with the White Coat Effect (WCE). Masked hypertension patients are those individuals who have normal values at the doctor's office but elevated BP at home or during 24-hour ABPM (24-hour or daytime). ABPM is a more practical and reliable method for detecting patients with WCH. MATERIAL AND METHODS: This observational study was conducted at Dayanand Medical College & Hospital, Ludhiana, over the course of one year (December 2015 to November 2016). The primary objective of the study was to determine whether there was a difference in blood pressure readings between the home setting and the hospital setting. The secondary objective was to determine whether the difference, if present, between the hospital and home readings was due to the hospital setting, physician presence, or a combination of both. Patients with stage 1 hypertension were included in the study, irrespective of antihypertensive treatment. Patients with ischemic heart disease, chronic liver failure, and chronic kidney disease who could not follow protocol instructions were excluded. RESULTS: In our study, the mean age of patients was 53.91±12.86 years. The patient's mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings at the hospital were higher than their home readings (p-0.012; p-0.001, respectively). Mean hospital SBP and DBP readings recorded by the physician were higher than readings recorded by patients alone at home (p-0.002; p-0.014, respectively) and alone at the hospital (p-0.004; p-0.001, respectively). BP readings taken by the physician with a manual sphygmomanometer were significantly lower than those taken with a digital sphygmomanometer by patients and physicians in all settings (p<0.05). The mean rise in BP was significant in both the physician's presence and the hospital environment (p<0.05 for both), and this rise was more significantly associated with the hospital effect than the physician effect (p<0.05). CONCLUSION: Misdiagnosis of hypertension results in inappropriate prescription and overuse of antihypertensive medications for individuals who are not persistently hypertensive. So it is very important to rule out WCH in both the hospital setting and the physician's presence, more precisely by ABPM. WCH can be diagnosed with regular BP monitoring by a digital sphygmomanometer at home.

Risk Factors and Outcome Analysis of Gram-Positive Bacteremia in Critically Ill Patients.

Introduction Bloodstream infection (BSI) is a common problem for patients in the intensive care unit (ICU). Nearly 60% of primary bloodstream infections are caused by Gram-positive cocci. Gram-positive bacteria gain access to the bloodstream through invasive procedures and various patient care equipment like catheters, intravenous lines, and mechanical ventilators. S. aureus is considered to be the major cause of septicemia. Knowledge of healthcare-associated infections and the antimicrobial susceptibility patterns of the isolates are crucial in guiding empirical treatment. Methods This prospective observational study was conducted in Medical ICU, Dayanand Medical College & Hospital, Ludhiana over a period of one year (December 2015 to November 2016). Patients whose blood cultures tested positive for Gram-positive bacteria were included in the study. This study was carried out to assess the implications and risk factors for nosocomial BSI and several factors, including the age of the patient, the severity of illness, the presence of catheters, and the microorganisms causing the BSI to independently predict mortality. Chief complaints and risk factors were evaluated. APACHE-II scores were calculated for all patients and outcomes were analyzed. Results In our study, the mean age of patients was 50.93±14.09 years. Central line insertion was found as the most common risk factor (58.7%). A statistically significant correlation was obtained between APACHE-II scores and the presence of risk factors i.e. central line insertion (p-value=0.010) and diabetes mellitus (p-value=0.003). The most common Gram-positive pathogen isolated by blood culture was methicillin-sensitive S. aureus (44.2%). For management, the majority of the patients were prescribed teicoplanin (58.7%). The 28-day overall mortality rate in our study was 52.9%. Conclusion We conclude that independent risk factors like diabetes mellitus, central line insertion, and acute pancreatitis in adult patients with Gram-positive bacteremia were associated with higher mortality. We have also concluded that the administration of early appropriate antibiotics improves patient outcomes.

Towards the World's Smallest Gravimetric Particulate Matter Sensor: A Miniaturized Virtual Impactor with a Folded Design.

