Water, sanitation, and hygiene (WaSH) practices among people living with HIV/AIDS (PLHA) - need to relook, in the era of COVID-19 pandemic.

Background: Water, sanitation, and hygiene (WaSH) practices always have been neglected among HIV/AIDS (Human immunodeficiency virus/ Acquired immunodeficiency syndrome) programs, even when HIV and WaSH services have robust bearing on each other. With COVID-19 pandemic on the go, it is utmost necessary for the people living with HIV/AIDS (PLHA) to ensure adequate WaSH practices. Objective: This study was carried out with an objective to assess baseline WaSH practices among PLHA and to find out if any association between nutritional status and WaSH parameters so as to identify the shortcomings and highlight the importance of WaSH practices among PLHAs and give suitable recommendations to program managers. Methodology: A cross-sectional study was carried out among PLHA registered in ART centres of western Maharashtra. A sample size of 378 consented to be part of the study were included in the study, by means of systematic random sampling. Data were collected by means of pretested questionnaire prepared from guidelines and previous studies. Institutional ethical clearance was obtained and informed consent was taken from study participants before data collection. Strict confidentiality was maintained throughout the study period. Results: When asked about the water processing method, 76% of them told they do not treat/process the water supplied to them. In contrast, only a few PLHA told they would filter (17%), boil (7%), and use aquaguard (1%). The majority (67%) had their latrines, and while 29% of them were using public latrines and its hygienic sanitation was a concern for them and 4% were still practising open-air defecation in rural areas. Almost all study participants were handwashing after toilet use and handwashing before consuming food. The majority (79%) told they used soap and water, while 20% were using only water, soil and water (1%) and ash and water (1%) which was a concern. Of all the households, 87% cooked their food twice and consumed it thrice a day, while 4% prepared thrice. 10% of them cooked only once and consumed thrice a day; 56% practised consumption of leftover food of the previous night which was a concern. A majority (54%) did not consume street food while remaining said that they used to consume street food. But majority (59%) said they did not follow the habit of checking hygiene or sanitation of hotel where they used to consume food while the remaining 41% did not check the hotel before ordering the food; 50% of them bought packaged milk while 40.9% brought from unpasteurized dairy. On analysis, hygiene and sanitation factors had no statistically significant association with the nutritional status of study participants. Conclusion: WaSH factors act synergistically with other factors to affect the holistic health of PLHA. Information, Education and Communication (IEC) activities (continuous and regular), that focus on improving awareness level on WaSH practices, need to be promoted and integrated into HIV program, including providing basic care packages to PLHA like household water treatment products and soap, etc., Such measures will go a long way in maintaining health of PLHA even during ongoing COVID-19 pandemic scenario.

Non-communicable disease risk factors among people living with HIV/AIDS (PLHA) - A relook during the covid-19 pandemic.

Background: The Covid-19 pandemic has resulted in syndemic due to factors like overcrowding, loneliness, poor nutrition, and lack of access to health care services. With the ongoing pandemic, people with NCDs, including PLHA, are at high risk for developing severe and even fatal Covid-19 infections. Our study, which was carried out prior to the pandemic gives us an insight into the NCD risk factors profile of PLHAs so that effective interventions could be initiated to protect them from Covid-19 severity and NCDs. Materials And Methods: A prospective study was carried out among PLHA in western Maharashtra, where PLHA were selected from five ART centers by means of a systematic random sampling method. Data were collected by means of a pretested questionnaire to assess NCD risk factors and anthropometric measurements were done. Data were collected at the baseline during the time of ART initiation and then after one year. Analysis was done by means of SPSS software (version 20.0). Results: The mean age of the study participants was 41.73 years. 59% belonged to rural areas, 21% were illiterate, and 12% belonged to the lower class as per the Modified BG Prasad scale. 33% were laborers by occupation, 66% were married, and 22% were widowed. At baseline, during the start of ART, 26% of the subjects were found to be overweight or obese, 36% had tobacco or smoking habits, and 15% had alcohol consumption habits. Even after one year, despite repeated counseling, about 32% of the subjects were found to be overweight or obese, 28% had tobacco and 8% had alcohol consumption habits, pointing to the need to integrate NCD prevention measures, such as screening routinely as per the national program, even in the PLHAs. 34% had normal BMI, while 35% were underweight, 14% overweight, and 17% obese after one year. 24% of PLHA had abnormal waist circumference at the end of one year. Conclusion: These findings indicate the incorporation of early screening for NCD risk factors among PLHA and effective behavior change communication (BCC) strategies to prevent and manage the same at the earliest before it can aggravate the already compromised immune status in these subjects, particularly during this Covid 19 pandemic. It will also act as a guiding article for family physicians or primary care physicians to help them look at specific basic parameters while screening of NCDs among PLHAs.

