Evidence of a Hardening in the Cosmic Ray Proton Spectrum at around 166 TeV Observed by the GRAPES-3 Experiment

We present the measurement of the cosmic ray proton spectrum from 50 TeV to 1.3 PeV using 7.81×10^{6} extensive air shower events recorded by the ground-based GRAPES-3 experiment between 1 January 2014 and 26 October 2015 with a live time of 460 day. Our measurements provide an overlap with direct observations by satellite and balloon-based experiments. The electromagnetic and muon components in the shower were measured by a dense array of plastic scintillator detectors and a tracking muon telescope, respectively. The relative composition of the proton primary from the air shower data containing all primary particles was extracted using the multiplicity distribution of muons which is a sensitive observable for mass composition. The observed proton spectrum suggests a spectral hardening at ∼166  TeV and disfavors a single power law description of the spectrum up to the Knee energy (∼3  PeV).

Significant enhancement in the cold emission characteristics of chemically synthesized super-hydrophobic zinc oxide rods by nickel doping

The current article presents a huge enhancement in the field emission characteristics of zinc oxide (ZnO) micro/nanorods by nickel doping. The synthesis of pure and nickel-doped zinc oxide (ZnO) micro/nanorods was done by a simple low-temperature chemical method. Both the as-prepared pure and doped samples were analyzed by X-ray diffraction and electron microscopy to confirm the proper phase formation and the developed microstructure. UV-vis transmittance spectra helped in determining the band gap of the samples. Fourier-Transform Infrared Spectroscopy (FTIR) spectra showed the different bonds present in the sample, whereas X-ray Photoelectron Spectroscopy (XPS) confirmed the presence of nickel in the doped sample. Photoluminescence (PL) spectra showed that after doping, the band-to-band transition was affected, whereas defect-induced transition had increased significantly. After the nickel doping, contact angle measurement revealed a significant decrease in the sample's surface energy, leading to a remarkably high water contact angle (within the superhydrophobic region). Simulation through ANSYS suggested that the doped sample has the potential to function as an efficient cold emitter, which was also verified experimentally. The cold emission characteristics of the doped sample showed a significant improvement, with the turn-on field (corresponding to J = 1 μA cm-2) reduced from 5.34 to 2.84 V μm-1. The enhancement factor for the doped sample reached 3426, approximately 1.5 times higher compared to pure ZnO. Efforts have been made to explain the results, given the favorable band bending as well as the increased number of effective emission sites.

Assessing Awareness and Palliative Care Needs in Rural Haryana, North India: A Community-Based Study

Background Community-based palliative care offers a solution to ensure continuity of treatment for patients with life illnesses or life-threatening conditions. Hence, to advocate for community-based palliative care services, it is imperative to generate evidence for palliative care needs in the community. This study aimed to assess the need for and awareness of palliative care in rural Haryana, North India. Methods This was a community-based cross-sectional study conducted in six villages of Haryana. A trained investigator conducted house-to-house visits to screen the population for those who require palliative care. The screening was done using three questions, i.e., (1) the presence of a bedridden patient, (2) a person in need of help in activities of daily living, or (3) not able to go to work due to any physical chronic illness. If the answer to any of these questions was positive, a list of patients was prepared, and a community physician trained in palliative care contacted them. Patients and their caregivers were evaluated for their awareness of palliative care through the following question: 'Have you heard about the term palliative care/end-of-life care/home care for bedridden people/community-based care/supportive care?'. Data collection was done using Epicollect5 mobile application, and a descriptive analysis was conducted using the R software. Results A total of 1,983 households were visited, and 152 households were excluded as they were found locked during two separate visits. Therefore, a total of 1,831 households, comprising 9,727 individuals, were screened. The need for palliative care was found to be 3.7 per 1,000 population (95% CI: 2.5 - 4.9) and 18.6 per 1000 households (12.4 - 24.8). The most common diseases requiring palliative care were stroke with a focal neurological deficit (27.8%) and cancer (22.2%). One patient with cancer was receiving palliative care. None of the patients or their caregivers was aware of the terms palliative care/end-of-life care/home care for bedridden people/community-based care/supportive care. Conclusion The need for palliative care in rural Haryana (North India) was found to be 3.7 per 1000 population. Neither the patients nor their caregivers had an awareness of palliative care.

Palliative Care Need in India: A Systematic Review and Meta-analysis

Background

To achieve sustainable development goal 3.8, countries must prioritise the provision of palliative care. We aimed to estimate the prevalence of palliative care needs in India.

Methods

A systematic literature search was conducted in databases of PubMed, Cochrane, Embase, Web of Science, and EBSCO Host. We included community-based studies published in English between inception and April 30, 2023. We excluded hospital-based studies that were conducted solely including diseased patients. Data were extracted independently, and a quality assessment was performed. To estimate the pooled prevalence and 95% confidence intervals (CI), we used the random-effects model. Heterogeneity was assessed using the Q statistic and I2 test. Subgroup analyses were conducted based on the study site, urban-rural distribution, gender, and age groups. Publication bias was evaluated using a funnel plot and Egger test. STATA software was used for data analysis.

Results

Out of the 2632 articles identified, 8 cross-sectional studies were included. Using the random-effects model, the pooled estimate of palliative care needs was found to be 6.21/1000 population (95% CI: 2.42-11.64). The southern region showed a prevalence of 10.83/1000 compared to 2.24/1000 in the northern region. Urban areas had a prevalence of 3.34/1000, while rural areas had a prevalence of 7.69/1000. Among females, the prevalence was 9.64/1000, compared to 6.77/1000 among males. Notably, individuals aged over 60 years had a higher prevalence of palliative care needs, with a rate of 37.86/1000 population.

Conclusion

This systematic review and meta-analysis highlight a substantial need for palliative care in India, with a prevalence of 6.21 individuals/1000 population.

Tracking Changes in Global Longitudinal Strain in Lung Cancer Patients Receiving Thoracic Radiation

PURPOSE/OBJECTIVE(S)

Thoracic radiation improves survival in many lung cancer patients. However, radiation-induced cardiotoxicity is a major source of morbidity and mortality in such patients. Global longitudinal strain (GLS), a novel echocardiography (ECHO) method of assessing left ventricular function, has been shown to predict long-term adverse cardiovascular risk in diverse patient populations. We hypothesized that receipt of thoracic radiation is associated with GLS changes in lung cancer patients.

