Assessment of Dependency in Activities of Daily Living (ADL) and its Predictors: A Cross-Sectional Study among the Elderly Rural Population in a Sub-Himalayan UT of India

Background

With an increase in life expectancy over the last few decades, there has been a parallel increase in the prevalence of disabilities among the elderly population. To estimate the prevalence of dependency in activities of daily living (ADL) and its predictors among the rural elderly population.

Material and Methods

This was a cross-sectional study carried out in the community among the rural geriatric population in the field practice area of PG Department of Community Medicine, Government Medical College Jammu. The Barthel Scale Index was used to measure ADL dependency. PSPP software was used to analyze the data.

Results

The mean age of study participants was 68.31 ± 7.9 years. ADL dependency was observed in 46.3% of the subjects, with the majority demonstrating mild to moderate dependence. Only 2.5% of the respondents reported a severe degree of ADL dependence. The mean ADL score was 94.47 ± 8.98. On multivariate logistic regression analysis, age, educational status, the presence of stress in the family, personal history, and the presence of co-morbidities emerged to be independent predictors of ADL dependence.

Conclusion

High prevalence of physical disability in the geriatric population is now an area of major concern. This emphasizes the significance of setting up geriatric care centers especially in rural areas preferably integrating with health and wellness centers.

Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

CHSI costing study-Challenges and solutions for cost data collection in private hospitals in India

INTRODUCTION

Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB PM-JAY) has enabled the Government of India to become a strategic purchaser of health care services from private providers. To generate base cost evidence for evidence-based policymaking the Costing of Health Services in India (CHSI) study was commissioned in 2018 for the price setting of health benefit packages. This paper reports the findings of a process evaluation of the cost data collection in the private hospitals.

METHODS

The process evaluation of health system costing in private hospitals was an exploratory survey with mixed methods (quantitative and qualitative). We used three approaches-an online survey using a semi-structured questionnaire, in-depth interviews, and a review of monitoring data. The process of data collection was assessed in terms of time taken for different aspects, resources used, level and nature of difficulty encountered, challenges and solutions.

RESULTS

The mean time taken for data collection in a private hospital was 9.31 (± 1.0) person months including time for obtaining permissions, actual data collection and entry, and addressing queries for data completeness and quality. The longest time was taken to collect data on human resources (30%), while it took the least time for collecting information on building and space (5%). On a scale of 1 (lowest) to 10 (highest) difficulty levels, the data on human resources was the most difficult to collect. This included data on salaries (8), time allocation (5.5) and leaves (5).

DISCUSSION

Cost data from private hospitals is crucial for mixed health systems. Developing formal mechanisms of cost accounting data and data sharing as pre-requisites for empanelment under a national insurance scheme can significantly ease the process of cost data collection.

Cost of Surgical Care at Public Sector District Hospitals in India: Implications for Universal Health Coverage and Publicly Financed Health Insurance Schemes

BACKGROUND

In low- and middle-income countries (LMICs), provisioning for surgical care is a public health priority. Ayushman Bharat Pradhan Mantri-Jan Aarogya Yojana (AB PM-JAY) is India's largest national insurance scheme providing free surgical and medical care. In this paper, we present the costs of surgical health benefit packages (HBPs) for secondary care in public district hospitals.

METHODS

The costs were estimated using mixed (top-down and bottom-up) micro-costing methods. In phase II of the Costing of Health Services in India (CHSI) study, data were collected from a sample of 27 district hospitals from nine states of India. The district hospitals were selected using stratified random sampling based on the district's composite development score. We estimated unit costs for individual services-outpatient (OP) visit, per bed-day in inpatient (IP) and intensive care unit (ICU) stays, and surgical procedures. Together, this was used to estimate the cost of 250 AB PM-JAY HBPs.

RESULTS

At the current level of utilization, the mean cost per OP consultation varied from US$4.10 to US$2.60 among different surgical specialities. The mean unit cost per IP bed-day ranged from US$13.40 to US$35.60. For the ICU, the mean unit cost per bed-day was US$74. Further, the unit cost of HBPs varied from US$564 for bone tumour excision to US$49 for lid tear repair.

CONCLUSIONS

Data on the cost of delivering surgical care at the level of district hospitals is of critical value for evidence-based policymaking, price-setting for surgical care and planning to strengthen the availability of high quality and cost-effective surgical care in district hospitals.

454 Sinus of Valsalva Rupture

Background

Sinus of Valsalva (SVA) rupture is a rare cardiac pathology which is important to recognise and diagnose early.

Case Summary

This case report details a 30-year-old gentleman who presented with a 3-day history of dyspnoea and palpitations on a background of previous congenital heart disease. The patient's examination highlighted a continuous harsh pan-systolic murmur as well as an ECG finding of sinus tachycardia. Transthoracic echocardiography identified a ruptured Sinus of Valsalva. The patient was transferred to a cardiothoracic surgery centre and definitively treated with an aortic root and ventricular septal defect repair.

Discussion

This case highlights the clinical findings of a patient with an acute left to right shunt and the importance of early diagnosis and urgent surgery. This case emphasises the factors required to decide which surgical approach is appropriate such as the presence of aortic valvular pathology size, size of Sinus of Valsalva aneurysm, any simultaneous cardiac anomaly and the cardiac chamber involved.

