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: ObjectiveAlthough the prevalence of obesity is not high in Asian Indians, increased prevalence rates of metabolic perturbations and cardiovascular risk factors have been reported. In this study, we evaluated body mass index (BMI), anthropometric measurements, and body fat profiles of obese and non-obese subjects and correlated those values with cardiovascular risk factors.: MethodsThis cross-sectional study involved 639 subjects (170 men and 469 women) from low socioeconomic stratum residing in urban slums of New Delhi. Non-obese subjects were categorized into quartiles of percentage of body fat (%BF) and waist circumference (WC). Using logistic regression analysis, the odds ratios (ORs) and 95% confidence intervals (CIs) for the occurrence of cardiovascular risk factors (diabetes mellitus [DM], hypertension, hypercholesterolemia, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, and high levels of low-density lipoprotein cholesterol) were computed with first quartile in the non-obese group as the reference category for the following five categories: %BF and WC quartiles in the non-obese group and obese group (BMI ≥ 25 kg/m2).: ResultsIn the non-obese group, approximately 66% of men and 88% of women had at least one risk factor. In non-obese women, significantly high ORs and 95% CIs were found for hypertension (3.2, 1.4–7.2), DM (2.8, 1.2–6.3), and hypertriglyceridemia (3.9, 1.9–8.3) in the upper quartiles of %BF, and significantly high OR (95% CIs) was observed for hypertriglyceridemia (3.9, 1.4–10.8) in non-obese men. Among non-obese men, significantly high OR (95% CIs) was found for hypertriglyceridemia (3.2, 1.0–10.3); among non-obese women, significantly high ORs (95% CIs) were observed for hypertension (2.5, 1.1–5.8) and hypertriglyceridemia (2.5, 1.2–5.2) in the normal range of WC (70–80 cm).: ConclusionThe study showed that Asian Indians have excess cardiovascular risk at BMI and WC values considered “normal.” These data suggested that definitions of “normal” ranges of BMI and WC need to be revised for Asian Indians. [Copyright &y& Elsevier]

The current study estimated incident breakthrough seizures, serum matrix metalloproteinase-9 (MMP-9), and perfusion magnetic resonance imaging (MRI) parameters in five- to 18-year-olds with neurocysticercosis (NCC) from colloidal or vesicular through calcified stages over at least 24 months' follow-up. Single, colloidal, or vesicular parenchymal NCC cases were treated with albendazole and steroids and followed at a tertiary care north Indian hospital. Serum MMP-9 was estimated in colloidal or vesicular treatment-naive state and in a subset of calcified cases at six-month follow-up. The same subset of calcified cases also underwent perfusion MRI of the brain at six-month follow-up. Among 70 cases, 70% calcified at six-month follow-up. Over a median follow-up of 30 months, the incidence of breakthrough seizures was 48.6% (61.2% in calcified and 19.2% in resolved, P = 0.001; 32.9% early [within six months] and 15.7% late [beyond six months], P = 0.02). Serum MMP-9 levels were higher in colloidal and vesicular compared with calcified stage (242.5 vs 159.8 ng/mL, P = 0.007); however, there was no significant association with breakthrough seizures and/or calcification in follow-up. In a subgroup of calcified cases (n = 31), the median relative cerebral blood volume on perfusion MRI in and around the lesion was lower in those with seizures (n = 12) than in those without (n = 19) (10.7 vs 25.2 mL/100 g, P = 0.05). In post-treatment colloidal or vesicular NCC, incident breakthrough seizures decrease beyond six months. In calcified NCC with remote breakthrough seizures, significant perilesional hypoperfusion is seen compared with those without seizures. [ABSTRACT FROM AUTHOR]