MATERIALS/METHODS

We retrospectively identified patients with lung cancer treated at our institution between 2005-2020 who had ECHOs performed both before and after RT, and in whom GLS was extractable. ECHO Board-Certified cardio-oncologists measured GLS and left ventricular ejection fraction (LVEF) from these ECHOs.

RESULTS

A total of 40 patients met inclusion criteria. Median time to ECHO was 78 days prior and 172 days after RT. Two chamber (2C), 3C, 4C, and average GLS were significantly decreased after RT on paired t-test [mean difference (SD) 2.23 (3.29), 2.99 (2.78), 2.25 (3.63), 2.51 (2.66) respectively, all p < 0.001]. Thirteen patients (32.5%) had abnormal GLS (<18%) prior to RT. 5 of those 13 patients (38.5%) had abnormal LVEF (< 50%). 27/40 patients (67.5%) had an abnormal GLS or clinically significant (≥15%) drop in GLS after RT. This difference (32.5% patients pre-RT vs 67.5% post-RT) was statistically significant (p < 0.01). Among patients (n = 27) who had normal LVEF before RT, 1 patient (3.7%) developed abnormal LVEF (<50%) after RT. Backwards logistic regression showed significant interaction between heart volume receiving 5 Gray and change in GLS.

CONCLUSION

This cohort exhibited a significant decrease in 2C, 3C, 4C, and average GLS after RT. ∼1/3 of patients had abnormal GLS at baseline (suggesting a high-risk group for cardiac complications) and 67.5% of patients had clinically significant decrease in GLS after RT. Among the patients with normal GLS before RT, although 51.9% of patients demonstrated a clinically significant drop in GLS after RT, only 3.7% of patients developed abnormal LVEF, suggesting that this is a late occurrence. GLS changes may serve as a valuable tool for early identification of patients who are at high risk for future cardiac complications after receiving thoracic radiation.

Hypertension-related distress and its associated factors: findings from an urban primary health centre of South Delhi, India

Background

Living with hypertension (HTN) has been found to cause distress, which adversely affects one's self-care and may lead to elevated blood pressure. There is a paucity of data regarding the prevalence of HTN-related distress. This study was conducted to estimate the prevalence of HTN-related distress among adults with HTN attending an outpatient department in an urban primary health centre and to determine the factors associated with distress.

Methods

This was a cross-sectional study conducted at the outpatient department of an urban primary health centre in Delhi, India. The enrolled participants were administered a questionnaire, which included a Distress Scale for patients with diabetes mellitus and/or hypertension (DSDH17 M) (to assess for HTN-related distress) and Health-Related Quality of Life, Healthy Days Measure. A descriptive analysis was performed. Factors associated with HTN-related distress were tested using logistic regression.

Results

One hundred forty-one participants were enrolled in this study. Most were women (73.76%) with a mean age of 60.15 years (standard deviation [SD]: 0.78). The prevalence of HTN-related distress (average DSDH17 M score ≥3) was 14% (95% confidence interval [CI]: 9.30-21.03). Patients with HTN-related distress had significantly poor health and reported a greater number of days where they were physically or mentally unhealthy. Patients with uncontrolled blood pressure had six times the odds (95% CI: 1.69-21.77, P value = 0.006) of HTN-related distress compared to those with controlled blood pressure.

Conclusions

Hypertension-related distress was present in 14% of adults with HTN. Patients with uncontrolled blood pressure had six times the odds of HTN-related distress.

Options of Funding and Ethical Clearance for Medical Researchers in India

Research forms an integral part of present world development and interest. It is the primary source of speculation and outcome-based decision making. Medical research work proves to be a big challenge in low- and middle-income countries due to the constraint of resources and capacity building. The disparities in the distribution of resources, inadequate policy implementation, and lack of prioritization of research make the research challenging. There has been an increase in medical research in India but it is not adequate when compared to other countries or areas. Medical researchers face multiple issues, mainly funding and ethical approval and are stunted by the unacceptance in high-indexed journals. In this paper, we have compiled the options for funding and ethical options and ways available for researchers in India. This will help and encourage researchers pro-actively by providing some guidance on the issues related to finance and ethics required for conducting scientific research.

Monitoring of Non-communicable Diseases in a Primary Healthcare Setting in India: A Quality Improvement Initiative

Background The majority of patients with non-communicable diseases (NCDs) seek care in a primary healthcare setting. There is a lack of effective monitoring of patients with NCD, which leads to poor disease control and an increase in morbidity and mortality. We wanted to explore the feasibility of maintaining patient health record and utilising it for disease monitoring in a primary healthcare setting. Therefore, we aimed to increase the availability of patient health records from 0% to 100% using the principles of quality improvement (QI) among patients with hypertension and/or diabetes within six weeks and to use these records for assessing the disease control status of patients through cohort monitoring approach. Methods This QI initiative was conducted at an urban health centre (UHC) located at Dakshinpuri, New Delhi. We specifically focused on two major NCDs: diabetes and hypertension. We formed a QI team and identified the gaps using fishbone analysis and a process flow diagram. We used the model for improvement and the Plan-Do-Study-Act (PDSA) framework. We conducted repeated rapid PDSA cycles for the designed intervention and monitored the change every week using a run chart. The data from the patient health record were entered into Microsoft Excel (Microsoft^® Corp., Redmond, WA) using Google Forms (Google, Inc., Mountain View, CA) and Epicollect5 (Oxford Big Data Institute, Oxford, England). We used the cohort monitoring approach of the India Hypertension Control Initiative to assess the quarterly control rate for hypertension and diabetes at the UHC. Results The root cause analysis revealed that the lack of a policy for keeping patient records and the lack of perceived need in the past were the primary reasons behind the absence of NCD health records. In brainstorming sessions with the QI team, we designed a paper-based patient health record system involving unique identity (ID) generation, an index register, an NCD record file and an NCD passbook (Dhirghayu card) for each patient. We reorientated the process of patient flow and devised a mechanism for record-keeping at the UHC. This initiative increased the availability of patient health records from 0% to 100% in the initial three weeks. The system of maintaining patient health records was well received by the patients and was better utilised by treating physicians for NCD management. After the intervention, we were able to use the data from the NCD file to assess the quarterly control rates of the patients with hypertension and/or diabetes. Conclusion Our study showed that patients' health records can be generated and maintained in a primary healthcare setting by using the principles of quality improvement. These records can be utilised for the disease monitoring of patients with hypertension and/or diabetes, which can lead to better disease control. The sustainability of this initiative and the performance of the health facility can be assessed in future studies using annual control rates.

