Complementary feeding at 4 versus 6 months of age for preterm infants born at less than 34 weeks of gestation: a randomised, open-label, multicentre trial

BACKGROUND

Evidence on the optimal time to initiation of complementary feeding in preterm infants is scarce. We examined the effect of initiation of complementary feeding at 4 months versus 6 months of corrected age on weight for age at 12 months corrected age in preterm infants less than 34 weeks of gestation.

METHODS

In this open-label, randomised trial, we enrolled infants born at less than 34 weeks of gestation with no major malformation from three public health facilities in India. Eligible infants were tracked from birth and randomly assigned (1:1) at 4 months corrected age to receive complementary feeding at 4 months corrected age (4 month group), or continuation of milk feeding and initiation of complementary feeding at 6 months corrected age (6 month group), using computer generated randomisation schedule of variable block size, stratified by gestation (30 weeks or less, and 31-33 weeks). Iron supplementation was provided as standard. Participants and the implementation team could not be masked to group assignment, but outcome assessors were masked. Primary outcome was weight for age Z-score at 12 months corrected age (WAZ12) based on WHO Multicentre Growth Reference Study growth standards. Analyses were by intention to treat. The trial is registered with Clinical Trials Registry of India, number CTRI/2012/11/003149.

FINDINGS

Between March 20, 2013, and April 24, 2015, 403 infants were randomly assigned: 206 to receive complementary feeding from 4 months and 197 to receive complementary feeding from 6 months. 22 infants in the 4 month group (four deaths, two withdrawals, 16 lost to follow-up) and eight infants in the 6 month group (two deaths, six lost to follow-up) were excluded from analysis of primary outcome. There was no difference in WAZ12 between two groups: -1·6 (SD 1·2) in the 4 month group versus -1·6 (SD 1·3) in the 6 month group (mean difference 0·005, 95% CI -0·24 to 0·25; p=0·965). There were more hospital admissions in the 4 month group compared with the 6 month group: 2·5 episodes per 100 infant-months in the 4 month group versus 1·4 episodes per 100 infant-months in the 6 month group (incidence rate ratio 1·8, 95% CI 1·0-3·1, p=0·03). 34 (18%) of 188 infants in the 4 month group required hospital admission, compared with 18 (9%) of 192 infants in the 6 month group.

INTERPRETATION

Although there was no evidence of effect for the primary endpoint of WAZ12, the higher rate of hospital admission in the 4 month group suggests a recommendation to initiate complementary feeding at 6 months over 4 months of corrected age in infants less than 34 weeks of gestation.

FUNDING

Indian Council of Medical Research supported the study until Nov 14, 2015. Subsequently, Shuchita Gupta's salary was supported for 2 months by an institute fellowship from All India Institute Of Medical Sciences, and a grant by Wellcome Trust thereafter.

Serum Vitamin B12 Levels in Type 2 Diabetes Patients on Metformin Compared to those Never on Metformin: A Cross-sectional Study

CONTEXT

There are limited data about the effect of metformin use on serum Vitamin B12 levels in type 2 diabetes patients from India.

AIMS

We studied serum Vitamin B12 levels in patients with type 2 diabetes mellitus who were receiving metformin and compared them to those never treated with metformin.

SUBJECTS AND METHODS

A total of 183 patients ("metformin" group 121, "no metformin" group 63) of type 2 diabetes from the endocrinology clinic of a tertiary care center in North India were studied. Serum Vitamin B12 levels were measured in all patients. Diabetic neuropathy symptom score (DNS) and diabetic neuropathy examination score (DNE) were used to assess peripheral neuropathy while hemoglobin and mean corpuscular volume (MCV) were used to assess anemia.

RESULTS

The serum Vitamin B12 levels were 267.7 ± 194.4 pmol/l in metformin group and 275.1 ± 197.2 pmol/l in the no metformin group (P = 0.78). When adjusted for duration of diabetes, metformin use was associated with a 87.7 ± 37.7 pmol/l (95% confidence interval [CI], -162.1--3.3, P = 0.02) lower serum Vitamin B12 levels. No significant increase in the prevalence of neuropathy (DNS and DNE scores), anemia, or MCV was found in the Vitamin B12 deficient patients (levels <150 pmol/l) as compared to patients with normal Vitamin B12. However, serum Vitamin B12 levels for the entire cohort were higher by 12.2 ± 3.0 pmol/l (95% CI 6.4-18.0, P < 0.001) for every 1 year increase in the duration of diabetes.