Sleep disorders are common in childhood and adolescence with mental and physical consequences needing appropriate intervention by caregivers and health care providers (HCPs). The objective of the study, conducted at a tertiary teaching hospital and public school in north India, was to develop validated questionnaires to evaluate childhood and adolescent sleep awareness in caregivers and HCPs. The study participants (caregivers represented by parents of 2-18 year olds attending a public school and of those attending outpatient services at the study hospital and HCPs represented by medical interns and nursing graduates within 1 year of graduation) were enrolled after appropriate screening. Two separate questionnaires in English for caregivers (also translated in Hindi) and HCPs were applied on 313 caregivers and 175 HCPs (110 medical interns and 65 nursing graduates) and developed and validated with a Cronbach α of 0.73 and 0.74, respectively. The questionnaires covered three domains: sleep hygiene, sleep related health problems, and miscellaneous. Both group of respondents had >50% correct responses in sleep hygiene. The ĸ agreement between knowledge and practice of sleep hygiene in caregivers was 0.2. Poor response (<50% correct responses) was seen in sleep-related health problems in both groups of respondents implying knowledge deficit in various sleep disorders. The HCPs performed poorly on basic theoretical questions in miscellaneous domain. For consultation of sleep problems, most caregivers (48%) chose pediatricians. There is a need to strengthen undergraduate medical and nursing curriculum in sleep. Caregivers should be made aware of implications of unhealthy sleep. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the effects of pistachio nuts as an adjunct to diet and exercise on body composition, metabolic, inflammatory, and oxidative stress parameters in Asian Indians with metabolic syndrome. Methods: In this 24-wk randomized control trial, 60 individuals with the metabolic syndrome were randomized to either pistachio (intervention group) or control group (diet as per weight and physical activity profile, modulated according to dietary guidelines for Asian Indians) after 3 wk of a diet and exercise run in. In the first group, unsalted pistachios (20% energy) were given daily. A standard diet and exercise protocol was followed for both groups. Body weight, waist circumference (WC), magnetic resonance imaging estimation of intraabdominal adipose tissue and subcutaneous abdominal adipose tissue, fasting blood glucose (FBG), fasting serum insulin, glycosylated hemoglobin, lipid profile, high-sensitivity C-reactive protein (hs-CRP), adiponectin, free fatty acids (FFAs), tumor necrosis factor (TNF)-α, leptin, and thiobarbituric acid reactive substances (TBARS) were assessed before and after the intervention. Results: Statistically significant improvement in mean values for various parameters in the intervention group compared with control group were as follows: WC (P < 0.02), FBG (P < 0.04), total cholesterol (P < 0.02), low-density lipoprotein cholesterol (P < 0.006), hs-CRP (P < 0.05), TNF-α (P < 0.03), FFAs (P < 0.001), TBARS (P < 0.01), and adiponectin levels (P < 0.001). Conclusion: A single food intervention with pistachios leads to beneficial effects on the car-diometabolic profile of Asian Indians with metabolic syndrome. [ABSTRACT FROM AUTHOR]

Ivermectin is an antiparasitic drug which has in-vitro efficacy in reducing severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) viral load. Hence, Ivermectin is under investigation as a repurposed agent for treating COVID-19. In this pilot, double blind, randomized controlled trial, hospitalized patients with mild-to-moderate COVID-19 were assigned to a single oral administration of an elixir formulation of Ivermectin at either 24 mg or 12 mg dose, or placebo in a 1:1:1 ratio. The co-primary outcomes were conversion of RT-PCR to negative result and the decline of viral load at day 5 of enrolment. Safety outcomes included total and serious adverse events. The primary outcomes were assessed in patients who had positive RT-PCR at enrolment (modified intention-to-treat population). Safety outcomes were assessed in all patients who received the intervention (intention-to-treat population). Among the 157 patients randomized, 125 were included in modified intention-to-treat analysis. 40 patients each were assigned to Ivermectin 24 mg and 12 mg, and 45 patients to placebo. The RT-PCR negativity at day 5 was higher in the two Ivermectin arms but failed to attain statistical significance (Ivermectin 24 mg, 47.5%; 12 mg arm, 35.0%; and placebo arm, 31.1%; p-value = 0.30). The decline of viral load at day 5 was similar in each arm. No serious adverse events occurred. In patients with mild and moderate COVID-19, a single oral administration of Ivermectin did not significantly increase either the negativity of RT-PCR or decline in viral load at day 5 of enrolment compared with placebo. [ABSTRACT FROM AUTHOR]

Objectives: This Systematic Review was conducted to evaluate the global status of the knowledge of prevention and emergency management of traumatic dental injuries among non-dental healthcare professionals (NDHCP).Methods: The protocol was designed as per PRISMA guidelines and registered in PROSPERO (CRD42020192381). A broad-based search using text-words and MeSH terms was performed in established databases as per a predefined strategy without any distinction of language and year of publication. Studies without details of the questionnaire, knowledge score, validity and reliability were excluded. Data extraction was performed and risk of bias assessment was done using the Joanna Briggs Institute's critical appraisal tool and a meta-analysis was performed.Results: The qualitative synthesis included 14 studies between 2009-2020 with nine of them from Asia. Majority of the studies had low risk of bias and reported poor overall level of knowledge. Less than 40% of the NDHCP had received a dental trauma first aid training in six of the 10 studies and majority of the participants (>50%) believed that dental trauma training was required in five studies. Less than 36% of the participants were adequately aware of the correct approach towards management of avulsed permanent tooth in five studies.Conclusion: The knowledge of non-dental health care professionals regarding the emergency management of traumatic dental injuries was insufficient or low in the majority of studies and the knowledge about prevention was not evaluated. There was a paucity of studies from the countries of Europe and Australia, with wide variability in the study methods, categories of the participants and questionnaire characteristics. [ABSTRACT FROM AUTHOR]