Correction: Monitoring of Non-communicable Diseases in a Primary Healthcare Setting in India: A Quality Improvement Initiative

[This corrects the article DOI: 10.7759/cureus.38132.].

Steps taken to fight the COVID-19 pandemic at the grassroots level of rural India: Experience of a community physician

Coronavirus disease (COVID-19) was first identified in Wuhan, China and then rapidly spread all over the world. The World Health Organization declared a pandemic on March 11, 2020 as a result of COVID-19. As it has caused substantial morbidity and mortality, most countries took several measures to control its spread, including India. As of now, India has witnessed three major waves of COVID-19. Several measures like nationwide lockdown, active case finding, contact tracing, home isolation, and vaccination were taken. There was involvement of multiple sectors (including private and government) and community participation. During the pandemic, I was posted at a primary health centre in a rural setting in India. A rural primary care setting has its own limitations. All the steps taken had several challenges at the grassroots level. Therefore, through this article, I highlighted the challenges faced during the implementation of steps taken to battle the pandemic and the outcome.

Sub-optimal knowledge with positive attitude and belief of frontline health workers toward the use of information technologies: A mixed-method study from rural Haryana, India

BACKGROUND

Information technology (IT) can be used by frontline health workers (FLWs) to connect and deliver care to the community. Various studies in India have assessed the beneficial impact of IT usage by FLWs, but for the long-term sustainability, the attitude and belief toward IT usage have not been adequately studied. We conducted this study to assess the knowledge and attitude and to explore the beliefs of FLWs toward the use of IT in a rural area of Haryana.

MATERIALS AND METHODS

We conducted a mixed-method study (qualitative and quantitative approach) in a rural setting of Haryana, India. We included FLWs of two primary health centers (PHCs). Data were collected from October 19, 2020 to December 31, 2020. We collected data from 75 accredited social health activists (ASHAs), 37 Anganwadi workers (AWWs), 28 multi-purpose workers (MPWs), two information assistants, and two medical officers using a semi-structured interview schedule. Their knowledge about the benefits of IT use, past use of IT applications and devices, and self-rating of knowledge regarding computers or laptops were collected. We used 14 attitude statements, each with a five-point Likert scale to assess the attitude; a total score ≥35 was considered a positive attitude. We conducted eight focus group discussions (FGDs) to explore the beliefs regarding IT usage (four FGDs with ASHAs, two FGDs with AWWs, and two FGDs with MPWs). A descriptive analysis was performed for the quantitative data, and a thematic analysis was performed for qualitative data.

RESULTS

Knowledge about the benefits of IT use was present among 77.8% of FLWs. Among the FLWs, 79.2% self-rated their knowledge of computers/laptops as 'do not have knowledge', 16% self-rated as 'low knowledge', and 4.8% self-rated as 'good knowledge'. The median total score for attitude statements among all the FLWs (n = 144) was 54 [inter-quartile range - 48-59]. Four themes emerged for beliefs toward IT usage, namely, positive beliefs, negative beliefs, challenges anticipated in adopting IT use, and facilitation factors. The positive beliefs were related to improvement in work efficiency and social status, less paperwork, timely report generation, and better learning. The negative beliefs were related to an increase in working hours, close monitoring, and feeling over-burdened.

CONCLUSION

We found that FLWs had knowledge regarding the benefits of IT use, but they lacked knowledge regarding laptop/computer use. They had a satisfactory level of confidence in using smartphones, and most of them were using mobile applications. The majority of the FLWs had a positive attitude and beliefs toward IT use and wanted to use it in the future.

Estimating the Need for Palliative Care in an Urban Resettlement Colony of New Delhi, North India

Objectives:

This study was aimed to estimate the need for palliative care in an urban resettlement colony of Dakshinpuri Extension, New Delhi.

Material and Methods:

This was a community-based cross-sectional study conducted in New Delhi. We trained four multipurpose workers to screen the households during their routine household-to-household visits. The screening for the need for palliative care was done using three questions – that is, (1) presence of a bedridden patient or (2) person in need for help in activities of daily living or (3) not able to go for work due to any physical chronic illness. If the answer to any of the three screening questions was yes for any member in a household, then these households were visited by a community physician trained in palliative care and a medical social service officer to confirm the need for palliative care. Patients were administered a semi-structured questionnaire containing the sociodemographic details and an assessment of disease status and review of health records was done. The patient and his/her caregiver were also assessed for awareness regarding palliative care.

Results:

A total of 2028 households were screened and the need for palliative care was found to be 1.5/1000 population (95% CI: 0.9–2.1). The mean age (SD) of patients who need palliative care was 60 years (SD–12.9). The common diseases which required palliative care were stroke with a focal neurological deficit (45.8%), osteoarthritis with marked dependence (20.8%) and cancer (12.5%). None of the patients was receiving palliative care as patients and their caregivers were not aware of the term palliative care/end of life care/home care for bedridden people/community-based care.

Conclusion:

The need for palliative care in an urban resettlement colony of North India was found to be 1.1/1000 population. Further studies are required to estimate the need for palliative care in North India.