The increasing air pollution across the globe has given rise to a global health crisis that is increasing at an alarming rate. Every year, millions of people lose their lives due to health risks caused by air pollutants. Hence, there is a pressing need for better solutions to accurately measure the amount of air pollution. This work is aimed at designing a highly compact, accurate, low-cost, self-resettable, and easy-to-use gravimetric-based particulate matter sensor solution for portable applications. Previous attempts have failed to realize true miniaturization, due to the size constraints of the virtual impactor needed-a mechanism that segregates the particulate matters based on their sizes. Our complete particulate matter sensor solution consists of three components (i) a piezoelectric resonating membrane, (ii) a virtual impactor, and (iii) a thermophoretic mechanism to reset the sensor. This paper presents a novel design of the virtual impactor, based on a folded configuration. This helps realize the entire system in a volume of 20 mm × 20 mm × 10 mm. We report here the design, working principles, fabrication, and experimental results of the virtual impactor.

Mechanistic Insight into Diosmin-Induced Neuroprotection and Memory Improvement in Intracerebroventricular-Quinolinic Acid Rat Model: Resurrection of Mitochondrial Functions and Antioxidants.

Neurodegeneration is the final event after a cascade of pathogenic mechanisms in several brain disorders that lead to cognitive and neurological loss. Quinolinic acid (QA) is an excitotoxin derived from the tryptophan metabolism pathway and is implicated in several ailments, such as Alzheimer's, Parkinson's, Huntington's, and psychosis disease. Diosmin (DSM) is a natural flavonoid possessing such properties that may halt the course of neurodegenerative progression. In past studies, free radical scavenging, along with properties, such as antihyperglycemic, anti-inflammatory, and vasoactive properties, of DSM were pragmatic. Hence, in the current experimentations, the neuroprotective activity of DSM was investigated in the QA rat prototype. QA was administered through the intracerebroventricular route (QA-ICV) in rats on day one, and DSM (50 and 100 mg/kg, intraperitoneal route) was given from day 1 to 21. Memory, gait, sensorimotor functions, and biomarkers of oxidative mutilation and mitochondrial functions were evaluated in the whole brain. Results showed significant deterioration of sensorimotor performance, gait, and working- and long-term memory in rats by QA-ICV. These behavioral anomalies were significantly attenuated by DSM (50 and 100 mg/kg) and donepezil (standard drug). QA-ICV-induced decrease in body mass (g), diet, and water ingestion were also attenuated by DSM or donepezil treatments. QA-ICV inhibited mitochondrial complex I and II activities that caused an increase in oxidative and nitrosative stress along with a reduction in endogenous antioxidants in the brain. DSM dose-dependently ameliorated mitochondrial functions and decreased oxidative stress in QA-ICV-treated rats. DSM can be a possible alternative in treating neurodegenerative disorders with underlying mitochondrial dysfunction pathology.

Rituximab in the Management of Refractory Myasthenia Gravis and Variability of Its Efficacy in Anti-MuSK Positive and Anti-AChR Positive Myasthenia Gravis.

Myasthenia gravis affects the neuromuscular junction of the skeletal muscles. It results in muscle weakness involving skeletal muscles (diaphragm, extraocular muscles) and myasthenic crisis. Treatment options for myasthenia gravis management have expanded, including azathioprine, corticosteroids, plasma exchange, and tacrolimus. Unfortunately, a few cases of myasthenia gravis don't respond to conventional treatment modalities. Monoclonal antibodies, rituximab (RTX), are novel treatments that have garnered interest as of late due to their efficacy within the patient population presented with refractory form myasthenia gravis. This review aims to showcase how RTX is an effective treatment within different forms of myasthenia gravis. A limited review was performed using databases that include PubMed and Google Scholar. The following keywords were used: "myasthenia gravis," "rituximab," "monoclonal antibody," "anti-AChR antibody," and "refractory myasthenia." The review focused on case reports, human studies, or research surveys based on the inclusion criteria of human studies involving participants more than 18 years of age and published in English literature. Out of 69 articles, 14 were duplicates, and 29 were relevant and met the inclusion criteria. The findings from the study demonstrate that patients with refractory myasthenia gravis responded well to RTX treatment. Furthermore, RTX has been shown to decrease corticosteroid dependence, induce sustained remission, and have a favorable response to anti-MuSK antibody positive myasthenia gravis compared to anti-AChR antibody positive myasthenia gravis. This literature review suggests that patients with refractory myasthenia gravis can benefit from rituximab; however, it has a variable response in different forms of myasthenia gravis.