CONCLUSIONS

Metformin use was associated with a lower serum Vitamin B12 levels when adjusted for duration of diabetes. Increasing duration of diabetes was associated with higher serum Vitamin B12 levels.

Pubertal Onset in Apparently Healthy Indian Boys and Impact of Obesity

OBJECTIVE

Primary - to determine the age of pubertal onset in Indian boys. Secondary - (a) to assess the impact of obesity on pubertal timing, (b) to assess the relationship between gonadotropins and puberty.

DESIGN

Cross-sectional.

SETTING

General community-seven schools across New Delhi.

PARTICIPANTS

Random sample of 1306 school boys, aged 6-17 years.

MATERIALS AND METHODS

Anthropometric measurement for weight and height and pubertal staging was performed for all subjects. Body mass index (BMI) was calculated to define overweight/obesity. Serum luteinizing hormone (LH), follicle stimulating hormone, and serum testosterone were measured in every sixth subject.

MAIN OUTCOME MEASURE

Age at pubertal onset-testicular volume ≥4 mL (gonadarche) and pubic hair Stage II.

RESULTS

Median age of attaining gonadarche and pubarche was 10.41 years (95% confidence interval [CI]: 10.2-10.6 years) and 13.60 (95% CI: 13.3-14.0 years), respectively. No significant difference in the age of attainment of gonadarche was observed in boys with normal or raised BMI, though pubarche occurred 8 months earlier in the latter group. Serum gonadotropins and testosterone increased with increasing stages of puberty but were unaffected by BMI. Serum LH level of 1.02 mIU/mL and testosterone level of >0.14 ng/mL showed the best prediction for pubertal onset.

CONCLUSION

The study establishes a secular trend of the age of onset of puberty in Indian boys. Pubarche occurred earlier in overweight/obese boys. The cutoff levels of serum LH and testosterone for prediction of pubertal onset have been established.

Accuracy of computed tomographic features in differentiating intestinal tuberculosis from Crohn's disease: a systematic review with meta-analysis

Abdominal computed tomography (CT) can noninvasively image the entire gastrointestinal tract and assess extraintestinal features that are important in differentiating Crohn's disease (CD) and intestinal tuberculosis (ITB). The present meta-analysis pooled the results of all studies on the role of CT abdomen in differentiating between CD and ITB. We searched PubMed and Embase for all publications in English that analyzed the features differentiating between CD and ITB on abdominal CT. The features included comb sign, necrotic lymph nodes, asymmetric bowel wall thickening, skip lesions, fibrofatty proliferation, mural stratification, ileocaecal area, long segment, and left colonic involvements. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio (DOR) were calculated for all the features. Symmetric receiver operating characteristic curve was plotted for features present in >3 studies. Heterogeneity and publication bias was assessed and sensitivity analysis was performed by excluding studies that compared features on conventional abdominal CT instead of CT enterography (CTE). We included 6 studies (4 CTE, 1 conventional abdominal CT, and 1 CTE+conventional abdominal CT) involving 417 and 195 patients with CD and ITB, respectively. Necrotic lymph nodes had the highest diagnostic accuracy (sensitivity, 23%; specificity, 100%; DOR, 30.2) for ITB diagnosis, and comb sign (sensitivity, 82%; specificity, 81%; DOR, 21.5) followed by skip lesions (sensitivity, 86%; specificity, 74%; DOR, 16.5) had the highest diagnostic accuracy for CD diagnosis. On sensitivity analysis, the diagnostic accuracy of other features excluding asymmetric bowel wall thickening remained similar. Necrotic lymph nodes and comb sign on abdominal CT had the best diagnostic accuracy in differentiating CD and ITB.

Prevalence of metabolic syndrome and cardiovascular changes in patients with chronic plaque psoriasis and their correlation with disease severity: A hospital-based cross-sectional study

BACKGROUND

Previous epidemiological studies suggest an association between psoriasis and metabolic syndrome and risk of subclinical atherosclerosis. However, there is a paucity of data in the Indian population on these associations.

OBJECTIVES

To evaluate the prevalence of metabolic syndrome and subclinical atherosclerosis in patients with chronic plaque psoriasis compared to healthy controls and to correlate the prevalence of metabolic syndrome with severity of psoriasis.

METHODS

A hospital-based cross-sectional study was performed on 140 patients with chronic plaque psoriasis and 140 controls. Psoriasis was categorized as mild, moderate and severe based on psoriasis area and severity index (<10, 10-14 and ≥15, respectively) and as disease of short (<1 year), intermediate (1-3 years) and long duration (>3 years). In all patients and controls, body mass index was calculated, blood pressure and waist circumference were measured and fasting bloaod sugar and lipid profile were estimated. Metabolic syndrome was diagnosed by the presence of 3 or more of the modified National Cholesterol Education Program's Adult Treatment Panel III criteria. A subset of 30 psoriatic patients and 30 healthy controls were selected by the systematic sampling method for cardiac evaluation including electrocardiography, echocardiography and carotid intima-media thickness measurement.