Modeling cell protrusion predicts how myosin II and actin turnover affect adhesion-based signaling

Orchestration of cell migration is essential for development, tissue regeneration, and the immune response. This dynamic process integrates adhesion, signaling, and cytoskeletal subprocesses across spatial and temporal scales. In mesenchymal cells, adhesion complexes bound to extracellular matrix mediate both biochemical signal transduction and physical interaction with the F-actin cytoskeleton. Here, we present a mathematical model that offers insight into both aspects, considering spatiotemporal dynamics of nascent adhesions, active signaling molecules, mechanical clutching, actin treadmilling, and nonmuscle myosin II contractility. At the core of the model is a positive feedback loop, whereby adhesion-based signaling promotes generation of barbed ends at, and protrusion of, the cell's leading edge, which in turn promotes formation and stabilization of nascent adhesions. The model predicts a switch-like transition and optimality of membrane protrusion, determined by the balance of actin polymerization and retrograde flow, with respect to extracellular matrix density. The model, together with new experimental measurements, explains how protrusion can be modulated by mechanical effects (nonmuscle myosin II contractility and adhesive bond stiffness) and F-actin turnover.

Anatomage - the virtual dissection tool and its uses: A narrative review

Advancement in technology has given students and institutes an educational, interactive, and diagnostic aid with virtual reality functionality known as the Anatomage table. This review analyses the various spheres of the medical field where the 3D virtual tool is being used and assesses its acceptability, convenience, and practical application. A search for relevant studies in various databases namely Pubmed, Embase, Wiley Library, and Google Scholar was performed, and the data was compiled to understand the use of the Anatomage table. The search yielded a total of 24 studies that focused on the use of the Anatomage table. Eleven articles focused on using Anatomage as a learning tool and 13 described the perception of the Table. Anatomage table offers an excellent tool for learning anatomy by virtual dissection. The tool is not only used as a teaching aid, but also as a diagnostic and planning tool in residency programs. Adding the tool as an educational aid boosts the existing curriculum and helps to counter the challenges with cadaveric dissection. The equipment cost and its maintenance charges may be a deciding factor for the underutilization of the tool in developing countries.

Epidemio-toxicological profile and reasons for fatal suicidal poisoning: A record-based study in South India

Introduction:

Poisoning is the second frequent cause of suicide in India. To plan an effective intervention and awareness program, it is essential to know the sociodemographic profile, pattern, and reasons for suicide.

Objective:

We conducted this study to find the sociodemographic profile, pattern, and reasons for fatal suicidal poisoning.

Methods:

We conducted a record-based study in a tertiary hospital in Puducherry. We reviewed autopsies conducted between January 2010 and December 2014 for fatal suicidal poisoning. We extracted data using a data collection sheet for age, gender, marital status, occupation, residence, the reason for suicide, time of injury, time of death. We entered data in Microsoft Excel, and we did a descriptive analysis by using R software version.

Results:

We reviewed 3996 medicolegal autopsies, out of which 595 cases were of fatal suicidal poisoning. The mean age of the cases was 35.8 years (SD-14.6). The majority of the cases were married (74.8%) for 20–30 years (31.8%). Most of the victims were agriculture workers (22.2%), lived in a rural setting (84.4%), died during the daytime (61.2%), and in the summer season (54.5%). The most common poison used was organophosphates (48.7%), and the most common reason was family problems (30.2%). The median survival time (h) for the cases (n = 564) was 45.8 h (IQR: 16.4 to 110.6).

Conclusion:

We found fatal suicidal poisoning was common among males, young adults, married, agriculture workers/laborers, and in a rural setting. The findings help plan an effective intervention for suicide prevention in India.

Prevalence of Long COVID-19 and its Impact on Quality of Life Among Outpatients With Mild COVID-19 Disease at Tertiary Care Center in North India

Literature is lacking on the spectrum of symptoms of long COVID-19 (defined as symptoms persisting beyond 28 days of diagnosis) and its impact on quality of life. This single-center, cross-sectional study included mild COVID-19 cases as determined by a positive real-time reverse transcription polymerase chain reaction test. Patients were contacted at least 28 days after diagnosis and were interviewed telephonically using semi-structured questionnaires for duration of symptoms, fatigue using Fatigue Severity Scale (FSS) and quality of life using the World Health Organization Quality of Life: Brief Version (WHOQOL-BREF). A total of 251 COVID-19 patients were included; of which 169 (67.3%) were males. The mean age of the patients was 35.8 years (SD = 12.5). The prevalence of long COVID-19 was 28.2% (n = 71, 95% CI: 23.0–34.2). The most common symptoms involved the musculoskeletal system (12.7%), upper respiratory tract (7.6%), and fatigue among 17 (6.8%) patients. Patients with long COVID-19 had significantly higher FSS score and lower WHOQOL-BREF score compared to the patients without long COVID-19 (<28 days).

Impact of COVID-19 on the patients' income and work in Delhi, India

Background

Currently, there is no data on the impact of COVID-19 on patients' income and work in India.

Methods

We conducted a cross-sectional study at a tertiary hospital in New Delhi. We included all the patients who were ≥18 years of age and consecutively diagnosed with COVID-19 between the 1^st of May 2020 to 31^st July 2020. Patients were interviewed by a physician using a semi-structure questionnaire. Data were collected on socio-economic status, occupation, income loss, leaves taken, decrease in work efficiency (self-perceived) and about-facing any stigma/discrimination at the workplace.

Results

Out of 245 patients, 190 patients were employed. A total of 126 patients (66.3%) self-reported their work was affected due to COVID-19 disease. A total of 30.5% of patients (n = 58/190) reported deduction in their salary. The median amount of salary loss was INR 10,000 (IQR 9000-25000). Decrease in income and work efficiency (self-perceived) was found to be 37.3% (n = 71) and 12.1% (n = 23), respectively. A total of 47 patients (37.3%) took personal leaves (median number - 17 days (IQR 14-25), and discrimination/stigma related to the COVID-19 at the workplace was faced by 22.6% of patients.

Conclusion

Income and work of a substantial number of patients was affected due to COVID-19, as there was a decrease in income and work efficiency. Patients also had to take personal leaves and face stigma in the workplace. This will inform the policymakers to formulate strategies to mitigate the impact of COVID-19.