Learning Points

Publication Pressure versus Ethics, in Research and Publication

Research is undertaken to increase scientific knowledge. Knowledge enters the domain of science after it is presented to others. Publishing research, contributes to medical community's knowledge. Research publications earn mileage to the researcher in carrier. Presently, a lot of pressure has built up on medical fraternity to publish in terms of quantity, thereby compromising the quality of papers as official bodies governing the medical professionals have linked the quantity of publications with career growth. These rules are to promote research but they create stress among medical teachers, lowering the quality of research and publications. Hence, It is the responsibility of authors to strictly follow guidelines while doing and publishing research. To promote academic research and deter plagiarism, educational institutions are to establish Academic Misconduct Panel to investigate the allegations, and report to Plagiarism Disciplinary authority which can impose penalties as conduct and publishing of research is a serious issue.

Estimation of Baseline Widal Antibody Titers among Apparently Healthy Urban Population of District Jammu

Introduction:

Definitive diagnosis of Enteric fever is by blood culture for Salmonella enterica serotype Typhi, Paratyphi A, and Paratyphi B which takes long turnaround time and is costly, whereas Widal test is simple, rapid, and cost-effective test whose interpretation depends on the baseline Widal titers among healthy individuals in a defined population.

Objectives:

To determine the baseline Widal titers among apparently healthy urban population of district Jammu (J&K).

Materials and Methods:

302 individuals in the age group of 18–50 years were recruited. A pretested questionnaire was used to collect demographic and clinical details. The Widal testing was done using commercial Salmonella antigen kit.

Results:

A total of 302 samples were screened by Widal test. 138 samples (45.69%) were reactive for TO antigen and 64 (21.19%) tested reactive for TH antigen, 3 (0.01%) samples showed agglutination for AH antigen and 3 (0.01%) were positive for BH antigen. Majority of seropositive samples were in dilutions of 1:40 for both TO and TH antigens.

Conclusions:

Hence, next higher dilutions showing positivity for both TO and TH antigens, i.e., ≥1:80 may be considered diagnostic for enteric fever in the urban population of Jammu district.

Prevalence and Determinants of Cognitive Impairment and Depression among the Elderly Population in a Rural Area of North India

Background:

Demographic transition has resulted in population aging, which has led to advancement in multiple geriatric problems including cognitive impairment (CI) and depression.

Objectives:

The objective was to find the prevalence and determinants of CI and depression in the rural elderly population.

Materials and Methods:

This was a community-based cross-sectional study conducted in a rural area. The prevalence of CI was measured using the Mini-Mental State Examination scale and depression was assessed using the Geriatric Depression Scale. The data so collected were analyzed using PSPP software.

Results:

The mean age of the study participants was 67.47 ± 6.43 years. The prevalence of CI and geriatric depression was found to be 36% (153/425) and 29.1% (124/425), respectively. Variables which were found to have independent significant association on multivariate analysis with CI were literacy, memory complaints, and depression. For geriatric depression, an independent association was seen with literacy, socioeconomic status, memory complaints, stress in the family, and presence of CI. CI and geriatric depression were found to be strongly correlated with each other (r = −0.252, P < 0.001).

Conclusions:

Almost one-third of the geriatric population is suffering from depression (29.1%) and CI (36%). This necessitates for accurate and timely diagnosis, so as to ensure proper care and support to the elderly population with emphasis on geriatric mental health care.

P3732Proportion of acute ischaemic strokes attributable to cardiac causes in an all-comer population of young patients

Introduction

The incidence of stroke in young patients is increasing and is associated with significant morbidity, mortality and socioeconomic cost. Identifying potential underlying causes is central to their overall management to reduce recurrence and improve long-term outcomes. A proportion of these patients are found to have an underlying cardiac cause including atrial fibrillation (AF), patent foramen ovale (PFO) or an intracardiac source of embolus. This area has recently gained greater interest with evidence demonstrating a significant reduction in recurrent ischaemic events following PFO closure. The identification of these patients however, requires extensive investigation and has implications relating to cardiology resources. Outside of clinical trials the true incidence of these patients in a “real-world” population is poorly defined.

Purpose

The aim of this study was to determine the proportion of strokes attributable to cardiac causes in young patients presenting with ischaemic stroke.

Methods

The Sentinel Stroke National Audit Programme (SSNAP) database of a large UK stroke service was used to identify patients ≤55 years old presenting with stroke between 1/1/15 and 31/12/17. Clinical letters, imaging reports and laboratory reports were reviewed. Patients were then categorised by cause of stroke using the Trial of Acute Stroke Treatment (TOAST) criteria. Cardiac causes of stroke were defined as: AF, PFO and intracardiac source of embolus. Patients presenting with a haemorrhagic stroke or where an alternate diagnosis to stroke was more likely were excluded.

