Altered Expression of Complement Regulatory Proteins CD35, CD46, CD55, and CD59 on Leukocyte Subsets in Individuals Suffering From Coronary Artery Disease

Studies conducted in animal models have suggested that membrane complement regulatory proteins play an important role in the pathophysiology of coronary artery disease (CAD). In this study, a total of 100 individuals, with stable CAD and 100 healthy controls, both groups predominantly male, were recruited. We evaluated the plasma levels of complement regulatory proteins (Cregs) CD35, CD46, CD55, and CD59 and their surface expression on granulocytes, lymphocytes, and monocytes by flow cytometry. The mRNA expression of these Cregs in total leukocytes was determined by quantitative PCR. The soluble forms of Cregs, C3c, Mannose binding protein-associated serine protease 2 (MASP-2), Platelet activating factor-acetyl hydrolase (PAF-AH), and inflammatory cytokines were quantified by ELISA. High plasma levels of C3c, indicative of complement activation, in addition to significantly low levels of Cregs, were observed in CAD patients. A significantly lower expression of CD46 and CD55 on the surface of lymphocytes, monocytes, and granulocytes and higher surface expression of CD35 and CD59 on granulocytes (p < 0.0001) was seen in CAD patients as compared to healthy donors. The high expression of CD59 on granulocytes positively correlated with the severity of disease and may serve as a potential marker of disease progression in CAD.

Arthroscopic and 3D CT Scan Evaluation of Femoral Footprint of the Anterior Cruciate Ligament in Chronic ACL Deficient Knees

The outcome of single-bundle anterior cruciate ligament (ACL) reconstruction depends largely on the anatomic placement of bone tunnel. The lateral intercondylar ridge (LIR) and bifurcate ridge (BR) are useful bony landmarks for femoral tunnel placement. The purpose of our study was to compare the bony landmarks of ACL footprint on femur by three-dimensional computed tomography (3D CT) scan and arthroscopy in chronic ACL-deficient knees. Fifty patients above 18 years of age who were diagnosed of having ACL tear were selected for the study. All the cases were more than 6 months old since the injury. Preoperative 3D CT scan of the affected knee was obtained for each of them. They underwent single-bundle anatomic ACL reconstruction. Measurements were done on the preoperative 3D CT and arthroscopy to quantify the position of the LIR and BR. The proximodistal distance of lateral femoral condyle was 21.41+/-2.5 mm on CT scan and 22.02+/-2.02 mm on arthroscopy. On preoperative 3D CT scan, the midpoint of the LIR was found to be located at a mean distance of 11.17±2.11 mm from the proximal margin of the lateral femoral condyle. On arthroscopy, it was at 10.18+/-1.52 mm from the proximal margin the lateral femoral condyle. The "bifurcate ridge"(BR) was not visible in any of the cases during arthroscopy or CT scan. We concluded that LIR is an easily identifiable bony landmark on arthroscopy in all cases. It can also be identified on CT scans. BR is not identified both on arthroscopy and CT scans in chronic ACL tears. The arthroscopic measurements of bony landmarks are quite close to those of CT scan. Midpoint of LIR is at 52.185% of the proximodistal distance on CT scan evaluation and it is at 46.21% on arthroscopic evaluation.

Serum and Bronchoalveolar Lavage Fluid 25(OH)Vitamin D3 Levels in HIV-1 and Tuberculosis: A Cross-Sectional Study from a Tertiary Care Center in North India

BACKGROUND

Vitamin D is an immunomodulator, and its deficiency is associated with Tuberculosis (TB) infection. Bronchoalveolar lavage fluid (BALF) is a rich milieu of macrophages that form the first line of defense against invading TB bacilli. As there is an increased prevalence of vitamin D deficiency in TB and human immunodeficiency virus-1 (HIV-1) subjects, we intend exploring the possibility of a localized deficiency of vitamin D metabolites in BALF of these patients.

OBJECTIVE

The primary objective was to assess the level of 25D3 in serum and BALF of subjects and look for a significant difference among patients and controls. The secondary objective was to find a correlation between serum and BALF 25D3 levels.

METHODS

We performed a cross-sectional study with subjects divided into four groups: Controls (group 1), HIV positive without active TB (group 2), active TB without HIV (group 3), and HIV-TB coinfection (group 4). BALF and serum 25D3 levels were compared between the groups.

RESULTS

Among the 149 (an immunomodulator) successive subjects enrolled, there were 40 subjects in group 1 (HIV-TB-), 48 in group 2 (HIV+TB-), 37 in group 3 (HIV-TB+), and 24 in group 4 (HIV+TB+). Females constituted 31.6% of the study subjects. In groups 3 and 4, there were significantly lower serum 25D3 levels compared to group 1 (p-value group 3: 0.002; group 4: 0.012). In groups 2, 3, and 4, there were significantly lower BALF 25D3 levels compared to group 1 (p-value group 2: 0.000; group 3: 0.000; group 4: 0.001). There was a significant correlation between serum and BALF 25D3 levels (Spearman's rank correlation coefficient 0.318, p-value = 0.0001).

CONCLUSION

Lower levels of serum and BALF 25D3 were observed in HIV, TB, and HIV-TB coinfected patients. Localized deficiency of vitamin D metabolites might be associated with increased vulnerability to TB infection.