Tobacco use and nicotine dependence among patients with diabetes and hypertension in Ballabgarh, India

 Tobacco use is one of the most important modifiable risk factors for cardiovascular mortality and has a synergistic effect with diabetes and hypertension. This study was conducted to estimate the prevalence of tobacco use and nicotine dependence among adult diabetic and/or hypertensive patients. We conducted a cross-sectional study among 419 consecutively enrolled patients from the non-communicable diseases (NCDs) outpatient clinic of a secondary level hospital in Ballabgarh, India between July 2018 and January 2019. We administered a pre-tested questionnaire to assess tobacco use and Fagerstrom Test for Nicotine Dependence (FTND) to assess nicotine dependence. Current tobacco users were defined as those who smoked in the past seven days. Nicotine dependence was classified as low, moderate or high for the FTND score of 0 -3, 4-6, and 7-10, respectively. Seventy-nine patients had diabetes, 226 had hypertension, and 114 had both. The prevalence of tobacco use was 20.8% (95% CI : 17.1 - 24.9); prevalence of smoking was 15% (95% CI: 11.9 â€" 18.8) and smokeless tobacco use was 7.2% (95% CI: 5 - 10.1). Moderate to high nicotine dependence was found among 59.7% of tobacco users; 75.9% tobacco users attempted to quit tobacco in the past one month. One-fifth of attendees of a NCD clinic in a secondary level hospital used tobacco, most of whom had moderate-to-high nicotine dependence.  High level of nicotine dependence and inability to quit despite making an attempt for it necessitates the inclusion of tobacco cessation services in the management of patients with non-communicable diseases.

Odderon Exchange from Elastic Scattering Differences between pp and pp[over ¯] Data at 1.96 TeV and from pp Forward Scattering Measurements

We describe an analysis comparing the pp[over ¯] elastic cross section as measured by the D0 Collaboration at a center-of-mass energy of 1.96 TeV to that in pp collisions as measured by the TOTEM Collaboration at 2.76, 7, 8, and 13 TeV using a model-independent approach. The TOTEM cross sections, extrapolated to a center-of-mass energy of sqrt[s]=1.96  TeV, are compared with the D0 measurement in the region of the diffractive minimum and the second maximum of the pp cross section. The two data sets disagree at the 3.4σ level and thus provide evidence for the t-channel exchange of a colorless, C-odd gluonic compound, also known as the odderon. We combine these results with a TOTEM analysis of the same C-odd exchange based on the total cross section and the ratio of the real to imaginary parts of the forward elastic strong interaction scattering amplitude in pp scattering for which the significance is between 3.4σ and 4.6σ. The combined significance is larger than 5σ and is interpreted as the first observation of the exchange of a colorless, C-odd gluonic compound.

Costs of TB care incurred by adult patients with newly diagnosed drug-sensitive TB in Ballabgarh block in northern India

BACKGROUND

India's National Tuberculosis Elimination Programme (NTEP) provides free diagnosis and treatment services but does not monitor TB-related costs. This study aimed to estimate the direct and indirect costs borne by adult patients with newly diagnosed TB.

METHODS

A longitudinal study in Ballabgarh block, Haryana (North India) was conducted. A total of 110 patients were interviewed and data regarding costs were collected at three points of time (after diagnosis, at the end of intensive phase and at the end of the treatment) using a semistructured questionnaire. The total direct (out-of-pocket expenses) and indirect (income lost) costs before and during treatment were calculated for patients who completed the treatment.

RESULTS

We enrolled 110 patients with drug-sensitive TB; 6 patients could not complete the treatment. The TB-related median total cost was US$150 (IQR 65-335). The median prediagnosis and postdiagnosis costs were US$42 (IQR 19-313) and US$63 (IQR 10.2-190), respectively. The median direct and indirect costs were US$75 (IQR 36-148) and US$16 (IQR 0-197), respectively. A catastrophic cost was experienced by 18% (95% CI 12 to 27%) of households.

CONCLUSION

Despite free diagnosis and treatment services, there is a substantial TB-related cost for TB care under the NTEP. Accelerated efforts are needed to achieve the target of zero catastrophic cost.

Diagnostic Pathways and Delays in Initiation of Treatment among Newly Diagnosed Tuberculosis Patients in Ballabgarh, India

A delay in diagnosis and initiation of treatment in patients with tuberculosis (TB) can affect the period of communicability and cost of treatment. We aimed to describe the diagnostic pathways and delays in initiation of treatment among drug-sensitive newly diagnosed TB patients in Ballabgarh, India. In May 2019, we interviewed 110 TB patients who were put on treatment in the past 2 months. It was a cross-sectional study where data collection was conducted by a physician. We used a structured questionnaire to collect the information on care-seeking practices, delays, and patient's cost. Descriptive analysis was carried out for the pathways, delays, and patient cost. The mean number of health facility contacted before the diagnosis of TB was 2.8 (SD: 1.3); 76% of patients first sought care at a private health facility. The median total delay was 34.5 (IQR: 21-60) days; median patient delay seven (IQR: 2-21) days, median health system delay 16 (IQR: 8-45) days, median diagnostic delay 32.5 (IQR: 18-57) days, and median treatment delay two (IQR: 1-3) days. Health system delay was 2.2 times longer than patient delay; the health system delay was primarily due to delay in diagnosis. Patients contacting private health facility first had 1.7 times total delay, 2.4 times longer health system delay, and 3.4 times of direct cost compared with patients contacting a public health facility first. Accelerated efforts are needed to achieve India's target to eliminate TB by 2025.

Thyroid dysfunction and incident heart failure phenotypes among older adults: the atherosclerosis risk in communities (aric) study

Background/Introduction

Abnormal thyroid hormone concentrations have been associated with adverse cardiovascular outcomes, but the relationship between thyroid dysfunction and specific heart failure phenotypes is less clear.

Purpose

To examine the association of thyroid dysfunction with the risk of incident HF in older adults without pre-existing HF.

Methods

We analyzed participants enrolled in the Atherosclerosis Risk in Communities (ARIC) study who attended the visit 5 examination (2011–2013). Participants with previous HF history, and participants treated with amiodarone, levothyroxine, and antithyroid medication were excluded. We used Cox regression models to assess the associations between serum thyroid indices (free thyroxine [FT4], total triiodothyronine [TT3], or thyroid stimulating hormone [TSH]) and incident adjudicated HF with reduced (HFrEF) and preserved (HFpEF) left ventricular ejection fraction. Continuous associations between TT3 and outcome were further assessed via Cox model using restricted cubic spline.