RESULTS

The prevalence of metabolic syndrome was significantly more in psoriatic patients than in controls (39.3% vs. 17.1%, odds ratio = 3.13). Psoriatic patients also had a significantly higher prevalence of hypertension, abdominal obesity and diabetes. There was a significant trend to increase in prevalence of metabolic syndrome, hypertension and type 2 diabetes with increased severity and longer duration of the psoriasis. Patients with psoriasis had significantly higher carotid intima-media thickness (mean 0.61 mm ± 0.01 mm vs. 0.37 mm ± 0.01 mm) than controls.

LIMITATION

This was a hospital-based cross-sectional study with a relatively small sample size. A prospective study with a larger sample would have validated the results further.

CONCLUSION

There is a significantly higher prevalence of metabolic syndrome in psoriasis patients as compared to controls; the prevalence of metabolic syndrome and its components increases with severity and duration of psoriasis. There is a higher prevalence of subclinical atherosclerosis in patients with psoriasis thus increasing the risk of cardiovascular disease. We suggest that patients with moderate to severe psoriasis be screened routinely for metabolic syndrome and cardiovascular disease and encouraged to correct modifiable cardiovascular risk factors.

Vitamin D-binding protein, vitamin D status and serum bioavailable 25(OH)D of young Asian Indian males working in outdoor and indoor environments

Urban Asian Indians generally have low serum 25(OH)D. Information on serum bioavailable 25(OH)D and the effect of prolonged sun-exposure in them is not known. We assessed serum 25(OH)D and bioavailable 25(OH)D in males with varying durations of sun-exposure in Delhi during August-September. Serum 25(OH)D, vitamin D-binding protein (DBP), bioavailable 25(OH)D, free 25(OH)D index, iPTH, ionized calcium and sun-index were assessed in outdoor, mixed outdoor-indoor and indoor workers (n = 88, 32 and 74, respectively). The mean sun-index (12.0 ± 6.25, 4.3 ± 2.20 and 0.7 ± 0.62, respectively; P < 0.001) was highest outdoors and lowest indoors. Serum 25(OH)D (29.0 ± 8.61, 19.1 ± 5.73 and 10.9 ± 4.19 ng/ml, respectively; P < 0.001), bioavailable 25(OH)D and free 25(OH)D index were maximum in outdoor workers followed by mixed-exposure and indoor workers. Their mean serum DBP levels (241.2 ± 88.77, 239.3 ± 83.40 and 216.6 ± 63.93 µg/ml, respectively; P = 0.12) were comparable. Mean serum iPTH was significantly lower in outdoor than indoor workers and showed inverse correlations with serum 25(OH)D, bioavailable 25(OH)D and free 25(OH)D index (r = -0.401, -0.269 and -0.236, respectively; P < 0.001 in all). Daily dietary-calorie intake was higher and calcium lower in outdoor than indoor workers. On regression analysis, sun-exposure was the only significant variable, increasing serum 25(OH)D by 2.03 ng/ml per hour of sun-exposure (95 % confidence interval 1.77-2.28; P < 0.001). Outdoor workers with prolonged sun-exposure were vitamin D-sufficient, with higher serum bioavailable 25(OH)D than the indoor workers during summer. Use of serum DBP levels did not affect the interpretation of their vitamin D status.

Coagulase-negative staphylococci causing blood stream infection at an Indian tertiary care hospital: Prevalence, antimicrobial resistance and molecular characterisation

INTRODUCTION

Recent years have seen a rise of coagulase-negative staphylococci (CoNS) from common contaminants to agents of nosocomial blood stream infections (BSI's). Molecular typing and establishing a correlation with antibiotic resistance is essential particularly in countries like India where genotyping studies for drug-resistant CoNS are sparse.

METHODS

A prospective study was done over 18 months, wherein 42,693 blood samples were received, and 59 patients with BSI due to CoNS were evaluated. The isolates recovered were identified by a biochemical test panel and matrix-assisted laser desorption ionization - time of flight mass spectrometry followed by antimicrobial susceptibility testing by Kirby-Baur disc diffusion method and E-test strips. Staphylococcal chromosomal cassette mec (SCCmec) element was characterised by multiplex polymerase chain reaction for all methicillin-resistant (MR) isolates.