Compliance of WHO Guideline on Dengue Management among Indian Patients: An Interventional Quality Improvement Study

INTRODUCTION

Dengue fever management is guided by WHO guideline, the recent one being 2009; however, compliance to the guideline is difficult to assess and in India there is no data on it. The present study, a longitudinal pre-post interventional quality improvement study, was done to determine the compliance to the guideline on dengue patients before and after resident physicians' training during two peak seasons and their impact on survival.

METHODS

This study was conducted in a tertiary health care centre in North India over 18 months. Data of hospitalized patients who admitted with dengue fever diagnosis in a peak season was collected in the form of quality indicators as described by the WHO-2009 guideline on dengue. Resident physicians were then given appropriate training about the guideline during the off season. Data of new dengue patients in next peak season after resident training was collected and compared with the baseline by standard statistical tests.

RESULTS

The post-intervention compliances of all components increased (total mean score by giving one point to each of the quality indicators reached 7.9 from 6.4). The compliance to individual indicator also increased: the admission criteria (baseline, 44% to post-intervention, 52%, p = 0.37), classification criteria (91.7% to 96%, p = 0.33), correct staging/triage (42.9% to 86%, p <0.001), vitals monitoring (85.7% to 92%, p = 0.28), correct usage of bolus fluids (34.3% to 69.5%, p <0.001), crystalloid as choice of fluid (100% in both groups), proper fluid titration (26.2% to 56%, p <0.001), hematocrit monitoring (95.2% to 98%, p = 0.42), platelet transfusion when indicated (65.5% to 58%, p = 0.39), antibiotic use when required (61.5% to 80%, p = 0.03), and discharge criteria (100% in both groups). The mortality decreased from 7.1% (baseline) to zero (post-intervention). The median duration of hospital stay also reduced by 1 day.

CONCLUSION

The study affirms that the compliance to WHO guideline on dengue management in India can be further improved by regular physician training on the guideline. Simultaneously, this educational intervention not only improves patient outcomes but also direct proper resource utilization especially platelet transfusion and antibiotic use. Furthermore, every hospital/institute should have an internal quality improvement program like this to improve the management of dengue patients. Future studies are needed to understand various barriers to 100% implementation of the guideline.

Epidermal growth factor receptor (EGFR), KRAS, and BRAF mutations in lung adenocarcinomas: A study from India

Mitogen-Activated Protein (MAP) Kinase pathway involves several oncogenic genes which can serve as potential targets for therapy. Therefore, aim of the present study is to analyze mutations in the MAP Kinase pathway in pulmonary adenocarcinoma (ADCA) of Indian patients along with clinico-pathologic correlation and determination of the survival status in patients receiving therapy. Blocks and slides of 125 pulmonary ADCA of last 5 years were retrieved. Histo-morphology and tumor content were determined. EGFR, KRAS, BRAF and MEK1 genes were analyzed using Sanger sequencing and Real-time polymerase chain reaction (PCR). Clinico-pathologic correlation and survival analysis were performed. Fifty-eight (46.4%) patients harbored genetic mutations of which 49 had single somatic mutations, 5 had multiple exonic and 4 showed coexisting EGFR and KRAS mutations. EGFR mutations were seen in 24.8%, KRAS in 19.2% and BRAF (non-V600E) in 2.4% cases. There was no difference in progression-free survival of wild- type/single mutations when compared with multiple/ coexisting mutations (P = 0.09). However, the P value may indicate borderline correlation. To conclude, EGFR and KRAS mutations may coexist in the same patient in lung ADCA. Multiple exonic mutations of KRAS gene formed substantial percentage of our cohort, requiring further exploration. Lung ADCA harbouring BRAF mutations are commonly non-V600E. Testing of all major genetic driver mutations of lung ADCA irrespective of histology and other demographic characteristics is necessary.

1011. Sepsis and Secondary Hemophagocytic Lymphohistiocytosis

Background

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory condition diagnosed by HLH 2004 criteria. This criterion has common clinical and laboratory features with sepsis and tropical fevers, but there is marked difference in management and outcome of these two entities. The study is conducted to know whether there is any difference in the clinico-laboratory features, management, and outcome of sepsis with or without secondary HLH.

Methods

This is a prospective observational study where patients presenting with sepsis and bicytopenia are included. The patients underwent relevant investigations according to 2004 HLH diagnostic criteria. The patients are divided into sepsis with or without HLH. The underlying etiology, treatment, and outcome of the two groups are analysed.

Results

Fifty sepsis patients are included in the study, out of which 28 fulfilled the HLH diagnostic criteria which comprised of 18 men and 10 women. The etiology were bacterial (three enteric fever, three tuberculosis, two scrub typhus, one Staphylococcal aureus), viral (one dengue fever, two HIV, two encephalitis), fungal (one aspergillosis, one mucormycosis, two others), parasites (three malaria, one leishmania) malignancy (two hodgkin lymphoma, one non-Hodgkins lymphoma), and unknown etiology in six patients, with >1 etiology in three patients (Figure 2). The percentage of each criterion fulfilled in both groups is given in Figure 1, showing an increased occurrence of splenomegaly, low NK cell activity, hypertriglyceridemia in HLH patients. Steroids along with supportive treatment was given to 53% and etoposide was added in 7%. Treatment for underlying etiology alone without immunosuppressive treatment was given in 39%. The mortality in those with HLH vs. without HLH was 42% and 31%, respectively. The median duration of hospital stay was 18 and 36 days in HLH and without HLH group, respectively.