Results

During the study period, 206 patients were identified as having suffered a stroke. 35 patients were excluded resulting in a final study population of 171 patients (Figure). 24% (41/171) were identified as having a cardiac cause of stroke including 9.4% (16/171) PFO, 8.8% (15/171) intracardiac source of embolus and 5.8% (10/171) atrial fibrillation. 50.3% (86/171) were thought to have other causes: 24.6% (42/171) small vessel disease; 9.4% (16/171) large artery atherosclerosis; and 16.4% (28/171) other determined aetiology including 5.1% (8.8/171) with arterial dissection. 25.7% (44/171) presented with a stroke but with no clear underlying cause found.

Causes of stroke in young patients

Conclusion

A high proportion (24%) of strokes in young patients were found to be likely secondary to a cardiac cause. With the significant benefit of intervention (medical or procedural) in this patient group, the resource provision allocated to this population does appear to be warranted and further demonstrates the importance of close interdisciplinary links between cardiologists and stroke physicians.

Placental growth factor testing for suspected pre-eclampsia: a cost-effectiveness analysis

Objective

To calculate the cost‐effectiveness of implementing PlGF testing alongside a clinical management algorithm in maternity services in the UK, compared with current standard care.

Design

Cost‐effectiveness analysis.

Setting

Eleven maternity units participating in the PARROT stepped‐wedge cluster‐randomised controlled trial.

Population

Women presenting with suspected pre‐eclampsia between 20⁺⁰ and 36⁺⁶ weeks’ gestation.

Methods

Monte Carlo simulation utilising resource use data and maternal adverse outcomes.

Main outcome measures

Cost per maternal adverse outcome prevented.

Results

Clinical care with PlGF testing costs less than current standard practice and resulted in fewer maternal adverse outcomes. There is a total cost‐saving of UK£149 per patient tested, when including the cost of the test. This represents a potential cost‐saving of UK£2,891,196 each year across the NHS in England.

Conclusions

Clinical care with PlGF testing is associated with the potential for cost‐savings per participant tested when compared with current practice via a reduction in outpatient attendances, and improves maternal outcomes. This economic analysis supports a role for implementation of PlGF testing in antenatal services for the assessment of women with suspected pre‐eclampsia.

Tweetable abstract

Placental growth factor testing for suspected pre‐eclampsia is cost‐saving and improves maternal outcomes.

Placental growth factor testing for suspected pre‐eclampsia is cost‐saving and improves maternal outcomes.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study

OBJECTIVE

To compare the maternal and neonatal outcomes of operative vaginal delivery in relation to the use of episiotomy.

DESIGN

Pilot randomised controlled trial (RCT).

SETTING

Two urban maternity units in Scotland and England.

SAMPLE

Nulliparous women anticipating a singleton cephalic vaginal delivery were recruited in the antenatal period.

METHODS

If an operative vaginal delivery was required in the second stage of labour, women were randomised to either routine (in all cases) or restrictive (only if tearing apparent) use of episiotomy.

MAIN OUTCOME MEASURES

The primary outcome was anal sphincter tearing (third or fourth degree). Secondary outcomes included postpartum haemorrhage (PPH), neonatal trauma and pelvic floor symptoms up until 10 days postpartum.

RESULTS

In a group of 317 women requiring operative vaginal delivery, 200 were randomised: 99 to routine use of episiotomy and 101 to restrictive use. There were small differences in the rates of anal sphincter tears (8.1% routine versus 10.9% restrictive, OR 0.72, 95% CI 0.28-1.87) and primary PPH (36.4% routine versus 26.7% restrictive, OR 1.57, 95% CI 0.86-2.86). Neonatal trauma was similar between the two groups (45.5% routine versus 43.6% restrictive, OR 1.08, 95% CI 0.62-1.89), as was prolonged catheterisation, urinary incontinence, faecal incontinence, perineal infection and prolonged hospital admission.

CONCLUSIONS

This pilot study does not provide conclusive evidence that a policy of routine episiotomy is better or worse than a restrictive policy. A definitive RCT is feasible but will require a large sample size to inform clinical practice.

Effect of vitamin A administered at Expanded Program on Immunization contacts on antibody response to oral polio vaccine

OBJECTIVE

Vitamin A supplementation to mothers in the postpartum period and to their infants at routine immunization contacts is being considered to reduce vitamin A deficiency in infancy. This study was conducted to determine the impact of maternal and infant vitamin A supplementation on antibody response to oral polio vaccine (OPV).

DESIGN

Randomized, double blind, placebo-controlled trial.

INTERVENTIONS

Mothers in the intervention group received 60 mg retinol equivalent (RE) vitamin A 3-4 weeks after delivery and their infants 7.5 mg RE with each OPV dose at 6, 10 and 14 weeks of age. The control group mothers and their infants received a placebo at each of these contacts.

MAIN OUTCOMES

Geometric mean (GM) titer of neutralizing antibodies and proportion of children with protective titer to the three polioviruses at 26 weeks of age.

RESULTS

Vitamin A supplementation increased the proportion of infants with protective antibody titer against poliovirus type 1 (relative risk (RR) 1.15, 95% confidence interval (CI) 1.03-1.28) and the GM antibody titer (ratio of GM 1.55, 95% CI 1.03-2.31) following immunization. The proportion of infants with protective antibody titer against poliovirus type 2 (RR 0.99, 95% CI 0.94-1.05) or type 3 (RR 1.05, 95% CI 0.96-1.15) was not significantly different in vitamin A and placebo groups. The GM antibody titer for poliovirus type 2 (ratio of GM 0.99, 95% CI 0.64-1.54) or poliovirus type 3 (ratio of GM 1.10, 95% CI 0.69-1.75) also did not differ across groups.