RESULTS

The majority of CoNS isolated were constituted by Staphylococcus haemolyticus (47.5%) followed by Staphylococcus epidermidis (33.9%), Staphylococcus hominis (11.86%), Staphylococcus cohnii (5.08%) and Staphylococcus warneri (1.69%). Among all isolates 57.6% were MR with statistically significant higher resistance versus methicillin sensitive-CoNS. This difference was significant for erythromycin (76% vs. 44%, P = 0.011), rifampicin (50% vs. 12%,P= 0.002) and amikacin (26.5% vs. 4%, P = 0.023), ciprofloxacin (64.7% vs. 20%, P = 0.001) and cotrimoxazole (55.9% vs. 20%, P = 0.006). SCCmec type I was predominant (61.8%, P = 0.028) and exhibited multidrug resistance (76.2%). Coexistence of SCCmec type I and III was seen in 8.82% MR isolates.

CONCLUSION

CoNS exhibit high antimicrobial resistance thereby limiting treatment options. The presence of new variants of SCCmec type in hospital-acquired CoNS may predict the antibiotic resistance pattern. This is the first evaluation of the molecular epidemiology of CoNS causing BSI from India and can serve as a guide in the formulation of hospital infection control and treatment guidelines.

Development and validation of visceral fat quantification as a surrogate marker for differentiation of Crohn's disease and intestinal tuberculosis

BACKGROUND AND AIM

Crohn's disease (CD) and intestinal tuberculosis (ITB) have close phenotypic resemblance. Mesenteric fat (a component of visceral fat [VF]) hypertrophy and fat wrapping, which is visible radiologically as fibrofatty proliferation, is seen more commonly in CD than in ITB.

AIM

The present study was conducted to study the role of VF in differentiating CD and ITB.

METHODS

Visceral fat area and subcutaneous (SC) fat area were measured on computed tomography in two cohorts (development and validation). VF/SC ratio was also calculated for all patients. In the development cohort, retrospective data collection was carried out for 75 patients with CD and ITB who were on follow-up from January 2012 to November 2014. In the validation cohort, 82 patients were recruited prospectively from December 2014 to December 2015 and were diagnosed as CD or ITB according to standard diagnostic criteria.

RESULTS

Visceral fat area and VF/SC ratio were significantly higher in CD patients (n = 42: development, n = 46: validation) than in ITB patients (n = 33: development, n = 36: validation) in both the development (106.2 ± 63.5 vs 37.3 ± 22, P = <0.001; 1.1 ± 0.57 vs 0.43 ± 0.24, P = <0.001) and validation cohorts (102.2 ± 69.8 vs 55.8 ± 44.9, P = 0.01; 1.2 ± 0.68 vs 0.56 ± 0.33, P = <0.001). A cut-off of 0.63 for VF/SC ratio in the development cohort had a high sensitivity (82%) and specificity (81%) in differentiating CD and ITB. Similar sensitivity (81%) and specificity (78%) were seen when this cut-off was applied in the validation cohort.

CONCLUSION

The VF/SC ratio is a simple, cost-effective, non-invasive and single objective parameter with a good sensitivity and specificity to differentiate CD and ITB.

Prevalence and distribution of Chlamydia trachomatis genovars in Indian infertile patients: a pilot study

To determine the prevalence and distribution of Chlamydia trachomatis genovars in patients with infertility by PCR-RFLP and ompA gene sequencing. Prevalence of other etiological agents (viz., Ureaplasma spp. and Mycoplasma hominis) were also assessed. Endocervical swabs were collected from 477 women and urine was collected from 151 men attending the Infertility Clinic. The samples were screened for C. trachomatis by cryptic plasmid, ompA gene and nested ompA gene PCR. Genotyping was performed by PCR-RFLP and sequencing. Samples were screened for Ureaplasma spp. and M. hominis. The prevalence of C. trachomatis in infertile women and their male partners were 15.7% (75 of 477) and 10.0% (15 of 151) respectively. Secondary infertility was significantly associated with chlamydial infection. Genovar E was the most prevalent followed by genovar D and F. Twenty-four C. trachomatis strains were selected for ompA gene sequencing. No mixed infection was picked. Variability in ompA sequences was seen in 50.0%. Both PCR-RFLP and ompA gene sequencing showed concordant results. High prevalence of C. trachomatis in infertile couples warrants routine screening for C. trachomatis infection in all infertile couples. Genotyping of the ompA gene of C. trachomatis may be a valuable tool in understanding the natural history of C. trachomatis infection.