Methanol Poisoning.

Mortality associated with methanol has been of great concern time and again. The concurrence of cases from a particular area raises doubts about methanol as the culprit. Knowledge of the patho-physiological changes that occur in the body after methanol consumption is essential for all practicing doctors. This article elucidates the clinical presentation and emergency management of these cases under the framework of basic physiological and biochemical phenomena after methanol exposure. Conversion of methanol to formaldehyde by hepatic enzyme alcohol dehydrogenase triggers the cascade of metabolic events. The manifestations begin as early as 30 minutes and progress to decompensated metabolic acidosis in about 12 hours, if left untreated. Seizures, hypoglycemia and blindness frequently complicate the picture. Acute kidney injury warrants urgent haemodialysis. Fundoscopic examination and arterial blood gas analysis are the key diagnostic elements. The management comprises of intravenous sodium bicarbonate, correction of dyselectrolytemia, ethanol, folic acid and haemodialysis, if necessary. The basic steps in approach must be carried out in the emergency department and followed-up with meticulous monitoring in the intensive care unit for salvage as well as prevention of long term sequelae.

Comparison of Different Dosing Protocols of Anti-Snake Venom (ASV) in Snake Bite Cases.

INTRODUCTION: Considering the cost of Anti-Snake Venom (ASV) and irregularity in its supply, there is often a need to curtail doses of ASV, despite guidelines for management of snake bite. During June 2013 to September 2013, when ASV was in short supply, our institutional committee reviewed the overall hospital statistics of snake bite cases as well as scientific literature and formulated a working modified protocol that used low dose of ASV in snake bite cases. AIM: To retrospectively analyse and compare the modified ASV protocol versus conventional ASV protocol with respect to outcome, number of ASV vials required, duration of stay in the hospital/ ICU, and additional supportive interventions needed. MATERIALS AND METHODS: This was a retrospective study conducted at a tertiary care teaching hospital, Maharashtra, India. Hospital records of inpatients admitted for snake bite during June 2013 to September 2013 (since introduction of the modified protocol) as well as during June 2012 to September 2012, (when patients received conventional protocol-historical controls) were retrospectively analysed to assess the number of ASV vials received by the patients during the stay, need for supportive therapy, duration of stay and outcome of the patients. RESULTS: There was a significant reduction in average number of ASV vials per patient, required vide the modified protocol compared to their historical controls (10.74±0.95 vs 28.17±2.75 p<0.001). There was no significant difference in outcome, need for dialysis, fresh frozen plasma requirement, need for ICU stay and duration of hospitalization of snake bite patients. Yet, the average cost of management of each patient reduced by approximately 11974.41 INR per treated patient, based on the requirement of ASV. CONCLUSION: The modified ASV protocol used in this study is more cost effective as compared to the conventional protocol, deserves prospective evaluation and may be followed at least during prime time of scarcity of ASV.

Primary Maxillary Sinus Plasmablastic Lymphoma in HIV/AIDS.

Classically, the HIV/AIDS-related lymphomas are of the B cell type and involve the central nervous system and the abdominal cavity. Primary maxillary sinus lymphoma is rare. Plasmablastic lymphoma (PBL) is an aggressive form of non-Hodgkinvs lymphoma, and is extremely rare. Here we present a case of plasmablastic lymphoma with primary site being maxillary sinus, a rare location.