CONCLUSIONS

Vitamin A given to the mothers in the postpartum period and their infants with OPV did not interfere with the antibody response to any of the three polioviruses and enhanced the response to poliovirus type 1.

Food supplementation with encouragement to feed it to infants from 4 to 12 months of age has a small impact on weight gain

It is unclear whether a substantial decline in malnutrition among infants in developing countries can be achieved by increasing food availability and nutrition counseling without concurrent morbidity-reducing interventions. The study was designed to determine whether provision of generous amounts of a micronutrient-fortified food supplement supported by counseling or nutritional counseling alone would significantly improve physical growth between 4 and 12 mo of age. In a controlled trial, 418 infants 4 mo of age were individually randomized to one of the four groups and followed until 12 mo of age. The first group received a milk-based cereal and nutritional counseling; the second group monthly nutritional counseling alone. To control for the effect of twice-weekly home visits for morbidity ascertainment, similar visits were made in one of the control groups (visitation group); the fourth group received no intervention. The median energy intake from nonbreast milk sources was higher in the food supplementation group than in the visitation group by 1212 kJ at 26 wk (P < 0.001), 1739 kJ at 38 wk (P < 0.001) and 2257 kJ at 52 wk (P < 0.001). The food supplementation infants gained 250 g (95% confidence interval: 20--480 g) more weight than did the visitation group. The difference in the mean increment in length during the study was 0.4 cm (95% confidence interval: -0.1--0.9 cm). The nutritional counseling group had higher energy intakes ranging from 280 to 752 kJ at different ages (P < 0.05 at all ages) but no significant benefit on weight and length increments. Methods to enhance the impact of these interventions need to be identified.

Localization of protein Ser/Thr phosphatase 5 in rat brain

Protein phosphatase 5 is a recently discovered Ser/Thr phosphatase that is structurally related to calcineurin and protein phosphatases 1 and 2. Northern blot and in situ hybridization studies have shown that protein phosphatase 5 mRNA is present at high levels in brain and is localized to discrete regions. In the present study, we used immunocytochemistry and immunoblot analyses to examine the regional and subcellular distribution of this enzyme in brain. Our work demonstrates that protein phosphatase 5 is widely expressed throughout brain, but is not uniformly distributed. The most intense staining occurred in neurons of the cerebellum, cerebral cortex, and the supraoptic nucleus of the hypothalamus. Other areas also contained immunoreactive cell bodies, including the globus pallidus, hippocampus, thalamus, lateral preoptic area of the hypothalamus, substantia nigra and other brainstem nuclei. Staining in these cells was observed primarily in perikarya and proximal processes.

Effect of micronutrient supplementation on linear growth of children

This review summarizes the results of published, randomized clinical trials that have examined the impact of administration of micronutrients, singly or in combination to infants, preschool and school children on linear growth. Supplementation of single micronutrients resulted in small or no benefits on linear growth. A meta-analysis of zinc supplementation trials confirmed that zinc has a significant but small impact (0.22 sd units) on length gain in children 0-13 years of age. However, a recent study reported a substantially greater benefit (>1 sd) in stunted and non-stunted breast-fed infants 6-12 months of age. With iron supplementation, a beneficial effect was found only in anemic children. Vitamin A supplementation trials have reported little or no benefit on linear growth. Data currently available suggest some impact in children with clinical or biochemical vitamin A deficiency, but this issue needs confirmation. Few studies could be identified where a combination of micronutrients was given as a supplement or as fortified food; in the latter set of studies energy availability was assured. The impact on length without multiple micronutrient supplementation was no greater than that observed with single micronutrients. In conclusion, zinc and iron seem to have a modest effect on linear growth in deficient populations. Vitamin A is unlikely to have an important effect on linear growth. Limited available evidence does not allow us to conclude whether a combination of micronutrients, with or without additional food, would have a greater impact than that seen with zinc alone.

Oxidative stress status: possible guideline for clinical management of critically ill patients

BACKGROUND

Critical care medicine has developed in the last few years into a separate scientific discipline and studies related to the outcome after intensive care usually suggest a long hospital stay that becomes cost prohibitive. The majority of problems (death) amongst critically ill patients requiring critical care involve sepsis, inflammation, tissue damage-oxidative stress, oxygen tension PO2, lipid peroxidation. The present investigation involves monitoring of serum levels of MDA, SOD as a possible guideline for severity of clinical situations in critically ill patients.

METHODS

Fifty critically ill heterogeneous patients requiring intensive care in the ICU of IKDRC were selected as subjects with ages varying from 17 to 75 years. Serum levels of MDA (ng/ml), SOD (U/ml) were determined right from admission to discharge due to improvement / DAMA / death. MDA and SOD were estimated according to the methods of Buege and Aust et al. (1978), Nandi and Chatterji (1988).