Comparison of TST and IGRA in Diagnosis of Latent Tuberculosis Infection in a High TB-Burden Setting

Background

There are currently two tests for diagnosing latent tuberculosis infection (LTBI); TST and IGRA. However, it is still unclear that which one of these tests performs better in high TB-burden settings.

Methods

1511 household contacts of pulmonary TB patients were enrolled to compare the performance of TST and IGRA for LTBI. At baseline all participant underwent testing for IGRA [QuantiFERON-TB® Gold In-tube (QFT-GIT) assay] and TST [2 tuberculin unit (TU), purified protein derivative (PPD), RT23, Staten Serum Institute (SSI), Copenhagen, Denmark]. All the household contacts were followed-up for two years for incident TB cases.

Results

Active TB was diagnosed in 76 household contacts at an incidence rate of 2.14 per 1000 person-years. Both, TST [Hazard Ratio (HR): 1.14, 95% confidence interval (CI): 0.72–1.79, p = 0.57], as well as QFT-GIT assay (HR: 1.66, 95% CI: 0.97–2.84, p = 0.06) results at baseline were not significantly associated with subsequent development of active TB among household contacts of pulmonary TB patients.

Conclusion

Neither TST nor IGRA predicted subsequent development of active TB among household contacts of pulmonary TB patients during follow-up. However, keeping in view the cost, and other logistics, TST remains the most preferred method for LTBI diagnosis in resource-limited, high TB-burden settings.

Primary Definitive Procedure versus Conventional Three-staged Procedure for the Management of Low-type Anorectal Malformation in Females: A Randomized Controlled Trial

Introduction:

Females with Krickenbeck low-type anorectal malformations - vestibular fistula (VF) and perineal fistula (PF) - are managed either by a primary definitive or conventional three-staged approach. Ultimate outcome in these children may be affected by wound dehiscence leading to healing by fibrosis. Most of the literature favors one approach over other based on retrospective analysis of their outcomes. Whether a statistically significant difference in wound dehiscence rates between these approaches exists needed to be seen.

Materials and Methods:

A randomized controlled trial for girls <14 years with VF or PF was done. Random tables were used to randomize 33 children to Group I (primary procedure) and 31 to Group II (three-staged procedure). Statistical analysis was done for significance of difference (P < 0.05) in the primary outcome (wound dehiscence) and secondary outcomes (immediate and early postoperative complications).

Results:

Of the 64 children randomized, 54 (84%) had VF. Both groups were comparable in demography, clinical profile and age at surgery. The incidence of wound dehiscence (39.4% vs. 18.2%; P = 0.04), immediate postoperative complications (51.5% vs. 12.9%; P = 0.001), and early postoperative complications (42.4% vs. 12.9%; P = 0.01) was significantly higher in Group I as compared to Group II. Six of 13 children (46.2%) with dehiscence in Group I required a diverting colostomy to be made.

Conclusions:

Females with VF or PF undergoing primary definitive procedure have a significantly higher incidence of wound dehiscence (P = 0.04), immediate (P = 0.001) and early postoperative complications (P = 0.01).

Vertebral Fractures and Bone Mineral Density in Patients With Idiopathic Hypoparathyroidism on Long-Term Follow-Up

CONTEXT

Bone mineral density (BMD) is increased in idiopathic hypoparathyroidism (IH). Parathyroid hormone (PTH) deficiency, hypocalcemic seizures, and anticonvulsants could compromise skeletal health in IH.

OBJECTIVE

We assessed vertebral fractures (VFs) and related factors in IH and change in BMD during follow-up.

DESIGN

VFs were assessed by morphometry. BMD was assessed by dual-energy X-ray absorptiometery at the lumbar spine, hip, and forearm. Change in BMD was assessed in a subset after a 10-year follow-up.

SETTING

The endocrine clinic of All India Institute of Medical Sciences, New Delhi, India.

SUBJECTS

Included were 104 patients with IH and 64 healthy controls. Hypocalcemia, hyperphosphatemia, normal kidney function, and low serum PTH levels were used to diagnose IH.

RESULTS

VFs were seen in 18.3% of patients with IH and 4.7% of controls (odds ratio, 4.54; 95% confidence interval, 1.28 to 16.04). Use of anticonvulsants and menopause were significantly associated (P < 0.05) with VF. Mean BMD at lumbar spine and hip were higher by 21.4% and 8.6%, respectively, in IH than in controls (P < 0.001), respectively. BMD significantly increased during follow-up at all sites. Change in BMD correlated with maintenance of the serum calcium/phosphorus ratio during follow-up.