Expanded Dengue.

The World Health Organization (WHO) has coined the term expanded dengue to describe cases which do not fall into either dengue shock syndrome or dengue hemorrhagic fever. This has incorporated several atypical findings of dengue. Dengue virus has not been enlisted as a common etiological agent in several conditions like encephalitis, Guillain Barre syndrome. Moreover it is a great mimic of co-existing epidemics like Malaria, Chikungunya and Zika virus disease, which are also mosquito-borne diseases. The atypical manifestations noted in dengue can be mutisystemic and multifacetal. In clinical practice, the occurrence of atypical presentation should prompt us to investigate for dengue. Knowledge of expanded dengue helps to clinch the diagnosis of dengue early, especially during ongoing epidemics, avoiding further battery of investigations. Dengue has proved to be the epidemic with the ability to recur and has a diverse array of presentation as seen in large series from India, Srilanka, Indonesia and Taiwan. WHO has given the case definition of dengue fever in their comprehensive guidelines. Accordingly, a probable case is defined as acute febrile illness with two or more of any findings viz. headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leucopenia and supportive serology. There have been cases of patients admitted with fever, altered mentation with or without neck stiffness and pyramidal tract signs. Some had seizures or status epilepticus as presentation. When they were tested for serology, dengue was positive. After ruling out other causes, dengue remained the only culprit. We have come across varied presentations of dengue fever in clinical practice and the present article throws light on atypical manifestations of dengue.

Comparative study of electrophysiological changes in snake bites.

AIMS: To study and compare the electrophysiological changes in neuroparalytic or vasculotoxic snakebites. MATERIALS AND METHODS: 40 patients who had a definite history of snakebite, either vasculotoxic or neuroparalytic, were selected. They were grouped as Group A, 20 patients having a neuroparalytic snakebite with definite envenomation at the time of admission, and Group B, 20 patients having a vasculotoxic snakebite with definite envenomation at the time of admission. All patients underwent a detailed clinical examination, all relevant investigations and nerve conduction studies according to protocol. RESULTS: In this study, we noticed that the motor nerve conduction amplitude, conduction velocity and distal latency were within normal limits in both the groups. On RNS (repetitive nerve stimulation study) of facial and median nerves, a decremental response was seen in 13 (65%) patients in facial nerve and in 7 (35%) patients in median nerve in Group A; while, the same response was seen in 8 (40%) patients in facial nerve and 3 (15%) patients in median nerve in Group B. A post exercise decremental response was seen in 13 (65%) patients in median nerve and 16 (80%) patients in facial nerve in Group A; and, in 3 (15%) patients in median nerve and 8 (40%) patients in facial nerve in Group B. CONCLUSIONS: In our study, we noticed that the decremental response on RNS was not only present in neuroparalytic snake bite (post-synaptic neuromuscular blockade) but also in vasculotoxic snakebite [pre-synaptic neuromuscular blockade] (seen in Russel's viper).

Governance and management of national telehealth programs in Asia.

UNLABELLED: Telehealth and telemedicine are increasingly becoming accepted practices in Asia, but challenges remain in deploying these services to the farthest areas of many developing countries. With the increasing popularity of universal health coverage, there is a resurgence in promoting telehealth services. But while telehealth that reaches the remotest part of a nation is the ideal endpoint, such goals are burdened by various constraints ranging from governance to funding to infrastructure and operational efficiency. OBJECTIVES: enumerate the public funded national telehealth programs in Asia and determine the state of their governance and management. METHOD: Review of literature, review of official program websites and request for information from key informants. CONCLUSIONS: While there are national telehealth programs already in operation in Asia, most experience challenges with governance and subsequently, with management and sustainability of operations. It is important to learn from successful programs that have built and maintained their services over time. An IT governance framework may assist countries to achieve success in offering telehealth and telemedicine to their citizens.