RESULTS

Critically ill patients irrespective of the disease process indicated significantly very high serum levels of MDA and low levels of SOD at the time of admission (13.28+/-4.26 ng/ml, 3.80+/-2.60 U/ml, respectively) according to the severity of the prevalent clinical situation. The pattern of serum levels of MDA and SOD according to subsequent clinical performance did indicate a decreasing trend of MDA (oxidant) and fluctuating trend of SOD (antioxidant enzyme except in those who inevitably succumbed to death in spite of adequate clinical management.

CONCLUSIONS

The results of the present study have amply revealed the utility and relevance of monitoring oxidative stress in critically ill patients as biochemical markers, cost-effectiveness and role in decision making (withdrawal/continuation of different support modalities) as deemed fit.

Frequent alterations in the expression of tumor suppressor genes p16INK4A and pRb in esophageal squamous cell carcinoma in the Indian population

PURPOSE

Alterations in the cell cycle regulatory p16INK4a/Cyclin D1/pRb pathway play a pivotal role in tumorigenesis. Knowledge of alterations in the tumor suppressor protein pRb and its negative regulator, p16CDKN2/MTS1/INK4a in esophageal squamous cell carcinoma (ESCC) from the Indian subcontinent is meager. To gain insight into the mechanisms underlying tumorigenesis and to search for diagnostic molecular markers for ESCC, we analyzed the expression of p16INK4a and pRb in ESCCs in the Indian population.

METHODS

Immunohistochemical analysis of pRb and p16INK4a proteins was carried out in paraffin-embedded sections from 61 surgically resected ESCCs and matched normal tissues, and the results correlated with clinicopathological parameters using chi square and Fisher's exact tests. Dual immunohistochemical analysis has been carried out to demonstrate the concomitant loss of expression of p16INK4a and pRb.

RESULTS

Fifty-nine of 61 (97%) cases showed aberration(s) in either or both of these proteins confirming their critical role in esophageal tumorigenesis. Loss of pRb was observed in 51 of the 61 (84%) and loss of p16INK4a was observed in 35 of 61 (57%) cases. Loss of pRb showed significant association with dedifferentiation of the tumor (P = 0.004). p16-/pRb-, and p16+/pRb- phenotypes were significantly associated with nodal metastasis (P = 0.017 and 0.027, respectively), while p16-/pRb+ phenotype was associated with dedifferentiation of the tumor (P = 0.012).

CONCLUSION

pRb/p16INK4a pathway plays a critical role in esophageal tumorigenesis in the Indian population. The dual hits (concomitant loss) of pRb and p16INK4a expression suggest that these two components are not mutually exclusive, and can both be altered in a significant proportion of primary ESCCs serving as putative diagnostic markers for esophageal cancer. However, the impact of dual hit on tumor behavior and disease prognosis remains to be determined.

Prognostic factors for persistent diarrhoea managed in a community setting

Two hundred and five cases (mean age 13.4, SD 9.5) of persistent diarrhoea (PD) of 14-28 days duration, attending an urban slum clinic and treated according to standard WHO guidelines, were monitored at weekly intervals to obtain an estimate of treatment failure rates and to identify its clinical predictors. Vitamin and micronutrients (daily 2RDA) were additionally provided. Only 9 (8.2%) of 109 children with criteria for hospital care accepted in-patient care. Weight gain was considered inadequate if the daily increment between enrollment and day 7 of follow up was < 10 g at age 0-3 months, < 5 g at 4-6 months, and any weight loss for those older than 6 months. Recovery was considered delayed if diarrhoea ceased 7 days after enrollment. Overall, 28.3% cases had inadequate weight gain and 25.6% had delayed recovery. The non-breast milk calorie intake was 11.2% during infancy and 40.6% at later ages of the recommended intakes. In a logistic regression model, initial watery stool frequency greater than median (adjusted OR 2.30, p = 0.01), age < or = 6 months (adjusted OR 2.24, p = 0.04) and low consumption of micronutrient mixture (adjusted OR 2.62, p = 0.01) were associated with an increased risk of delayed recovery. In a Cox proportional hazards model for time to recovery from diarrhoea, low consumption of the micronutrient mixture and age < or = 6 months reduced the chances of recovery by 29% and 37% respectively. Low consumption of the prescribed micronutrient mixture (adjusted OR 2.21, p = 0.04), fever (adjusted OR 1.91, p = 0.05) and diarrhoea continuing beyond study day 7 (adjusted OR 2.29, p = 0.03) increased the risk of inadequate weight gain. Breast feeding status and animal milk consumption did not influence weight gain or recovery. Due to the low compliance for advised hospitalisation, approaches for care at community level itself need to be evolved. Focus should be on increasing the overall dietary intake and provision of generous but safe amount of micronutrients; our findings do not support need for routine elimination of animal milk. The efficacy of individual micronutrients needs evaluation in controlled trials.