Factors shaping political priorities for violence against women-mitigation policies in Sri Lanka.

BACKGROUND: Although violence against women (VAW) is a global public health issue, its importance as a health issue is often unrecognized in legal and health policy documents. This paper uses Sri Lanka as a case study to explore the factors influencing the national policy response to VAW, particularly by the health sector. METHODS: A document based health policy analysis was conducted to examine current policy responses to VAW in Sri Lanka using the Shiffman and Smith (2007) policy analysis framework. RESULTS: The findings suggest that the networks and influences of various actors in Sri Lanka, and their ideas used to frame the issue of VAW, have been particularly important in shaping the nature of the policy response to date. The Ministry of Women and Child Affairs led the national response on VAW, but suffered from limited financial and political support. Results also suggest that there was low engagement by the health sector in the initial policy response to VAW in Sri Lanka, which focused primarily on criminal legislation, following global influences. Furthermore, a lack of empirical data on VAW has impeded its promotion as a health policy issue, despite financial support from international organisations enabling an initial health systems response by the Ministry of Health. Until a legal framework was established (2005), the political context provided limited opportunities for VAW to also be construed as a health issue. It was only then that the Ministry of Health got legitimacy to institutionalise VAW services. CONCLUSION: Nearly a decade later, a change in government has led to a new national plan on VAW, giving a clear role to the health sector in the fight against VAW. High-level political will, criminalisation of violence, coalesced women's groups advocating for legislative change, prevalence data, and financial support from influential institutions are all critical elements helping frame violence as a national public health issue.

Prevalence of Depression, Anxiety and Stress among school going adolescent in Chandigarh.

CONTEXT: Depressive disorders often start at a young age. There is a need for early identification of depression, anxiety, and stress (DAS) and prevention. The present study was undertaken to find the magnitude of DAS among adolescents. AIMS: To find the mental health status of school going adolescents in Chandigarh. The objectives were (i) to study the prevalence of DAS among school going adolescents and (ii) to study the correlates of DAS. SETTINGS AND DESIGN: A Cross-sectional survey of students of four classes from 9th to 12th studying in government schools. SUBJECTS AND METHODS: Ten government schools in Chandigarh were randomly selected through lottery method. In each school, for each of the four classes, a section was randomly selected again by the lottery method. Forty students were selected from each school reaching sample size of 470. DAS scale 21 questionnaires were used. STATISTICAL ANALYSIS USED: The data entry was done in MS Office Excel 2007. The analysis was done in the form of frequency tables, charts cross tables. For statistical significance, Chi-square test and correlation was found between various factors. RESULTS: The prevalence of DAS was 65.53%, 80.85%, and 47.02%, respectively. Overall, comorbidity between depression and anxiety was 57.65%. Extremely severe depression was very less (3%). The prevalence of DAS was higher in females. For depression and anxiety, the peak age was 18 years. CONCLUSIONS: The prevalence of DAS was high among school going adolescents in Chandigarh. There is a need for early and effective identification of DAS that can prevent many psychiatric disorders at their nascent stage.

Surveillance of bacteriological quality of drinking water in Chandigarh, northern India.

The study was carried out in Chandigarh, India with the following objectives: (1) to monitor the bacteriological quality of drinking water; (2) to collect data on bacteriological contamination of water collected at point of use; (3) to test both groundwater being supplied through hand pumps and pre-treated water; and (4) to determine the pattern of seasonal variations in quality of water. The community-based longitudinal study was carried out from 2002 to 2007. Water samples from hand pumps and tap water were collected from different areas of Chandigarh following a simple random sampling strategy. The time trends and seasonal variations in contamination of water according to area and season were analysed. It was found that the contamination of water was higher during the pre-monsoon period compared with the rest of the year. The water being used in slums and rural areas for drinking purposes also had higher contamination levels than urban areas, with highest levels in rural areas. This study found that drinking water supply in Chandigarh is susceptible to contamination especially in rural areas and during pre-monsoon. Active intervention from public health and the health department along with raising people's awareness regarding water hygiene are required for improving the quality of drinking water.

A Leap above Friedewald Formula for Calculation of Low-Density Lipoprotein-Cholesterol.