Conclusion

HLH should be suspected in sepsis patients with bicytopenia specially in tropical fevers. There is increased mortality if the sepsis patients fulfil HLH criteria. Early diagnosis and management is of paramount importance.

Disclosures

All authors: No reported disclosures.

Development and validation of Cognitive Training Intervention for Alzheimer's disease (CTI-AD): A picture-based interventional program

Introduction

Alzheimer’s disease is a gradual and progressive disorder which cripples the person’s functionality due to cognitive decline. Many clinicopathological and pharmacological therapy has the potential to slow down the progression of the disease but has limited efficacy. One complimentary approach that has emerged is cognitive training interventions which have shown synergistic effect with the drug therapy. Nevertheless, many cognitive interventions lack on specificities of the intervention due to which its efficacy gets scrutinized.

Objective

To describe the foundation, content, and development of Cognitive Training Intervention for Alzheimer’s disease (CTI-AD) along with the treatment feasibility based on a pilot study.

Materials and methods

A culture-specific picture-based eight weeks cognitive training manual was developed based on extensive review and focused group discussions. It was standardized on 63 older participants (48 healthy controls (HC); 15 early Alzheimer’s disease cases).

Results

All the tasks were progressive in nature and were found effective in discriminating the cognitive performance of early Alzheimer’s disease and HC throughout the intervention period. Moreover, it also improved early Alzheimer’s disease performance on the memory (HC: 1st week/8th week = 21.6 ± 5.7/57.3 ± 19.0; early Alzheimer’s disease: 1st week/8th week = 48.5 ± 22.9/60.5 ± 21.8); attention (HC: 1st week/8th week = 90.2 ± 18.0/196.9 ± 28.0; early Alzheimer’s disease: 1st week/8th week = 216.6 ± 78.2/286.8 ± 87.0) and language (HC: 1st week/8th week = 29.8 ± 9.4/115.3 ± 31.1; early Alzheimer’s disease: 1st week/8th week = 211.8 ± 68.4/270.4 ± 104.9) domains, respectively, from the baseline level.

Conclusion

The current manual (CTI-AD) is one of the first promising non-pharmacological program developed nationally with a strong theoretical base to cater to the tertiary needs of the older adults with early Alzheimer’s disease.

Outcomes of Implementing the Central Venous Catheter Bundle at a Tertiary Care Hospital in North India, at AIIMS, New Delhi

INTRODUCTION

Central venous catheter (CVC) associated infection are many times higher in India compared to western countries. A group of interventions called as CVC bundle, if implemented effectively prevents CVC related complication.

METHODOLOGY

Our study was a prospective quasi-experimental study. The study evaluated the level of compliance with the central venous catheter bundle in the management of patients in our Medicine wards and Intensive care unit (ICU).

RESULTS

:In the study, the incidence of central line associated bloodstream infection (CLABSI) was zero and the incidence of pneumothorax was 5%. Most of the patients had higher Acute physiology and chronic health evaluation (APACHE II) at baseline and multi organ dysfunction. The compliance with whole CVC bundle improved from 0% at baseline to 10% in post-intervention phase. Compliance of many components increased significantly in the post intervention period. These were Hand washing before insertion (15% to 72.5%, p<0.001), Maintenance (0% to 52.5%, p<0.001), Prompt removal of catheters (40% to 70%, p=0.007), Skin antisepsis with chlorhexidine increased approaching significance (0% to 12.5%, p=0.055). Avoidance of femoral catheters was done in more than 95% of the cases. The predictors of mortality were higher APACHE II (OR 1.23 [CI 1.03-1.47], p=0.020) and duration of hospital stay (OR 0.87 [CI 0.78-0.97], p=0.022).

CONCLUSION

This study done at All India Institute of Medical Sciences showed improved outcome in terms of catheter infection and mechanical complications. CVC bundle compliance increased significantly though adherence to full bundle was less. In future, with rectification of barriers to bundle completion, the compliance with CVC bundle can be further improved.

Evaluation of the diagnostic yield of ARQIP: A new restless legs syndrome diagnostic questionnaire and validation of its Hindi translation

Background

Restless legs syndrome (RLS) is misdiagnosed due to a variety of clinical presentations and lack of a diagnostic biomarker. Sociocultural differences in patients' reporting of symptoms further contribute to this under diagnosis. We developed an expanded diagnostic tool for RLS, incorporating all International RLS Study Group (IRLSSG) diagnostic criteria with a number of additional questions mainly focusing on specific sociocultural influences in RLS symptom reporting among Indians. The purpose of this study was to examine the change in the diagnostic yield of RLS, if any, through administration of this expanded questionnaire.

Materials and Methods

The AIIMS RLS questionnaire for Indian patients (ARQIP) was developed in English language, and then translated into Hindi. All consecutive patients attending Neurology and sleep disorders clinic with complaints of leg discomfort were recruited in the study. Two examiners evaluated all patients with complaints of leg discomfort seen by a senior Sleep Medicine expert, one using only IRLSSG diagnostic criteria and the other using the ARQIP. Patients were categorized as RLS or "no-RLS" by the expert, and this was considered as the "standard" for analysis.