Results

Among 3349 participants (mean age 75±5 years, 56% women, 20% black), subclinical hypothyroidism was prevalent in 12% of participants and low T3 syndrome in 3%. Those with overt hypothyroidism (&lt;1%) or hyperthyroidism (&lt;1%) were not included in the analysis given the low prevalence. Over a median follow-up of 5.5 years, incident HF occurred in 198 subjects (5.9%) at a rate of 11.1 per 1000 person-years. Of these, 86 were HFrEF, 83 HFpEF, and 29 were unclassified HF. We observed an inverse association of TT3 level with risk of incident HFpEF, but not overall incident HF or incident HFrEF, after adjustment for clinical confounders and baseline NT-proBNP levels (HR per 1 SD 0.70, 95% CI 0.54–0.92; P 0.010) (Figure). Similar results were observed for the composite endpoint of incident HFpEF or all-cause death. No statistically significant associations were found between TSH or T4 levels and incident HF. Low T3 syndrome was associated with incident HFpEF, but not overall incident HF or incident HFrEF, after adjustment for clinical confounders (HR 2.71, 95% CI 1.08–6.82; P 0.035); however, its association was significantly attenuated after adjustment with NT-proBNP (HR 2.25, 95% CI 0.87–5.79; P 0.09). No statistically significant association was found between subclinical hypothyroidism and incident HF.

Conclusions

In a contemporary biracial cohort of older adults, serum T3 level was inversely associated with incident HFpEF hospitalization. T3 administration could be considered as a potential target in future clinical trials preventing HFpEF hospitalization.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Atherosclerosis Risk in Communities Study is performed as a collaborative study supported by National Heart, Lung, and Blood Institute contracts

Tobacco use and nicotine dependence among newly diagnosed pulmonary tuberculosis patients in Ballabgarh tuberculosis unit, Haryana

Introduction:

This study was conducted to estimate the burden of tobacco use and nicotine dependence among newly diagnosed pulmonary tuberculosis patients to help inform effective implementation of tobacco cessation strategies among tuberculosis patients to improve treatment outcomes.

Materials and Methods:

This was a cross-sectional study conducted among 211 consecutive newly diagnosed pulmonary tuberculosis patients between July 2018 till January 2019 at Ballabgarh tuberculosis unit (TU) in Faridabad district of Haryana, India. All participants were administered a pre-tested questionnaire to assess tobacco use and the Fagerstrom test for nicotine dependence (FTND) to assess nicotine dependence. Current tobacco users were defined as those who smoked in the past 7 days. Nicotine dependence was classified as low, moderate, or high for the FTND score of 0-3, 4-6, and 7-10, respectively.

Results:

Majority of the participants (71.1%) were male, aged 26–50 years (45.5%), and married (65.4%). Fifty (23.7%, CI: 18.0–29.4) participants were currently using tobacco; 29 (13.7%, CI: 9.1–18.4) reported smoking tobacco while 23 (10.9%, CI: 6.7–15.1) reported using smokeless tobacco. In the last month, the proportion of patients who attempted to quit smoking and smokeless tobacco was 31% and 26.1%, respectively. 86.2% of the smokers and 69.6% smokeless tobacco users reported moderate to a high level of nicotine dependence.

Conclusion:

High prevalence of tobacco use, a higher level of nicotine dependence and inability to quit despite an attempt among a large number of tuberculosis patients, necessitates the inclusion of routine tobacco cessation advice and nicotine replacement therapy in tuberculosis care.

The role of transoral fine needle aspiration in expediting diagnosis and reducing risk in head and neck cancer patients in the coronavirus disease 2019 (COVID-19) era: a single-institution experience

OBJECTIVE

The global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study.

METHOD

Diagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic.

RESULTS

Five patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis.

CONCLUSION

Transoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.

Direct and indirect patient costs of tuberculosis care in India

OBJECTIVE

To synthesise the evidence for estimating the direct and indirect patient costs of drug-sensitive and drug-resistant tuberculosis care in India.

METHOD

PubMed, Embase, Web of Science, IndMED and Google Scholar were searched for studies conducted in India between 2000 and 2018 and published in English. The search terms were "tuberculosis" AND "costs" (cost Analysis, economics, cost of illness, health care costs, health expenditures, direct service costs, catastrophic cost) AND "India". The cost of TB care was from the patient's perspective. Data regarding costs were extracted, indexed to the year 2018 using cumulative inflation rate and converted to US dollars at the exchange rate of 2018.

RESULTS

Thirteen studies were included in this review. The mean (unweighted) total cost incurred by patients being treated for drug-sensitive TB in a public health facility was $ 235.00 (SD- 222.10), and the median of means was $ 170.60 (range - 43.70-718.40). The mean direct cost was 45.5% of the total cost. Only one study, which was conducted in a private facility, reported the mean total cost for drug-resistant TB as $ 7778.04. Catastrophic cost (total cost ≥ 20% of the total annual household income) was experienced by 7% to 32.4% of drug-sensitive TB patients and by 68% of drug-resistant TB patients.

CONCLUSION

Despite free diagnostic and treatment services provided under the Revised National Tuberculosis Control Programme, the patient cost of tuberculosis care is high. Relevant studies vary widely in methodology and cost reporting.

100 Association of age-related left atrial remodeling with ischemic stroke in patients with normal sinus rhythm

OnBehalf

The ARIC Study

Background

Age-related left atrial (LA) structural/functional abnormalities in elderly patients with normal sinus rhythm and preserved ejection fraction may precede the development of overt atrial fibrillation, and also may be related to stroke.

Purpose

To evaluate the association of 3-dimensional echocardiographic (3DE) atrial contractility parameters with subclinical cerebral infarcts (SCIs), as assessed by brain MRI, and clinically diagnosed stroke

Methods

We studied 407 participants (mean age 76 ± 5 years, 40.5% male) from the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS) without AF and who underwent a brain MRI and a 3DE examination in 2011-13. We defined 3 groups: those with no cerebral infarcts on brain MRI (NCIs, N = 315); those with MRI-diagnosed SCIs (N = 58); and those with clinically diagnosed stroke (N = 34).