Gastric Antral Vascular Ectasia.

Iron deficiency anaemia secondary to gastrointestinal bleeding is very common in the elderly. Gastric antral vascular ectasia (GAVE) syndrome, also known as watermelon stomach is an uncommon but significant cause of acute or chronic gastrointestinal blood loss in the elderly. It is characterised endoscopically by "watermelon stripes." It is more common in females than males, and manifests mostly as iron deficiency anaemia due to the gradual blood loss. Pathogenesis is unknown though several humoral factors have been proposed. Diagnosis is based on the clinical history and endoscopic appearance and histological changes. We describe elderly patient who presented with haematemesis and iron deficiency anaemia and was diagnosed to have GAVE and was treated successfully with endoscopic band ligation.

HIV associated Burkitt's lymphoma.

Burkitt's lymphoma (BL) is a highly aggressive B-cell non-Hodgkin Lymphoma (NHL) associated with chromosomal translocations resulting in upregulation of the proto-oncogene C-MYC, which drives progression through the cell cycle NHL accounts for approximately one third of AIDS-related malignancies and the frequency of BL is 2.4-20% of HIV-associated NHL. The outcome of HIV-associated non-Hodgkin lymphoma (NHL) has improved substantially in the highly active antiretroviral therapy (HAART) era. However, HIV-Burkitt lymphoma (BL), which accounts for up to 20% of HIV-NHL, still has poor outcome with standard chemotherapy. We present here a 26 years old female who presented with congestive cardiac failure and sudden onset paraparesis and was finally diagnosed to have right atrial mass and had extradural lesion extending from L2 to S1 which turned out to be High grade NHL-Burkitt's Lymphoma.

Clinicoradiologic correlation in adult patients diagnosed with novel influenza A (H1N1).

BACKGROUND: Influenza A(H1N1) infection affected Indian population in 2009. Patients needed ICU admission and monitoring. OBJECTIVES: To describe and correlate clinical and radiographic features of Influenza A(H1N1) infection in patients hospitalised in Intensive care unit. MATERIAL AND METHODS: Retrospective study of records of 100 RT-PCR confirmed patients with Influenza A(H1N1) infection from August 2009 to March 2010 was done. Each patient underwent an evaluation to determine clinical and radiographic features. RESULTS: Mean age of the patients was 33.43 years (+/- 12.152) with maximum patients between 18-40 years, with 53% males and 43% females. Cough (96%), Fever (95%), breathlessness (83%), throat pain (34%), crepitations (69%), Tachypnoea (59%)were the prominent symptoms and signs. 61% (n = 63) had comorbid condition like pregnancy (n = 13,20.63%), Diabetes Mellitus (DM) (n = 12,19.05%), HT (n = 11,17.60%), Obesity (n = 10, 15.87%) and Rheumatic Valvular Heart Disease (RVHD) (n = 6,09.52%). Chest X ray was abnormal in 91% patients and normal in 09% pts. Bilateral findings were seen in 61.53% cases. Most common zones affected were lower zones (77.46%), then middle zones (71.42%), followed by upper zones (42.7%). Most common patterns were consolidation (64.83%), reticulonodular (24.17%) and nodular (10.98%). 27.47% had two, 21.97% had four, 19.78% had three,12.08% had six, 7.69% had five and 10.98% had single zone involvement. Fever, cough and tachypnoea were present in all 100% pts with nodular pattern while crepitations were observed in 79.66% cases of consolidation. Patchy consolidation was seen in comorbidities like pregnancy (n = 10) and obesity (n = 06), while reticulonodular pattern was observed in hypertensive patients (n = 06). Maximum number of deaths were between 21 and 30 years of age (60.71%). Total number of deaths were 28 with 60.71% (n = 17) deaths between 21 and 30 years of age. Deaths were more in presence of comorbidities like Pregnancy (n = 5, 17.85%), Hypertension (n = 4,14.28%), Diabetes (n = 3 10.21%) and RVHD (n = 3,10.71%), in presence of RLZ involvement (92.85%), RMZ (89.28%), LMZ (85.21%) and RUZ involvement (71.42%), with consolidation pattern (57.14%) followed by reticulonodular pattern (21.42%) and in presence of six zone involvement (36.37%) followed by four zone (35%) and then by three(33%) and two (32%) zone involvement. Mean duration of hospital stay was 9.1 days. 23% patients stayed for less than 5 days, 41% stayed between 9 and 14 days while only 7% required to stay for more than 15 days. 37% pts showed normal Xray at the time of discharge or death. 38% patients showed persistence of radiological lesion at discharge or death. CONCLUSIONS: Young to middle age patients were commonly affected. Common comorbidities were Pregnancy, Diabetes, Hypertension, and Obesity and patients had fever, cough, breathlessness, tachypnoea, crepitations as common clinical features. Radiologically it was multizonal, bilateral disease with predominant lower zone involvement and common patterns were consolidation followed by reticulonodular and nodular. Patchy consolidation was more common in pregnancy and obesity while reticulonodular pattern was more in hypertensive patients. Fever, cough and tachypnoea were present in all 100% pts with nodular pattern. Crepitations were common in pts with consolidation. Clinical recovery preceded radiological recovery. Young to middle aged individuals died more. Deaths were more in presence of comorbidities like Pregnancy, HT, DM and RVHD, also with RLZ, RMZ, LMZ involvement and with consolidation pattern and with six zone involvement.