Results

A total of 155 participants (78 males, 50.3%) with a mean age of 44.1 ± 14.5 years were enrolled. A total of 105 patients were diagnosed as having RLS (group 1) and the rest as having "non-RLS" (group 2). The ARQIP was found to have a much higher sensitivity (100% vs 73%), specificity (44% vs 32.7%), negative predictive value (100% vs 36.4%), and positive predictive value (79% vs 70%) compared to the standard questionnaire. The diagnostic yield of this tool was 26.7% (Confidence interval = 100-73.3).

Conclusions

The ARQIP for RLS diagnosis, validated in this study, has been observed to have a high sensitivity and a negative predictive value with a high diagnostic accuracy.

Patients Who Benefit from Intracranial Pressure Monitoring without Cerebrospinal Fluid Drainage After Severe Traumatic Brain Injury

BACKGROUND

India has a high traumatic brain injury (TBI) burden and intracranial pressure monitoring (ICP) remains controversial but some patients may benefit.

OBJECTIVE

To examine the association between ICP monitor placement and outcomes, and identify Indian patients with severe TBI who benefit from ICP monitoring

METHODS

We conducted a secondary analysis of a prospective cohort study at a level 1 Indian trauma center. Patients over 18 yr with severe TBI (admission Glasgow coma scale score < 8) who received tracheal intubation for at-least 48 h were examined. Propensity-based analysis using inverse probability weighting approach was used to examine ICP monitor placement within 72 h of admission and outcomes. Outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) score at discharge, 3, 6, and 12 mo. Death, vegetative, or major impairment defined unfavorable outcome.

RESULTS

The 200 patients averaged 36 [18 to 85] yr of age and average injury severity score of 31.4 [2 to 73]. ICP monitors were placed in 126 (63%) patients. Patients with ICP monitor placement experienced lower in-hospital mortality (adjusted relative risk [aRR]; 0.50 [0.29, 0.87]) than patients without ICP monitoring. However, there was no benefit at 3, 6, and 12 mo. With ICP monitor placement, absence of cerebral edema (aRR 0.54, 95% confidence interval 0.35-0.84), and absence of intraventricular hemorrhage (aRR 0.52, 95% confidence interval 0.33-0.82) were associated with reduced unfavorable outcomes.

CONCLUSION

ICP monitor placement without cerebrospinal fluid drainage within 72 h of admission was associated with reduced in-patient mortality. Patients with severe TBI but without cerebral edema and without intraventricular hemorrhage may benefit from ICP monitoring.

Higher Frequency of HIV-1 Drug Resistance and Increased Nucleoside Reverse Transcriptase Inhibitor Mutations among the HIV-1 Positive Antiretroviral Therapy-Naïve patients Coinfected With Mycobacterium tuberculosis Compared With Only HIV Infection in India

Background:

Emergence of human immunodeficiency virus (HIV) drug resistance mutations prior to highly active antiretroviral therapy is a serious problem in clinical management of HIV/AIDS. Risk factors for appearance of drug resistance mutations are not known. We hypothesize that Mycobacterium tuberculosis infection may contribute to rapid emergence of such mutations in antiretroviral therapy–naïve patients.

Methods:

A total of 115 patients were recruited in this study of which 75 were HIV+TB+ coinfected (group 1) and 40 were HIV+TB− (group 2). Blood samples from all the patients were collected and CD4+ cell counts; HIV-1 plasma viral load and sequencing of protease and two-third region of reverse transcriptase of HIV-1 was performed and analyzed for drug resistance pattern.

Results:

For patients with HIV+TB+, 10.6% (8/75) had mutations to non-nucleoside reverse transcriptase inhibitors (NNRTIs), 4% (3/75) to nucleoside reverse transcriptase inhibitors, and only 2.6% (2/75) patients had mutations to protease inhibitors. Interestingly, for group 2 (HIV+TB−), there were only NNRTI mutations found among these patients, and only 3 patients (7.5%) had these drug-resistant mutations. Clade typing and phylogenetic tree analysis showed HIV-1 subtype C predominance in these patients.

Conclusions:

Our study showed that higher percentage of HIV drug resistance mutations was found among HIV+TB+ individuals compared with tuberculosis-uninfected patients. Tuberculosis coinfection may be a risk factor for emergence of high frequency of drug resistance mutations. Studies with a larger sample size will help to confirm these findings from the Indian population.

Narrowing of the Anterior Chamber Angle during Valsalva Maneuver: A Possible Mechanism for Angle Closure

Purpose

To evaluate changes at the anterior chamber angle during Valsalva maneuver in eyes suspected to have a primary adult glaucoma.

Methods

Seventy-six consecutive patients underwent recording of applanation tonometry, measurement of the anterior chamber angle recess, angle opening distance, angle recess area, scleral spur-iris root distance, iris thickness, iridociliary angle, ciliary body thickness, anterior chamber depth, and pupil size on ultrasound biomicroscopy before and during the Valsalva maneuver. The Valsalva maneuver was standardized to a pressure of 40 mmHg for 15 seconds, using a manometer.