Results

While still within the normal range, LA indexed volume significantly increased across the 3 groups (P-trend = 0.01).This was accompanied by an increase in the LA global longitudinal strain (GLS), an echocardiographic index of LA reservoir function (P-trend = 0.004). E/e’ divided by LA GLS—index of atrial stiffness—worsened across groups (P-trend = 0.005) and was independently associated with SCIs and Stroke, pooled together, [OR per 1 %-1, 1.97; 95% CI (1.24, 3.11), P = 0.004], and Stroke [OR per 1 %-1, 2.30; 95% CI (1.23, 4.30), P = 0.009]. LA GLS was marginally associated with an increased odd of SCIs [OR per 1 %, 1.07; 95% CI (1.01, 1.13), P = 0.014].

Conclusions

Among elderly participants with normal sinus rhythm and preserved ejection fraction in a large cohort study, markers of LA function and stiffness are associated with increased odds of subclinical infarcts and stroke. These data suggest that even subtle LA dysfunction, which may contribute to LA stasis, may predispose to subclinical cerebral infarcts and stroke.

Hemoadsorption by extracorporeal cytokine adsorption therapy (CytoSorb®) in the management of septic shock: A retrospective observational study

INTRODUCTION

Sepsis results in immunologic disturbances with the release of various inflammatory mediators such as cytokines. Cytokines can damage the cells, and the continuous release of inflammatory mediators leads to severely impaired immunity. Therefore, the reduction in cytokine levels by hemoadsorption represents a new concept for blood purification. CytoSorb^® as a hemoadsorption device is a detoxification system, which aims to decrease the cytokines levels. This study was conducted to understand any beneficial effects of CytoSorb^® therapy in septic patients.

METHODOLOGY

This was a retrospective and observational study, approved by the scientific and ethics committee of Max Super Specialty Hospital, Patparganj, Delhi, India and conducted in compliance with current International Council for Harmonization, Good Clinical Practice, Schedule Y, and Indian Council of Medical Research guidelines. Subjects of either gender (age > 18 year) were included in the study. The data were presented as mean ± standard deviation and categorical as frequency and percentage (%). A p value less than 0.05 (p < 0.05) was considered to be statistically significant.

RESULTS

A total number of 36 patients were included in the study. Majority of the patients were male with mean age (56.36 ± 14.83). After therapy, procalcitonin and total leucocyte count levels decreased within 24 h. Post therapy, sepsis-related organ failure assessment (SOFA) score of Day (D)1, D2, and D3 reduced to 10.4 ± 3.63, 8.7 ± 4.02, and 7.8 ± 3.67, respectively. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality were lower in the survivor group as compared to the non-survivor group.

CONCLUSION

Hemoadsorption using the extracorporeal adsorption device (CytoSorb^®) might be an effective rescue therapy in stabilizing septic shock patients.

Evaluation of a Method to Determine Flavonol Aglycones in Ginkgo biloba Dietary Supplement Crude Materials and Finished Products by High-Performance Liquid Chromatography: Collaborative Study

An interlaboratory study was conducted for evaluation of a method to determine the flavonol aglycones quercetin, kaempferol, and isorhamnetin in Ginkgo biloba products. The method calculates total glycosides based on these aglycones formed after acid hydrolysis. Twelve matrixes were chosen for study by 12 collaborating laboratories in 2 countries. Test materials included crude leaf material, standardized dry powder extract, single and multiple entity finished products, ethanol and glycerol tinctures, and National Institute of Standards and Technology (NIST) standard reference materials (SRMs). Results from 11 laboratories were used for the final calculations. Eight of the 12 matrixes evaluated produced acceptable results for total flavonol glycosides, with HorRat scores ranging from 1.31 to 2.05; repeatability relative standard deviations (RSDr) from 1.46 to 4.14; and reproducibility relative standard deviations (RSDR) from 4.67 to 9.69. These 8 matrixes consisted primarily of simple dosage forms (e.g., dry powder extracts, crude leaf samples, liquid extracts, and SRMs) and a single tablet product (Ginkgo Awareness). Four additional matrixes, consisting of 3 tablets and 1 soft gel product (Ginkgold, Ginkoba, Ginkogen, and Ginkgo Phytosome, respectively), showed greater total flavonol glycoside HorRat scores in comparison, ranging from 2.39 to 5.13, with RSDr values from 2.83 to 8.16, and RSDR values from 8.53 to 20.4. Based on the results presented here, the method is recommended for Official First Action for determination of total flavonol glycosides calculated from quercetin, kaempferol, and isorhamnetin in dry powder extracts, crude leaf material, liquid extracts, and a select finished product, Ginkgo Awareness.

Measurement of the Electrical Properties of a Thundercloud Through Muon Imaging by the GRAPES-3 Experiment

The GRAPES-3 muon telescope located in Ooty, India records rapid (∼10  min) variations in the muon intensity during major thunderstorms. Out of a total of 184 thunderstorms recorded during the interval of April 2011-December 2014, the one on December 1, 2014 produced a massive potential of 1.3 GV. The electric field measured by four well-separated (up to 6 km) monitors on the ground was used to help estimate some of the properties of this thundercloud, including its altitude and area that were found to be 11.4 km above mean sea level and ≥380  km^{2}, respectively. A charging time of 6 min to reach 1.3 GV implied the delivery of a power of ≥2  GW by this thundercloud that was moving at a speed of ∼60  km h^{-1}. This work possibly provides the first direct evidence for the generation of gigavolt potentials in thunderclouds that could also possibly explain the production of highest-energy (100 MeV) gamma rays in the terrestrial gamma-ray flashes.