Comparison of demographic, clinical, radiological characteristics and comorbidities in mechanically ventilated and nonventilated, adult patients admitted in ICU with confirmed diagnosis of influenza A (H1N1).

INTRODUCTION: Influenza A(H1N1) infection affected Indian population in 2009. Patients needed ICU admission and monitoring. Simple demographic, clinical and radiological variables are described in this article in mechanically ventilated and nonventilated patients. OBJECTIVES: To describe and correlate demographic, clinical, radiographic characteristics and comorbidities in mechanically ventilated and nonventilated, adult patients admitted in ICU with confirmed diagnosis of Influenza A(H1N1) infection. MATERIAL AND METHODS: Retrospective study of records of 100 RT-PCR confirmed patients with Influenza A (H1N1) infection from August 2009 to March 2010 was done. Each patient underwent an evaluation to determine demographic, clinical and radiographic features, comorbidities, mechanical ventilator required or not. RESULTS: 35 Patients required mechanical ventilation. 27 required IMV, 4 required NIMV while 4 patients initially were put on NIMV required IMV subsequently. 19 (40.42%) female patients required mechanical ventilator. Mean age of mechanically ventilated patients was 33 years, mean duration of illness was 7.9 days, mean duration of hospital stay was 6.8 days. 07 (20.00%) patients with pregnancy, 05 (14.29%) with DM, 05 (14.29%) with HT, 04/11.43%) with obesity required mechanical ventilator. 97.14% patients with fever, 88.54% with breathlessness, 11.43% with haemoptysis, 31.42% patients with throat pain required mechanical ventilator. However except Tachypnoea (p <0.01) no other symptom was statistically significant for mechanical ventilation 33(36.26%) patients with abnormal X ray,16 (80.00%) patients with right sided, 09(60.00%) patients with left sided and 40(71.43%) patients with bilateral disease required mechanical ventilator, right sided (p < 0.01) and bilateral (p <0.01) disease is statistically significant for requirement of mechanical ventilator. 33(47.14%) patients with lower zone involvement, 44 (67.70%) patients with middle zone and 23 (47.92%) patients with upper zone involvement required mechanical ventilator. Upper zone disease (p < 0.01) and middle zone disease (p < 0.01) is statistically significant for requirement of ventilator. 23 (47.92%) patients with right upper zone, 29 (42.64%) patients with right middle zone, 29 (46.77%) with left middle zone, 32 (42.67%) with right lower zone involvement required mechanical ventilator. RUZ (p < 0.01), RMZ (p < 0.01), LMZ (p < 0.001) and RLZ (p < 0.01) involvement had statistical significance for requirement of mechanical ventilator. 20 (33.89%) patients with patchy consolidation, 08 (36.36%) patients with reticulonodular and 05 (50.00%) patients with nodular pattern required mechanical ventilator however none of the pattern is statistically significant for mechanical ventilator. 08 (72.72%) patients with 6 zone involvement, 05 (50.00%) patients with single zone, 08 (40.00%)patients with 4 zone and 06 (33.33%) patients with 3 zone involvement required mechanical ventilator,however none was statistically significant for mechanical ventilator. All four patients requiring NIMV survived, while 28 died out of 31 on IMV. CONCLUSIONS: Mechanical ventilation requirement was more in females, in presence of comorbidities like pregnancy, DM, HT, in presence of tachypnoea, in presence of bilateral disease and in presence of middle zone and right upper zone disease and with multiple zone disease. All patients with heart involvement required mechanical ventilator. If there is radiological finding of right upper zone involvement, then, there is more probability that these patients require mechanical ventilator for case management. Similarly, RMZ, LMZ and RLZ and cardiomegaly if shown in X-ray, the necessity of ventilator management is more.