Results

The mean baseline intraocular pressure changed from 19.5±4.1 mmHg to 29.5±4.8 mmHg during Valsalva (p<0.0001). The anterior chamber angle recess narrowed from 17.9±9.5 to 7.8±9.2 degrees (p=0.0001). The angle recess area diminished from 0.15±0.14 mm2 to 0.14±0.12 mm2 (p=0.03) and the scleral spur to iris distance decreased from 0.19±0.2 mm to 0.16±0.18 mm (p=0.0001). The iridociliary angle narrowed from 72.6±33.5 degrees to 62.5±32.8 degrees (p=0.04). There was a significant increase in the thickness of the ciliary body, from 0.99±0.19 mm to 1.12±0.16 mm (p=0.001) and in iris thickness from 0.47±0.07 mm to 0.55±0.09 mm (p=0.0001). There was no significant change in the angle opening distance, anterior chamber depth, or pupillary diameter. A significant narrowing of the angle to less than 5 degrees was seen in 37 eyes, with iridocorneal apposition present in 28 eyes. After multivariate regression analysis it was found that the baseline ciliary body thickness and angle recess were significant predictors of narrowing of the angle (R2=96.1%).

Conclusions

Significant elevation of the intraocular pressure, narrowing of the anterior chamber angle recess, thickening of the ciliary body, and increase in the iris thickness is seen during the Valsalva maneuver. The Valsalva maneuver may lead to angle closure in eyes anatomically predisposed to primary angle closure glaucoma.

Prevalence of severe acute malnutrition and associated sociodemographic factors among children aged 6 months-5 years in rural population of Northern India: A population-based survey

Introduction

National Family Health Survey (NFHS)-3 documented that nearly 57 million children are undernourished in India, which is one-third of the world's share. We planned a study to identify the prevalence of severe acute malnutrition (SAM) among children aged <5 years in a rural population of Northern India.

Materials and Methods

A cross-sectional study was conducted at 2 blocks of District Meerut during 2012-2014. A total of 70 villages were identified and all children in the age group 6-60 months were approached through house-to-house visits. Data on sociodemographic profile and anthropometry were collected utilizing standards methods and equipment. The Z-scores for weight-for-age, height-for-age, and weight-for-height (WHZ) were calculated using the World Health Organization (WHO) reference data as standard. SAM (severe wasting) was defined as per the WHO criteria (WHZ score <-3 standard deviation or severe visible wasting or bipedal edema).

Results

A total of 19,449 children were screened and 18,463 children (age, 32.6 ± 15.4 years, and 53.4% males) were enrolled, and 466 were excluded due to erroneous age estimation and physical deformities. The prevalence of SAM was 2.2%, 95% confidence interval (CI) 2.02-2.44%, (409/18,463). Multivariate logistic regression documented age (odds ratio [OR]: 0.97, 95% CI 0.96-0.98), nuclear family (OR: 1.25, 95% CI 1.01-1.54), lower occupation of head of family (OR: 1.29, 95% CI 1.05-1.59), and lower paternal education (OR: 1.49, 95% CI 1.16-1.91) as independent predictor of SAM.

Conclusion

The prevalence of SAM was lower (2.2%) in this Northern district of India as compared to national prevalence (7.9%). Younger age, nuclear family, lower parental education, and poor occupation of the head of the family predispose a child to SAM.

Nevirapine- versus Efavirenz-based antiretroviral therapy regimens in antiretroviral-naive patients with HIV and Tuberculosis infections in India: a multi-centre study

Background

According to World Health Organization (WHO) guidelines, which have also been adopted by the National AIDS Control Organization (NACO), India, Efavirenz-based Anti-Retroviral Therapy (ART) is better in Human-Immunodeficiency-Virus (HIV)-infected patients who are also being treated with Rifampicin-based Anti-Tuberculous Therapy (ATT). However, Efavirenz is much more expensive. We hypothesize that Nevirapine is a cheaper alternative that possesses equal efficacy as Efavirenz in HIV-Tuberculosis (TB) co-infected patients.

Methods

A parallel open-label randomized clinical trial was conducted at All India Institute of Medical Sciences (AIIMS), New Delhi and National AIDS Research Institute (NARI), Pune. Those who were ART-naïve and co-infected with TB were randomized to receive either Nevirapine (Group 1)- or Efavirenz (Group 2)-based ART along with Rifampicin-based ATT. ATT was begun first in ART-naïve patients according to the NACO guidelines, with a median of 27 days between ATT and ART in both groups. The primary endpoint was a composite unfavourable outcome (death and/or ART failure) at 96 weeks, and the secondary outcome was successful TB treatment at 48 weeks.

Results

A total of 284 patients (mean age 36.7 ± 8.1 years) were randomized in a 1:1 ratio to receive either Nevirapine (n = 144)- or Efavirenz (n = 140)-based ART after a median ATT-ART gap of 27 days. The median CD4 count was 105 cells/μl, with a median viral load of 820,200 copies/μl and no significant difference between the groups. Composite unfavourable outcomes were reported in 49 patients in the Nevirapine group and 51 patients in the Efavirenz group (35.3% vs. 36.9%; hazard ratio, 0.95, 95% confidence interval (CI), 0.63,1.43, adjusted). There was no difference in successful TB treatment outcome between the groups (71.5% vs. 65.6%, 95% CI -3.8,17.9, adjusted). The results were similar, showing no difference between the groups in the two centres of the study after adjusting for disease stage.