CONCLUSIONS

Despite increased BMD, prevalence of vertebral-fractures is greater in patients with IH, especially in postmenopausal women and those on anticonvulsant therapy.

What puts them at risk? A cross-sectional case-control survey of demographic profile and sexual behavior of patients with sexually transmitted infections at a tertiary care center in North India

BACKGROUND

Sexually transmitted infections (STIs) are a major public health problem in developing nations. Identification of risk factors can help in formulating effective strategies against them. The present study was conducted in a tertiary care hospital in North India over 1 year to identify the risk factors associated with STIs.

MATERIALS AND METHODS

A questionnaire-based cross-sectional case-control survey was conducted where participants answered questions on demographic details, sexual behavior, and awareness of STIs. Cases were patients with STIs whereas controls were randomly selected from healthy individuals accompanying patients with nonvenereal complaints attending our hospital.

RESULTS

There were 106 cases and 64 controls. STI patients had sexual debut 2 years before controls. A higher proportion of STI cases had lower education, multiple sexual partners, lived separately from their partner, had nonregular partners, had protected sex in the last month, had sex under influence of alcohol/illicit drugs, sex in unstructured settings, and engaged in transactional sex, in comparison to controls (P < 0.05). More cases were aware of the symptoms/preventive measures of STIs (P < 0.001). On multivariate analysis, multiple sexual partners, sex under influence of alcohol/illicit drugs with nonregular partner, protected sex in the last month, and knowledge of preventive measures were found to be statistically associated with STIs (P < 0.05).

CONCLUSIONS

Our study identifies risk-behavior patterns in patients with STIs, which should be modified to reduce the burden of these diseases. Increasing the knowledge about STIs in these patients can translate into more common condom usage that lends support for strengthening sexual health programs at grass-root levels.

LIMITATIONS

The small size of the study population could have led to decreased power of the study to detect differences between cases and controls. The external validity of our results needs to be tested in different population groups involving larger sample sizes.

What puts them at risk? A cross-sectional case-control survey of demographic profile and sexual behavior of patients with sexually transmitted infections at a tertiary care center in North India

BACKGROUND

Sexually transmitted infections (STIs) are a major public health problem in developing nations. Identification of risk factors can help in formulating effective strategies against them. The present study was conducted in a tertiary care hospital in North India over 1 year to identify the risk factors associated with STIs.

MATERIALS AND METHODS

A questionnaire-based cross-sectional case-control survey was conducted where participants answered questions on demographic details, sexual behavior, and awareness of STIs. Cases were patients with STIs whereas controls were randomly selected from healthy individuals accompanying patients with nonvenereal complaints attending our hospital.

RESULTS

There were 106 cases and 64 controls. STI patients had sexual debut 2 years before controls. A higher proportion of STI cases had lower education, multiple sexual partners, lived separately from their partner, had nonregular partners, had protected sex in the last month, had sex under influence of alcohol/illicit drugs, sex in unstructured settings, and engaged in transactional sex, in comparison to controls (P < 0.05). More cases were aware of the symptoms/preventive measures of STIs (P < 0.001). On multivariate analysis, multiple sexual partners, sex under influence of alcohol/illicit drugs with nonregular partner, protected sex in the last month, and knowledge of preventive measures were found to be statistically associated with STIs (P < 0.05).

CONCLUSIONS

Our study identifies risk-behavior patterns in patients with STIs, which should be modified to reduce the burden of these diseases. Increasing the knowledge about STIs in these patients can translate into more common condom usage that lends support for strengthening sexual health programs at grass-root levels.

LIMITATIONS

The small size of the study population could have led to decreased power of the study to detect differences between cases and controls. The external validity of our results needs to be tested in different population groups involving larger sample sizes.

Impact of initial topical medical therapy on short-term quality of life in newly diagnosed patients with primary glaucoma

Purpose:

To evaluate the impact of initial topical medical therapy on newly diagnosed glaucoma patients using the Indian Vision Function Questionnaire (IND-VFQ33).

Patients and Methods:

The IND-VFQ33 was used to evaluate the quality of life (QoL) in 62 newly diagnosed patients with moderate to severe primary glaucoma and 60 healthy controls. IND-VFQ33 is a 33 item QoL assessment tool with three domains: General functioning, psychosocial impact and visual symptoms. The glaucoma patients were started on medical therapy and the QoL assessment was repeated after 3 months.