Novel polymorphism in p21(waf1/cip1) cyclin dependent kinase inhibitor gene: association with human esophageal cancer

p21(waf1/cip1), an important regulator of the cell cycle, binds to PCNA and acts as a mediator of the growth suppressing and apoptosis promoting functions of p53. We report a hitherto unobserved polymorphism in the carboxy terminal domain (codon 149) of p21(waf1/cip1) gene, the domain encoding the PCNA binding motif. The codon 149 polymorphism (GAT-->GGT) was observed in 42 of 50 (84%) esophageal squamous cell carcinomas (ESCCs) and eight of 50 (16%) normal individuals. The resultant amino acid substitution from aspartate to glycine may have vital implication in PCNA mediated cell cycle regulation by p21(waf1/cip1). The second polymorphism at codon 31, involving a C-->A transversion at nucleotide 168 (AGC-->AGA) changing the amino acid from serine to arginine, was observed in 2/50 (4%) ESCCs at a relatively lower frequency in the Indian population than that reported in the West. No significant association was observed between p21(wap1/cip1) polymorphism at codon 149 and p21(wap1/cip1) protein expression in ESCC in this cohort of patients. Interestingly, the frequency of p21(wap1/cip1) variants (codon 149) in ESCCs (18 of 19 cases) with wild-type p53 was significantly higher than in tumors with p53 mutations, suggesting that this polymorphism affects the p53 pathway and may play an important role in esophageal tumorigenesis. Analysis of p21(waf1/cip1) expression in relation to p53 gene and protein status revealed its induction by p53-dependent as well as independent pathways in esophageal tumorigenesis.

Vitamin A administered with measles vaccine to nine-month-old infants does not reduce vaccine immunogenicity

After a report of reduced seroconversion to measles in infants, aged 6 mo, given vitamin A with their measles vaccination, serious concerns were raised regarding the safety of the WHO's recommendation that infants be supplemented with vitamin A at the time of measles immunization. To determine the impact of coadministered vitamin A on the antibody response to measles vaccine given to infants aged 9 mo, the more common age for immunization in developing countries, we conducted a randomized, double-blind, placebo-controlled trial in an urban slum community in Delhi. Infants (618) were randomly allocated to receive 30 mg vitamin A or a placebo with the measles immunization. Antibodies to measles were measured by ELISA in serum samples obtained at before (baseline) and 12 wk after immunization. Overall, the seroconversion rates did not differ between vitamin A (89.5%) and placebo (87.6%) groups. There were no significant differences in the geometric mean titers in the two groups (ratio of geometric means, 1.19; 95% confidence interval, 0.97-1.46). Among malnourished infants, the geometric mean titer was significantly greater in the vitamin A group compared to the placebo group (ratio of geometric means, 1.57; 95% confidence interval, 1. 18-2.0), but seroconversion rates did not differ. There were no differences in seroconversion rates and geometric mean titers in the two study groups among the well-nourished children. These results indicate that 30 mg vitamin A does not reduce the immune response to the coadministered vaccine and, therefore, can be continued to be given safely in public health programs.

Lessons learnt from Diarrheal Diseases Control Program and implications for the future

The national Diarrheal Disease Control Program was launched with the aim of improving the knowledge and practice of appropriate case management among caretakers of young children as well as health care providers. The National Family Health Survey (1992-3) revealed that 42.7% of mothers knew about ORS packets and 25.9% had ever used them. ORS use rates in children who suffered from diarrhea during the previous two weeks varied from 8.3% in Rajasthan to 50.1% in West Bengal. These findings represent substantial accomplishment, and also are a reminder that we still have to reach more than half of the households. Further analysis of the NFHS data showed that exposure to electronic mass media had a significant impact on mothers' awareness about ORS packets (56% in exposed, 32% in unexposed) and ORT use rates (38% in exposed, 25% in unexposed). In this review, future strategies for increasing the impact of the program are discussed. These include involvement of licensed and unlicensed medical practitioners, greater use of the electronic mass media, ORS standardization, greater focus on poorly performing states and resolving residual issues in the case management of diarrhea in malnourished children and infants under 6 months of age.

Role of protozoa as risk factors for persistent diarrhea

A case control study including 175 children aged 0-36 months suffering from diarrhea of > or = 14 days duration was undertaken to determine whether there is an association between Giardia lamblia, Entamoeba histolytica or Cryptosporidium infection and persistent diarrhea (PD). Subjects were identified by ongoing household surveillance and enrolled as cases. For each case two controls were selected by survey of neighbouring households--a child with acute diarrhea and one without diarrhea. Both the controls were matched with the case for age and nutritional status. Two fresh stool samples were collected from all cases and controls at enrollment and examined for trophozoites of Giardia lamblia, Entamoeba histolytica and Cryptosporidium. Giardia lamblia trophozoites were detected in a significantly higher proportion of PD cases (20.0%) than acute diarrheal and non diarrheal controls (4.6% each, p < 0.0001). There were no significant differences in the proportion of cases and controls who passed E. histolytica trophozoites or cryptosporidium in their stools. There was a consistent trend towards poorer weight gain in PD cases who passed Giardia trophozoites in stool; the differences were statistically significant at days 14 and 21, after enrollment. Giardia lamblia infection is more prevalent in PD cases than in acute diarrhea or non-diarrheal controls. This prevalence is not high enough to warrant routine anti-giardia therapy in patients with PD. However, as giardiasis was observed to have adverse growth impact in PD cases, stool microscopy for detection and subsequent treatment of Giardia lamblia seems to be justified.