Conclusions

Composite unfavourable outcome in HIV-TB co-infected patients who were ART-naïve showed no statistically significant difference in the Nevirapine or Efavirenz groups.. Therefore, Nevirapine-based ART is a reasonable alternative to Efavirenz in resource-limited settings. However, multi-centric studies with larger sample sizes are required to confirm these findings.

Trial registration

NCT01805258 (Retrospectively registered on March 6, 2013) Date of registration: March 2013.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2864-0) contains supplementary material, which is available to authorized users.

Development of All India Institute of Medical Sciences-Modified International Clinical Epidemiology Network Diagnostic Instrument for Neuromotor Impairments in Children Aged 1 Month to 18 Years

Introduction

There is shortage of specialists for the diagnosis of children with neuromotor impairments (NMIs), especially in resource limited settings. Existing International Clinical Epidemiology Network (INCLEN) instrument for diagnosing NMI have been validated for children aged 2–9 years. The current study modified the same including wider symptomatology and age group (1 month to 18 years).

Methods

The Modified INCLEN diagnostic tool (INDT) was developed by a team of experts by modifying the existing tool to widen the age range (1 month to 18 years) and include broader symptomatology (inclusion of milestones from the first 2 years of life and better elucidation of cerebellar and extrapyramidal features) in a tertiary care teaching hospital of North India between January and April 2015. A trained medical graduate applied the candidate tool, which was followed by gold standard evaluation by a Pediatric Neurologist (both blinded to each other).

Results

A total of 197 children (102 with NMI and 95 without NMI) were enrolled for the study. The sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratio of the modified NMI tool were 90.4% (82.6–95.5), 95.5% (88.7–98.7), 95.5% (88.9–98.7), 90.3% (82.4–95.5), 19.9 (12.1–32.6), and 0.13 (0.08–0.12), respectively.

Conclusion

The All India Institute of Medical Sciences modified INDT NMI tool is a simple and structured instrument covering a wider symptomatology in the 1 month to 18 years age group with acceptable diagnostic accuracy.

Survival and Recovery in Severely Wasted Under-five Children Without Community Management of Acute Malnutrition Programme

OBJECTIVE

To evaluate recovery and survival of severely wasted children without community management of acute malnutrition programme.

DESIGN

Single time point follow-up (24th December 2013 - 2nd April, 2014) of severely wasted children identified in a community-based cross-sectional survey (September 2012 - October 2013).

SETTING

Rural Meerut District, Uttar Pradesh, India.

PARTICIPANTS

409 severely wasted (WHO weight-for-height <-3Z), 6- to 59-month-old children.

OUTCOME MEASURES

Survival and recovery (weight-for-height ≥-2Z).

RESULTS

Median (IQR) follow-up contact duration was 7.4 (6.6, 10.1) months. Among 11 deaths, there were 5 (case-fatality 1.2%), 6 (1.5%), 8 (2.0%) and 10 (2.4%) events within 1, 1.5, 4 and 6 months of enrolment, respectively. Ten deaths occurred in children aged between 6 and 24 months. Younger age (P=0.04), poorer household-head occupation (P=0.04) and lower enrolment anthropometry (any variable; P<0.001) were significant predictors of mortality. Children below 18 months of age had higher adjusted mortality risk (HR 4.7; 95% CI 0.95, 22.51; P=0.053). At follow-up, 30% of survivors were still severely wasted, 39% were moderately wasted (weight-for-height -3 to <-2Z) and 31% had recovered spontaneously. Younger age (P<0.001), female gender (P=0.04) and longer follow-up duration (P=0.003) were significant independent predictors of recovery. The adjusted OR (95% CI) for recovery <24 months was 2.81 (1.70, 4.65).

CONCLUSION

Without community management of acute malnutrition in rural Meerut District, severely wasted children had low (1.2%-2.7%) case-fatality with long-term spontaneous recovery of around 25-30%.

Translation and Adaptation of Stroke Aphasia Depression Questionnaire-10 to Hindi

Background:

Depression is one of the most researched emotional responses after stroke and shows that the emotional impact of aphasia can have a marked negative impact on recovery, response to rehabilitation, and psychosocial adjustment. There is an evident dearth of validated instruments to assess depression in people with aphasia including Hindi, the national language of the country.

Aims:

The aim of this study was to translate and adapt the original English version of widely used hospital version of Stroke Aphasia Depression Questionnaire (SADQ-10) to Hindi.

Subjects and Methods:

English version of SADQ-10 was translated and adapted for the use in Hindi-speaking population in concordance to the WHO guidelines.

Statistical Analysis Used:

The intraclass correlation coefficient (ICC) analysis of the data was performed using SPSS, version 16, to compute the test–retest reliability.

Results:

The Hindi version of SADQ-10 yielded an overall high test–retest reliability (ICC = 0.91) as well as internal consistency (α = 0.98), which in turn were comparable to the original instrument in English.

Conclusions:

SADQ10-Hindi may assist the identification of depressed mood in patients with speech and language impairment in an Indian population as well. It is an easy to administer and quick test which can be used by health-care professionals in a hospital- or community-based settings.

Cathepsin L and B as Potential Markers for Liver Fibrosis: Insights From Patients and Experimental Models

OBJECTIVES

Cathepsin L (CTSL) and B (CTSB) have a crucial role in extracellular matrix (ECM) degradation and tissue remodeling, which is a prominent feature of fibrogenesis. The aim of this study was to determine the role and clinical significance of these cathepsins in liver fibrosis.