Results:

Glaucoma patients (mean age: 55.6 ± 9.6 years, range 40–77 years) and controls (mean age: 54.9 ± 6.7 years, 42–73 years) were matched with respect to age (P = 0.72), gender (P = 0.91) and literacy (P = 0.18). Glaucoma patients had significantly worse QoL as compared to controls at baseline across all the three domains (P < 0.001). 3 months after initiation of treatment, the overall QoL life significantly worsened from baseline with a decrease in general functioning (P < 0.001) and psychosocial impact (P = 0.041). Visual acuity in better eye significantly co-related to poor QoL at baseline (P < 0.001) and at 3 months (P = 0.04). In addition, the use of >2 topical medications significantly co-related to poor QoL at 3 months (P = 0.01).

Conclusions:

Evaluation using the IND-VFQ33 revealed that newly diagnosed glaucoma patients have a significant worsening of QoL after initiation of topical ocular hypotensive therapy. This should be an important consideration when educating patients about the disease and its therapy.

Efficacy of micellized vs. fat-soluble vitamin D3 supplementation in healthy school children from Northern India

BACKGROUND

Vitamin D deficiency is a widely recognized public health problem. Efficacy of a recently developed micellized form of vitamin D3 has not been studied. Hence, we undertook this study to compare its efficacy with the conventionally used fat-soluble vitamin D3.

METHODS

In this open-labeled nonrandomized pilot study, we recruited 180 healthy children, aged 13-14 years in two groups and supplemented Group A (60 children) with 60,000 IU of fat-soluble vitamin D3/month with milk and Group B (120 children) with 60,000 IU/month of water miscible vitamin D3 under supervision for 6 months. Serum 25(OD)D, parathyroid hormone (PTH), calcium, phosphate, and alkaline phosphatase (ALP) levels were evaluated before and after supplementation in 156 children (54 in Group A and 102 in Group B) who completed the study.

RESULTS

We observed a significantly greater increase in the serum 25(OH)D levels in group B as compared to group A (31.8±9.1 ng/mL vs. 23.7±10.4 ng/mL; p<0.001). All children in group B achieved adequate levels of serum 25(OH)D (>20 ng/mL) as against 83.3% children in group A. Serum PTH and ALP levels declined considerably in both the groups following supplementation.

CONCLUSIONS

Vitamin D supplementation significantly increased the serum 25(OH)D levels in both groups. Miscible form of vitamin D3 appears to be better in achieving higher levels of serum 25(OH)D than that observed with a similar dose of fat-soluble vitamin D3. Further studies with different dose regimens are required to establish its efficacy over the conventionally used fat-soluble vitamin D3.

Cross-Reactive Potential of HIV-1 Subtype C-Infected Indian Individuals Against Multiple HIV-1 Potential T Cell Epitope Gag Variants

Vaccine immunogen with expanded T cell coverage for protection against HIV-1 diversity is the need of the hour. This study was undertaken to examine the ability of T cells to respond to a broad spectrum of potential T cell epitope (PTE) peptides containing variable as well as conserved sequences that would most accurately reflect immune responses to different circulating strains. Set of 320 PTE peptides were pooled in a matrix format that included 40 pools of 32 peptides per pool. These pools were used in interferon-γ enzyme-linked immunospot assay for screening and confirmation of HIV-1 PTE Gag-specific T cell immune responses in 34 HIV-1 seropositive Indian individuals. "Deconvolute This" software was used for result analysis. The dominant target in terms of magnitude and breadth of responses was observed to be the p24 subunit of Gag protein. Of the 34 study subjects, 26 (77%) showed a response to p24 PTE Gag peptides, 17 (50%) to p17, and 17 (50%) responded to p15 PTE peptides. The total breadth and magnitude of immune response ranged from 0.75 to 14.50 and 95.02 to 1,103 spot-forming cells/10⁶ cells, respectively. Seventy-six peptides located in p24 Gag were targeted by 77% of the study subjects followed by 51 peptides in p17 Gag and 46 peptides in p15 Gag with multiple variants being recognized. Maximum study participants recognized PTE peptide sequence Gag_271→285NKIVRMYSPVSILDI located in p24 Gag subunit. T cells from HIV-1-infected individuals can recognize multiple PTE peptide variants, although the magnitude of the responses can vary greatly across these variants.

Patients with mild enteropathy have apoptotic injury of enterocytes similar to that in advanced enteropathy in celiac disease

BACKGROUND

Severity of villous atrophy in celiac disease (CeD) is the cumulative effect of enterocyte loss and cell regeneration. Gluten-free diet has been shown to benefit even in patients having a positive anti-tissue transglutaminase (tTG) antibody titre and mild enteropathy.

AIM

We explored the balance between mucosal apoptotic enterocyte loss and cell regeneration in mild and advanced enteropathies.