Plasma zinc as a predictor of diarrheal and respiratory morbidity in children in an urban slum setting

The association between low initial plasma zinc concentration and risk of morbidity over the subsequent 3 mo was examined in a cohort of 116 children aged 12-59 mo recovering from acute diarrhea. Children with low initial plasma zinc (< or = 8.4 micromol/L) had more episodes of diarrhea [risk ratio (RR): 1.47; 95% CI: 1.03, 2.49) and severe diarrhea, defined as passage of > or = 5 liquid stools in a 24-h period, (RR: 1.70; 95% CI: 1.06, 2.72) than did children with normal plasma zinc (> 8.4 micromol/L). The mean prevalence rate of diarrhea associated with fever was 4 times higher in the zinc-deficient group (P = 0.01). Overall, the difference in the number of episodes of acute lower respiratory tract infections (ALRIs) between the two groups was not statistically significant (RR: 1.76; 95% CI: 0.88-3.53) but the mean prevalence rate of ALRIs was 3.5 times higher in children with low plasma zinc (P = 0.05). The increased risk of diarrhea and ALRIs episodes in zinc-deficient children was larger in boys than in girls. These results show that children with low plasma zinc concentrations are at risk for increased diarrheal and respiratory morbidity.

The impact of vitamin A supplementation on physical growth of children is dependent on season

OBJECTIVE

To determine the impact of vitamin A supplementation on physical growth in young children.

DESIGN

Randomized, double blind, placebo controlled trial.

SETTING

Urban slum community clinic.

SUBJECTS

900 children, aged 12-59 months, attending the community clinic with diarrhea of < or = 7 d were included in the trial.

INTERVENTION

Each child was given a single dose capsule containing 200,000 IU vitamin A or placebo at enrollment.

MAIN OUTCOME MEASURES

Mean increments in weight and height during the 90 d period post supplementation.

RESULTS

In all children, the mean increments in weight following supplementation were 0.66 kg (s.d. 0.5) and 0.64 kg (s.d. 0.6) in the vitamin A and placebo groups (P = 0.5). The mean increments in height were also similar in the two treatment groups (P = 0.5). Serum vitamin A was measured in 40 randomly selected children in each group; the proportion of subclinical deficiency (serum retinol < 20 micrograms/dl) was 62.5% in those enrolled during summer (April through July) as compared to 21.1% in those enrolled during the remaining cooler months of the year (P = 0.02). In the children supplemented with vitamin A during summer, the mean increment in weight was 140 g more than those who received placebo (95% confidence interval CI 30-250); there was also a significant reduction in the proportion of children who were wasted (< -2 weight-for-height Z-score) at end study (Odds Ratio 0.53, 95% CI 0.28-1.0, P = 0.03). There was no significant impact of vitamin A on height increments in children supplemented during summer.

CONCLUSION

Vitamin A supplementation in 12-59 month old children improves weight gain in the subsequent three months only in the summer season, but not during the rest of the year.

Breast-feeding status alters the effect of vitamin A treatment during acute diarrhea in children

Vitamin A administration in children reduces the incidence of severe diarrhea during the subsequent few months. We therefore examined the effect of treatment with vitamin A during acute diarrhea on the episode duration and severity. In a double-blind controlled field trial, 900 children 1 to 5 y of age with acute diarrhea of < or = 7 d duration were randomly assigned to receive vitamin A (60 mg) or a placebo. Children were followed up at home every alternate day until they recovered from the diarrheal episode. In all study children, those treated with vitamin A had a significantly lower risk of persistent diarrhea [odds ratio (OR) 0.30, 95% confidence interval (CI) 0.07-0.97], but there was no effect on the mean diarrheal duration or the mean stool frequency, in the subgroup of children who were not breast-fed, the mean diarrheal duration [ratio of geometric means (GM) 0.84, 95% CI 0.72-0.97], mean number of stools passed after the intervention (ratio of GM 0.73, 95% CI 0.56-0.95), the proportion of episodes lasting > or = 14 d (P = 0.002) and the percentage of children who passed watery stools on any study day (OR 0.40, 95% CI 0.21-0.77) were significantly lower in those treated with vitamin A. We conclude that administration of vitamin A during acute diarrhea may reduce the severity of the episode and the risk of persistent diarrhea in non-breast-fed children. Similar benefit was not seen in breast-fed children.

Efficacy of antimicrobial treatment in non-dysenteric persistent diarrhoea in a community setting

OBJECTIVES

To determine the efficacy of antimicrobial treatment in non-dysenteric persistent diarrhoea in a community setting.

METHODS

In this double-blind field trial, 156 children aged 4-36 months with persistent diarrhoea not associated with Giardia lamblia infestation seeking treatment in a community outpatient clinic, were randomized to receive a combination of nalidixic acid and metronidazole, metronidazole alone, or placebo for 7 days.