METHODS

Hepatic histological CTSL and CTSB expression were assessed in experimental models of liver fibrosis, patients with liver cirrhosis, chronic viral hepatitis, and controls by real-time PCR and immunohistochemistry. Plasma levels of CTSL and CTSB were analyzed in 51 liver cirrhosis patients (Child-Pugh stages A, B and C) and 15 controls.

RESULTS

Significantly enhanced CTSL mRNA (P=0.02) and protein (P=0.01) levels were observed in the liver of carbon tetrachloride-treated mice compared with controls. Similarly, hepatic CTSL and CTSB mRNA levels (P=0.02) were markedly increased in Abcb4-/- (ATP-binding cassette transporter knockout) mice compared with wild-type littermates. Elevated levels of CTSL and CTSB were also found in the liver (P=0.001) and plasma (P<0.0001) of patients with hepatic cirrhosis compared with healthy controls. Furthermore, CTSL and CTSB levels correlated well with the hepatic collagen (r=0.5, P=0.007; r=0.64, P=0.0001). CTSL and CTSB levels increased with the Child-Pugh stage of liver cirrhosis and correlated with total bilirubin content (r=0.4/0.2; P≤0.05). CTSL, CTSB, and their combination had a high diagnostic accuracy (area under the curve: 0.91, 0.89 and 0.96, respectively) for distinguishing patients from controls.

CONCLUSIONS

Our data demonstrate the overexpression of CTSL and CTSB in patients and experimental mouse models, suggesting their potential as diagnostic biomarkers for chronic liver diseases.

Frozen shoulder - A prospective randomized clinical trial

AIM

To compare the results of arthroscopic capsular release with intra-articular steroid injections in patients of frozen shoulder.

METHODS

Fifty-six patients with frozen shoulder were randomised to one of two treatment groups: Group 1, complete 360 degree arthroscopic capsular release and group 2, intra-articular corticosteroid injection (40 mg methyl prednisolone acetate). Both groups were put on active and passive range of motion exercises following the intervention. The outcome parameters were visual analogue scale (VAS) score for pain, range of motion and Constant score which were measured at baseline, 4, 8, 12, 16 and 20 wk after intervention.

RESULTS

All the parameters improved in both the groups. The mean VAS score improved significantly more in the group 1 as compared to group 2 at 8 wk. This greater improvement was maintained at 20 wk with P value of 0.007 at 8 wk, 0.006 at 12 wk, 0.006 at 16 wk and 0.019 at 20 wk. The Constant score showed a more significant improvement in group 1 compared to group 2 at 4 wk, which was again maintained at 20 wk with P value of 0.01 at 4, 8, 12 and 16 wk. The gain in abduction movement was statistically significantly more in arthroscopy group with P value of 0.001 at 4, 8, 12, 16 wk and 0.005 at 20 wk. The gain in external rotation was statistically significantly more in arthroscopy group with P value of 0.007 at 4 wk, 0.001 at 8, 12, and 16 wk and 0.003 at 20 wk. There was no statistically significant difference in extension and internal rotation between the two groups at any time.

CONCLUSION

Arthroscopic capsular release provides subjective and objective improvement earlier than intra-articular steroid injection.

Cardiovascular Autonomic Dysfunction in Children and Adolescents With Rett Syndrome

BACKGROUND

Autonomic dysfunction is common in children with Rett syndrome. They usually manifest with agitation, persistent screaming, constipation, gastroesophageal reflux, aerophagia, hyperventilation, and breath-holding episodes. Cardiovascular autonomic dysfunction may result in fatal a arrhythmia. Many of these events are mistaken for seizures and treated with antiepileptics.

METHODS

The present study was conducted in a tertiary care teaching hospital in north India for more than a six month period. MeCP2 mutation positive, 24 cases with Rett syndrome and 24 age-matched healthy girls were evaluated for cardiovascular autonomic dysfunction (heart rate variability, head-up tilt test, and cold pressor test).

RESULTS

The mean age was 9.06 years (±3.4) and 9.75 years (±3.13) for patients and control subjects, respectively. The heart rate variability contributed independently by parasympathetic and sympathetic nervous system was significantly reduced in cases compared with control subjects (P = 0.033 and P = 0.001, respectively). There was significant sympathovagal imbalance with sympathetic overactivity in cases compared with control subjects (P = 0.001). The mean longest QT_c interval was significantly prolonged in cases compared with control subjects (P = 0.001). Cold pressor test and head-up tilt test could be done in 16 Rett syndrome patients (because of poor cooperation) and in all 24 control subjects. The change in blood pressure during cold pressor test and head-up tilt test was not significantly different in cases and control subjects.

CONCLUSIONS

Children with Rett syndrome exhibited significant cardiovascular autonomic dysfunction in the form of sympathetic overactivity, parasympathetic underactivity, and sympathovagal imbalance. These findings have potentially important therapeutic- and outcome-related implications.

Evaluation of plasma leptin, tumor necrosis factor-α, and prealbumin as prognostic biomarkers during clinical recovery from acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Inflammatory and nutritional biomarkers have an important bearing on outcomes of acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but the temporal profile of these compounds during an acute episode is unclear.