Retrospective analysis of necropsy findings in patients of H1N1 and their correlation to clinical features.

India reported its first case of H1N1 in July 2009 in Pune and since then, the number of reported cases and deaths exploded in India. Since very little data is available about histopathological findings in patients of H1N1 fatal cases in India, a retrospective chart analysis of necropsy findings of 15 cases of 2009 H1N1 fatal cases was performed. Common clinical features were fever, cough, and breathlessness followed by sore throat and rhinorrhea. Common lung findings were mononuclear cell infiltration, thick alveolar septae, intraalveolar hemorrhage. The other findings were congested pulmonary blood vessels, pulmonary edema, cytomegaly, fibrin accumulation and formation of eosinophilic membrane. These findings are suggestive of diffuse alveolar damage (DAD) and DAD with hemorrhage. All patients who underwent necropsy had radiographic findings suggestive of unilobar or multilobar pneumonia. This clinical finding can be correlated pathologically in these patients as all of them had either polymorphonuclear or mononuclear infiltrate. Furthermore, necrotizing pneumonitis pattern seen on these patients is the likely cause of mortality in these patients. Although clinical ARDS pattern was noted in all these patients, it was well correlated in lung pathology in all these cases.

Influenza A (H3N2) associated acute necrotising encephalopathy.

We present a case of 16 year old female admitted with complaints of influenza like symptoms followed by convulsions and sudden impairment of consciousness. Magnetic resonance imaging abnormalities were found in bilateral thalami including cerebellum. Diagnosis of influenza associated acute necrotizing encephalopathy was made on the basis of clinical features, neuroimaging findings and isolation of influenza A(H3N2) virus from throat swab. This is probably first case of Influenza associated acute necrotizing encephalopathy reported in India in 2009.

Comparison of bioavailability and pharmacodynamics of diltiazem from two pharmaceutical preparations.

Diltiazem, a calcium channel blocker, is used in multiple divided doses daily, due to its short elimination half-life. Hence, administration as a modified release (MR) formulation is suggested. In this double blind cross-over trial, the pharmacokinetics and pharmacodynamics of diltiazem was studied in eight healthy Indian adults. Diltiazem was administered as single dose (60 mg) of the two formulations viz immediate release (IR) and MR. Venous blood samples, for estimation of diltiazem by HPLC, were collected at frequent intervals and BP, HR and ECG were monitored during the 12h study period. With MR formulation, plasma half-life was significantly (P < 0.05) prolonged (6.25 +/- 1.2 h vs. 2.69 +/- 0.2 h), the extent of alterations in BP, HR and PR interval was significantly less, while the duration of prolongation of PR interval was significantly more as compared to IR formulation. Therefore, MR formulation of diltiazem has better pharmacokinetic and pharmacodynamic profile as compared to IR formulation.