Physio-biochemical assessment and expression analysis of genes associated with drought tolerance in sugarcane (Saccharum spp. hybrids) exposed to GA3 at grand growth stage

Drought is one of the most serious environmental factors limiting production of sugarcane worldwide. In order to assess the influence of gibberellins (GA₃ ) on drought and plant growth, along with associated physio-biochemical attributes, expression of eight drought-responsive genes were quantified and analysed. At grand growth stage (120 DAP) two sugarcane varieties (CoLk94184, CoPK05191) were exposed to drought by withholding irrigation. GA₃ (35 ppm) was applied using battery-operated uniform controlled dispensing sprayer twice at 1-week intervals on 2-week drought-stressed plants. Physio-biochemical attributes including antioxidant enzyme activities were estimated following standard protocols. RT-PCR was performed to visualise the drought-associated gene expression patterns. Drought triggered a reduction in RWC and chlorophyll content but these recovered when droughted plants were exposed to GA₃ . Proline content increased many fold in both varieties under stress, but decreased under the influence of GA₃ . There was a mixed response of antioxidant enzyme activity, which distinctly declined after GA₃ exposure, together with a lesser reduction in dry matter content over that of control plants. With increasing stress, expression of pyrroline-5-carboxylase synthetase (P5CS) and betaine-aldehyde dehydrogenase genes was observed, selectively up-regulated in CoPK05191. Expression of proline oxidase/transporter was high in CoPK05191 but diminished along with proline content after exposure to GA_3. CoLk94184 showed no significant difference in P5CS gene expression under stress condition, whereas expression of betaine-aldehyde dehydrogenase gene was unchanged in response to stress. Results demonstrated that exposure of droughted plants to GA₃ not only led to recovery of activity of drought-associated physio-biochemical attributes, but also minimised impact on cane dry weight and quality. Further, GA₃ application caused differential gene expression that possibly triggers increased responsiveness towards drought tolerance in sugarcane.

Expression analysis of genes associated with sucrose accumulation and its effect on source-sink relationship in high sucrose accumulating early maturing sugarcane variety

Sucrose synthesis/accumulation in sugarcane depends on the source-sink communication wherein source responds to sink demand for photoassimilate supply. Sucrose in stalk (sink) acts as signal, and sends feedback to restrain further synthesis of sucrose by regulating photosynthetic efficiency of leaves (source). Hence sucrose synthesis/accumulation is controlled by many genes and regulatory sequences including 3 invertases (SAI, CWI, NI), sucrose synthase (SuSy) and sucrose phosphate synthase (SPS). SPS and invertase play key role in enhancing sink strength which ultimately promotes greater sucrose accumulation in the sink tissues. In present study, a significant positive correlation was found between sucrose% of source and sink tissues which was greater in the top (R ² = 0.679) than middle (R ² = 0.580) and bottom (R ² = 0.518) internodes, depicting that sucrose accumulation in the stalk bears a direct relation with sucrose translocation efficiency from source. Results indicated an increased sucrose% with maturity, while reducing sugar content decreased with crop growth. qRT-PCR results exhibited an elevated expression of invertase in immature sink tissues depicting increased sink requirement, which declined with maturity. Similarly, increased PEP carboxylase gene expression as observed supported the fact that higher sink demand results in enhanced photosynthetic rate and thus influences the source activity. SPS was found active at initial stage of cane development indicating its role in sucrose synthesis. Thus by studying expression patterns of the different genes both, in source and sink tissues, a better understanding of the sucrose accumulation pathway in sugarcane is possible, which in turn can help in elucidating ways to enhance sucrose concentration in sink.

Qiwam: A Potential Carcinogenic Smokeless Tobacco Product Consumed With Paan

Background: Qiwam (Kimam) is a liquid tobacco preparation consumed with paan. It is mostly consumed in southeast Asian region. Evidences suggest that it causes potentially malignant disorders (PMD), oral cancer (OC) and decreases sperm count. Qiwam was mentioned in earlier research publications, however details are not known. It is produced for self-consumption as well as for commercial purpose. Aim: To study in detail the ingredients and processing steps involved in the production of Qiwam. In addition, also study the adverse health implication of this smokeless tobacco product on humans. Methods: The information on qiwam was collected via literature search study, study tour to different geographical areas of India, where group discussions with the people involved in the production of qiwam, paan vendors and with community members of different age group were done. Results: Qiwam is prepared by the user for his/her own consumption or by industry for sale. Tobacco leaves and tobacco roots are boiled for several hours then soaked in water flavored with varied spices and additives. The resultant mixture is mashed, strained, and finally dried into a thick paste. It is consumed mostly with paan. Conclusion: Processing of qiwam is a complex and time taking process which involves various steps and components that may influence the carcinogenic property of the product. The different processing steps gives different taste and texture to the product. Qiwam increases the risk of cancer and hence needs to be banned or better avoided.

Using Social Media as an Effective Tool for Motivating Cancer Prevention

Background: Cancer is among leading cause of death (8.8 million) worldwide. Around 14.2 million new cases were recorded in 2012 and increasing each year. On the other hand there are about 2.8 billion users of different social media platforms (i.e., 37% of the world population). This tremendous power of social media can be used for disseminating effective information and communication on cancer prevention more efficiently (i.e., in less time to more people) to create awareness against the disease. Tobacco, alcohol and food industry have been using social media for aggressive advertising and marketing of their products. There is an urgent need to maximally use this medium of communication for advancing cancer prevention globally. Aim: To assess the role of social media in implementing effective health promotion strategies to advance cancer prevention. Methods: Extensive Web search has been done on the way social media (e.g., Facebook) is used for advancing public health communication and how it has been leveraged in the field of cancer prevention. Several Facebook pages and groups, YouTube channels were analyzed thoroughly. Various reports and articles on social media have been reviewed and analyzed. Results: Social media has been found very effective in terms of engaging greater number of population globally. Many Facebook pages and groups are available that provide information regarding specific cancer or provide support for cancer survivors. Several informative videos related to cancer prevention and survivors' stories are broadcast on various YouTube channels run by individuals, government, and nongovernment organizations. There have been many Instagram accounts on cancer but many of them don't provide relevant information on cancer prevention. However, genuine and relevant information are available through several Twitter handles. These social media platforms have very high penetration power. Facebook, YouTube, Instagram and Twitter have monthly reach to more than 1871, 1000, 500 and 263 million users respectively. This large number of user base can become a great source of spreading information on various aspects of cancer prevention through a comprehensive social media campaign. Conclusion: Social media platforms improve outreach and can also help carrying the relevant preventive health messages on cancer prevention, not only for the cancer patient but the public at large. Social media will help in amplifying the messages to the global mass while motivating prevention and health promotion to achieve public health objectives.