PATIENTS AND METHODS

Plasma leptin, prealbumin, and tumor necrosis factor-alpha (TNF-α) were estimated at baseline and before hospital discharge in patients with AECOPD.

RESULTS

A total of 82 patients were evaluated (66 males; mean (standard deviation) age, 61.6 (10.1) years. Of these, 74 subjects (90.2%) were current or former smokers, with median (range) pack-years of 15 (0-96), duration of COPD of 8 years (range, 2-25 years) and duration of current symptoms being 5 days (range, 1-30 days). Majority (41.5%) had type I (severe) exacerbation. During the current episode, 46 patients (58.9%) required mechanical ventilation for a median of 6 days (range, 1-34). The median duration of hospital stay was 13 days, (range, 1-110). At discharge, significant reduction was observed in dyspnea, total leukocyte count, erythrocyte sedimentation rate (ESR), partial pressure of carbon dioxide, hemoglobin, urea, creatinine, potassium, aspartate transferase, and TNF-α levels compared to baseline, whereas arterial pH, PO₂, serum albumin, prealbumin, and leptin significantly improved. No difference was seen in leptin, prealbumin, and TNF-α between patients with mild/moderate and severe exacerbation, or between patients who required or did not require mechanical ventilation. Change in leptin correlated with body mass index and change in ESR; no associations were observed between leptin, prealbumin, and TNF-α with other clinico-laboratory variables.

CONCLUSION

Plasma levels of novel inflammatory and nutritional biomarkers, i.e., leptin, TNF-α, and prealbumin are altered in AECOPD episodes and lag behind other parameters during recovery. These biomarkers are not reliable predictors of clinical outcomes in these patients.

An Interventional Quality Improvement Study to Assess the Compliance to Cardiopulmonary Resuscitation Documentation in an Indian Teaching Hospital

Background

Cardiopulmonary resuscitation (CPR) should be performed as per the international guidelines; however, compliance to these guidelines is difficult to assess. This study was conducted to determine the compliance to American Heart Association (2010) guideline on CPR documentation by among resident physicians before and after resident training (two arms).

Methods

This pre-postinterventional quality improvement study was conducted in a referral center, North India. Data of hospitalized in-hospital CPR patients were collected in the form of quality indicators (checklists) as defined by the guideline and compared between two arms of before-after resident training. Residents were given appropriate training in CPR technique as per the guideline. The compliance of CPR documentation was assessed pre- and post-intervention.

Results

The baseline arm compliance of various components of CPR documentation was low. The postintervention arm compliances of all components significantly increased (baseline, 2.5% to postintervention, 15.11%, P = 0.03). Individual components assessed were documentation of assessment of responsiveness (65% to 77.9%, P = 0.19), assessment of breathing (37.5% to 58.1%, P = 0.03), assessment of carotid pulse (62.5% to 79%, P = 0.05), rate of chest compressions (20% to 39.5%, P = 0.04), airway management (62.5% to 82.5%, P = 0.02), and compressions to breaths ratio (12.5% to 31.4%, P = 0.02). Documentation of chest compression rate compared to nondocumentation (12 of 42 vs. 11 of 84, P = 0.04) was independently associated with a higher rate of return of spontaneous circulation. The study however did not show any survival benefits.

Conclusions

This study establishes that the compliance to CPR documentation is poor as assessed by CPR documentation content and quality, which improves after physician training, but not up to the mark level (100%) that may be due to busy Indian hospital settings and human behavioral factors. Due to ethical constraints of live CPR assessment, this document checklist approach may be considered as an internal quality assessment method for CPR compliance. Furthermore, correct instruction in CPR technique along with proper documentation of the procedure is required, followed up with periodic re-education during the residency period and beyond.

Serum Cortisol Level in Indian Patients with Severe Sepsis/Septic Shock

Background:

The relationship between cortisol level and sepsis is not known in Indian patients of severe sepsis/septic shock.

Aims:

The study was done to determine the optimal range of cortisol levels, defining the adrenocortical response, and predicting the mortality, if possible, in the above type of patients.

Settings and Designs:

The study was a single-centered prospective cohort study, conducted in a tertiary referral center, North India.

Materials and Methods:

Sixty patients with severe sepsis (n = 30) and septic shock (n = 30) were recruited. Basal and postcosyntropin (1 μg)-stimulated cortisol levels were measured, and all patients were closely monitored with daily assessments of clinical and laboratory variables. Western diagnostic criteria were followed for defining adrenal insufficiency (AI). The end point was the survival assessed at day 28 or death, whichever came earlier.

Results:

The mean basal (T0) and poststimulation (T30) cortisol levels were 31.77 ± 15.9 μg/dL and 37.58 ± 17.31 μg/dL, respectively. In all sepsis patients, 48.33% qualified as AI at T0 ≤ 24 μg/dL, 61.67% at delta cortisol (Δ = T30-T0) ≤7 μg/dL, and 78.33% at Δ ≤9 μg/dL. Using receiver operating characteristic curve, the area under the curve (AUC) was 0.4954, signifying poor prediction to death.

Conclusions:

Indians have completely different characteristics of cortisol levels in sepsis patients, in comparison to the Western data. They have higher range of basal cortisol levels, higher percentage of AI, and an inability to predict mortality with the cortisol levels. Hence, there is requirement of an international study to confirm the dichotomy of the results.