RESULTS

In comparison with placebo, metronidazole treatment did not result in a significant reduction in the mean post-enrollment diarrhoeal duration and stool frequency, increase in the proportion of patients recovered by days 3, 5 and 7 of treatment, and increase in weight gain at days 7 and 14. Comparing the combination of nalidixic acid and metronidazole with metronidazole alone, 17.5% more children treated with the combination recovered by day 3 of treatment (p = 0.08) and the mean stool frequency ascertained on day 7 for the previous 24 h was 26.8% less in them (p = 0.05). The weight gains at days 7 and 14 were similar in the two groups.

CONCLUSIONS

These findings indicate that metronidazole offers no therapeutic benefit in persistent diarrhoea not associated with Giardia lamblia and nalidixic acid has only a modest clinical benefit, which is not substantial enough to warrant its routine use.

Reduced-osmolarity oral rehydration salts solution multicentre trial: implications for national policy

World Health Organization (WHO) recommended standard ORS solution has sodium (90 mmol/L) and glucose (111 mmol/L) almost in the ratio of 1:1 and a total osmolarity of 311 mmol/L. There are concerns that the sodium or glucose concentration and the overall osmolarity in the formulation is not appropriate. Therefore, the efficacy of standard and reduced-osmolarity ORS solutions in young children with acute diarrhea was evaluated in a recent WHO supervised multicentre trial conducted in India (New Delhi), Brazil, Mexico and Peru. The implications of trial results are discussed. In non-cholera diarrhea, both the standard and reduced osmolarity ORS solutions were effective in achieving clinical rehydration. The stool output was 39% higher in the standard ORS solution group as compared to the reduced-osmolarity ORS solution group. The duration of diarrhea was 22% higher in the standard ORS solution group. The risk of requiring supplementary intravenous infusion was increased in children treated with standard ORS solution [relative risk 1.4 (0.9-2.4)]; this benefit was not observed in Indian patients due to high breast feeding rate. The mean sodium concentration at 24 hours after admission was lower in the reduced osmolarity ORS solution group [135 (134-136) vs 138 (136-139), p < 0.01). The low osmolarity ORS deserves to be evaluated in adult cholera to determine its efficacy and any excess hyponatreamia. Meanwhile, it is reassuring that the WHO formulation was effective and its use was not associated with hypenatremia even in young children. Efforts must continue to be made to promote WHO-ORS while research to improve it further is welcome.

Epidemiology & management of persistent diarrhoea in children of developing countries

Diarrhoea that begins acutely but lasts longer than two weeks is defined to be persistent. Revised estimates in developing countries including India showed that acute diarrhoea accounts for 35 per cent, dysentery 20 per cent and non-dysenteric persistent diarrhoea (PD) for 45 per cent of total diarrhoeal deaths. PD also often changes marginal malnutrition to more severe forms. Factors that increase the risk of acute diarrhoea becoming persistent have been identified in India and other developing countries. These include antecedent malnutrition, micronutrient deficiency particularly for zinc and vitamin A, transient impairment in cell mediated immunity, infection with entero aggregative Escherichia coli and cryptosporidium, sequential infection with different pathogens and lack of exclusive breast feeding during the initial four months of life particularly use of bovine milk. Several issues regarding the management of persistent diarrhoea in hospitalized children in India have been resolved. Diets providing modest amounts of milk mixed with cereals are well tolerated. In those who fail on such diets providing carbohydrate as a mixture of cereals and glucose or sucrose hasten recovery. The role of antimicrobial agents and individual micronutrients in PD is currently being investigated. A management algorithm appropriate for India and other developing countries has been developed and found to substantially reduce case fatality in hospital settings to about 2-3 per cent. Recent epidemiological and clinical research related to persistent diarrhoea is also reviewed.

Increased diarrhoeal and respiratory morbidity in association with zinc deficiency--a preliminary report

Plasma zinc levels, in a cohort of 116 children aged 12-59 months recently recovered from an episode of acute diarrhoea attending a community health clinic in an urban slum, were related to diarrhoeal and respiratory morbidity in the 3 month period following recovery. Children with low plasma zinc levels (< 60 micrograms dl-1) spent a significantly greater number of days with watery diarrhoea (rate ratio 1.69 (95% confidence intervals 1.03-2.78)), diarrhoea associated with fever (rate ratio 1.88 (95% confidence intervals 1.05-3.34)), and acute lower respiratory tract infections (rate ratio 2.69 (95% confidence intervals 1.64-4.38)).

A bacteriological study in hospitalized children with pneumonia

A total of 110 consecutive hospitalized children with severe lower respirator tract infection were studied with the aim of determining the main bacterial pathogens responsible. Of these, 57 were classified as severe pneumonia and 53 as very severe pneumonia. Streptococcus pneumoniae was the most common organism identified in 24.6% and 32.1% of cases of severe and very severe pneumonia, respectively, followed by Haemophilus influenzae type b, which was seen in 17.5% and 20.8%, respectively. The highest diagnostic yield was with the latex particle agglutination test on serum and urine. Blood culture was positive in only ten of the 110 children. No difference was found between the aetiological agents identified in severe and very severe cases of pneumonia. Therefore, the use of different parenteral antibiotics for two clinically defined groups of pneumonia, as recommended by WHO in their standard case management guidelines for the ARI control programme, does not seem necessary.