PURPOSE: The purpose was to compare the different calculated methods of low-density lipoprotein cholesterol (LDL-C) estimation and to determine which of them correlate best with the direct method. MATERIALS AND METHODS: The records of 480 samples for lipid profile were analyzed. Apart from the direct method, LDL-C was calculated by Friedewald low-density lipoprotein cholesterol method (F-LDL-C), modified Friedewald low-density lipoprotein cholesterol method (MF-LDL-C), and Anandaraja low-density lipoprotein cholesterol method (A-LDL-C). Paired t-test and Pearson correlation were evaluated between the different methods. Degree of agreement between the calculated methods and direct method was detected by Bland-Altman graphical plots. RESULTS: A strong correlation was found between all calculated LDL-C methods and direct low-density lipoprotein cholesterol method (D-LDL-C) assay, that is, F-LDL-C versus D-LDL-C = 0.94; A-LDL-C versus D-LDL-C = 0.93 and MF-LDL-C versus D-LDL-C = 0.95. No statistically significant difference was found between D-LDL-C and MF-LDL-C. Bland-Altman plot for MF-LDL-C showed minimal negative bias. CONCLUSIONS: The study pointed out that MF-LDL-C correlated maximally with D-LDL-C estimation at all levels of triglycerides and MF-LDL-C can be used in place of D-LDL-C when the direct method cannot be afforded.

Evaluating the impact of comprehensive epilepsy education programme for school teachers in Chandigarh city, India.

PURPOSE: School teachers can play a key role in the first-aid management of school children experiencing a seizure. The teachers have a pivotal role in disseminating knowledge to the children of diseases experienced by them and developing positive attitudes among the children regarding the diseases. The present study investigated the knowledge and practices used by teachers to manage epileptic seizures. The study also tested an epilepsy intervention educational package to see whether it improved the knowledge and practices of the teachers regarding epilepsy. METHODS: A total of 85 teachers in schools from Chandigarh, a city of northern India, participated in the study. At the start of the study the teachers completed a pre-tested, semi-structured questionnaire on the first-aid management of epileptic seizures. They were then presented with an intervention package that included audio-visual material on basic aspects of epilepsy. The teachers were then retested after the intervention (one immediately and another after three months from the intervention). A scoring system was devised to quantify the knowledge, attitude and skills of teachers. RESULTS: More than 90% of the teachers had previously either heard or read about epilepsy. Nearly half of the teachers said that books and magazines were the most common source of their information, followed by the internet. A comparison of the knowledge, attitudes and skills about the first-aid management of epilepsy based on the before and after questionnaire scores showed significant improvements in the various domains (p<0.05). CONCLUSION: The epilepsy intervention educational package provided a positive, short term, impact on the knowledge and skills of teachers about epilepsy. There is a need for regular workshops to improve and reinforce the knowledge and skills of the teachers about health problems like epilepsy.

Knowledge, attitude and practices of students about first aid epilepsy seizures management in a Northern Indian City.

BACKGROUND: Knowledge about epilepsy and its management is not satisfactory among school students in developing countries. The present study was planned to ascertain the knowledge, attitude and practices (KAP) of students regarding first-aid management of epilepsy seizures in school setting. MATERIALS AND METHODS: A total of 177 students of government schools of Chandigarh, a city of northern India, were taken. They were administered with a pre-tested semi-structured questionnaire (for knowledge and attitude assessment) and an observational checklist after role play (for practice assessment) on first-aid management of epilepsy. A scoring system was devised to quantify the knowledge and practices of students. RESULTS: Seventy-one percent of them had either heard or read about epilepsy. Half of the students believed epilepsy as a hindrance to education. Ayurvedic treatment was preferred by more than half of the students; however, many believed that visit to religious places and exorcism as ways to cure epilepsy. Nearly 74% of students would call a doctor as first-aid measure for seizure in a person with epilepsy. CONCLUSION: We concluded that the knowledge about various aspects of epilepsy was average among school students in Chandigarh. However, there was no significant difference in knowledge, attitude and practice between students who lived in urban, urban slum and rural areas. It is recommended that first-aid management of seizures in epilepsy should be a part of school curriculum.