METHODS

Duodenal biopsies from patients with mild enteropathy (Marsh grade 0 and 1) (n=26), advanced enteropathy (Marsh grade ≥2) (n=41) and control biopsies (n=12) were subjected to immunohistochemical staining for end-apoptotic markers (M30, H2AX); markers of cell death (perforin, annexin V); and cell proliferation (Ki67). Composite H-scores based on the intensity and distribution of markers were compared.

RESULTS

End-apoptotic markers and marker of cell death (perforin) were significantly up-regulated in both mild and advanced enteropathies, in comparison to controls; without any difference between mild and advanced enteropathies. Ki67 labelling index was significantly higher in crypts of mild enteropathy, in comparison to controls, suggesting maintained regenerative activity in the former.

CONCLUSIONS

Even in patients with mild enteropathy, the rate of apoptosis is similar to those with advanced enteropathy. These findings suggest the necessity of reviewing the existing practice of not treating patients with mild enteropathy.

Clinical Spectrum, Treatment and Relapse Patterns in 353 Patients with Squamous Cell Carcinoma of the Alveobuccal Complex Treated with a Curative Intent: A Retrospective Study

Aims and Objectives

Oral cancer is one of the most common cancers in Indian subcontinent with alveobuccal complex as most common cancer sub site. Cancers of Alveobuccal complex provides maximum challenge and management guidelines are not clear. The aim of the present study is to provide comprehensive demographic, clinical and treatment outcome data of alveobuccal squamous cell carcinoma (SCC) patients treated at a tertiary care cancer center in North India.

Materials and Methods

An analysis of prospectively maintained database in department of surgical oncology at Dr BRA-IRCH, AIIMS, Delhi, India was performed. All alveobuccal cancer patients who had undergone surgery from 1995 to 2010 were included for analysis.

Results

A total of 353 patients were included for analysis. Mean age was 49.75 years (SD ±12.04) with male and female ratio of 4:1. Composite resection without mandible was done in 25 % patients and 75 % underwent mandibular resection. Neck dissection was performed in 347 patients. Nodal deposits were identified in 124 (35.73 %) neck dissection specimens. Margin negative resection was performed in 89.5 % cases. After a median follow up of 30 months, 87 (24.64 %) patients developed disease relapse and 25 (7.08 %) patients developed second primaries. Overall 5-year disease free survival (DFS) was 57.65 % and 5 year overall survival (OS) was 59.86 %.

Conclusion

Among Indian oral cancer patients alveobuccal complex is most common sub site. Majority presents in locally advanced stage and reasonably good outcomes can be achieved with quality control surgery and judicious use of radiotherapy.

Factors determining outcomes in grown up patients operated for congenital heart diseases

Background:

The number of grown ups with congenital heart diseases (GUCHs) is steadily increasing.

Aims:

To analyze factors predicting early cardiac morbidity following cardiac surgery in GUCH at a tertiary care center.

Setting and Design:

Retrospective study at a multispeciality tertiary referral center.

Methods:

Between January 2004 and December 2014, 1432 patients ≥13 years of age (acyanotic defects: 843, cyanotic defects: 589) underwent surgery for congenital heart defects. Factors associated with early cardiac morbidity were analyzed.

Statistical Analysis:

Univariable and multivariable analysis of all factors affecting outcomes.

Results:

On multivariate analysis, previous sternotomy, aortic cross-clamp time >45 min, cyanosis, and emergency procedure were independent predictors of early morbidity with respective odds ratios (ORs) of 12.4, 3.6, 2.6, and 8.1. For more precise estimation, a risk score was generated. Taking the log odds with each of these four as respective weights, a score was generated. The variables were previous sternotomy (2.5), aortic cross-clamp >45 min (1.3), emergency procedure (2.1), and cyanosis (0.9), if the respective condition is present, zero otherwise. The score ranged from 0 to 4.5. The average value of the score based on the four variables was significantly higher in cases with morbidity (1.85 ± 1.17) vs. (0.75 ± 0.88), P < 0.001. Distribution of scores was significantly different between patients with and without morbidity. Sixty-seven percent patients without any morbidity had score <1 compared to 24.6% with morbidity. Only 0.9% patients without morbidity had score of ≥3 compared to 16.4% patients with morbidity. Compared with patients having score <1, patients with scores 1-2 had OR of 3.4, 2-3 had OR of 6.0, and >3 had OR of 48.7.

Conclusion:

GUCH can be safely operated when adequate caution is taken in the presence of independent predictors such as previous sternotomy, aortic clamp time >45 min, cyanosis, and emergency procedure.