Children with infantile epileptic encephalopathies comprising 3.5% of the Pediatric Neurology Clinic registrations in a tertiary care hospital were retrospectively analyzed. Data were retrieved from case records and analyzed for seizure semiology, prenatal and perinatal insults, developmental status and relevant investigations. The various therapeutic modalities and their influence on spasm frequency, long-term development and final seizure status were compared. The two primary outcome variables analyzed included final seizure status and developmental outcome. Of the 94 infantile epileptic encephalopathies, West syndrome was the commonest (55.3%), of which two thirds were symptomatic. Etiological factors were prenatal in 66.6% and perinatal in 33.3%. The initial response to ACTH was good in 54.5% with subsequent relapse in 27.8% and for prednisolone was 52.9 and 44.4%, respectively, compared to 25.3% spasms control with conventional antiepileptic drugs. Disease category of infantile epileptic encephalopathies evolved in 4, i.e. early myoclonic encephalopathy to West syndrome 1, early infantile epileptic encephalopathy to West syndrome 1, West syndrome to Lennox–Gastaut syndrome 2. Psychomotor retardation was seen in 88.2%, with 16.1% having normal development at onset of spasms. Microcephaly was associated with delayed development but did not influence final seizure outcome. Final seizure outcome was poor in children with delayed development at onset (adjusted odds ratio {OR}=4), delay in diagnosis >12 months (OR=2.27) and in children with Lennox–Gastaut syndrome (OR=4.75). ACTH/prednisolone and antiepileptic treatment versus antiepileptics alone showed a good final seizure response in 36.6% versus 20%. Development on follow up was delayed in children with initial psychomotor retardation (OR=23.4) and abnormal electroencephalogram (OR=7.46). Perinatal factors constituted one third of symptomatic West syndrome. The use of ACTH/corticosteroids resulted in good initial spasm control though final seizure outcome and development were unaffected. Prednisolone had similar response to ACTH in spasm control but higher subsequent relapse rate. Vigabatrin was useful though often unaffordable. The identification of a neurometabolic etiology, though uncommon, has significant therapy implications. Delay in diagnosis was common and negatively influenced final seizure outcome. [Copyright &y& Elsevier]

Background: The prevalence of sleep-disordered breathing is high in children with Down syndrome. Although the association between sleep-disordered breathing and developmental delay and behavioral abnormalities are proven among typically developing children, there are few such studies of children with Down syndrome. This study assesses the relationship between the severity of sleep apnea and development and behavioral abnormalities in individuals with Down syndrome.Methods: In a cross-sectional prospective study, 53 children with Down syndrome were assessed for sleep-disordered breathing by overnight polysomnography. Behavior was assessed using Child Behavior Checklist (CBCL) and developmental quotient (DQ) using Developmental Profile 3. The association between various domains of behavior and development with the Apnea-Hypopnea Index (AHI) was assessed using Spearman rank correlation. Multiple linear regression assessed the independent effects of various factors on development and behavior.Results: Of 53 subjects (three to 11.8 years), 51 (96%) were found to have obstructive sleep apnea (OSA). In both three to five year and six to 12 year age groups, there was a statistically significant positive correlation between the CBCL scores and the AHI (rho = 0.77 and 0.83, respectively). There was a statistically significant negative correlation between the DQ and the AHI (rho = -0.62). In multiple linear regression, AHI was the only independent variable that was associated with CBCL and DQ.Conclusions: This study provides robust evidence that OSA can negatively influence the development and behavior in children with Down syndrome as in typically developing children. Moreover, with increasing severity of OSA, children with Down syndrome have more behavioral abnormalities, especially attention deficit and hyperactivity, and also have poorer development scores. [ABSTRACT FROM AUTHOR]

• Collectively, uncommon and compound EGFR mutations are detected in 6.5 % of NSCLC patients. • Single exon 20 T790M mutations were the third most frequent EGFR mutations. • Uncommon/compound EGFR mutations showed poor treatment outcomes following EGFR TKI and chemotherapy. Mutations in the tyrosine kinase domain of the epidermal growth factor receptor gene (EGFR) are key driver alterations in lung adenocarcinomas (ADCAs). Exon 19 deletions (exon19del) and exon 21 L858R (L858R) mutations account for 70–90 % of all such alterations and predict sensitivity to EGFR tyrosine kinase inhibitors (TKIs). However, the predictive value of uncommon and compound EGFR mutations for TKIs has not been clearly established. To assess the spectrum of EGFR mutations in non-small-cell lung carcinoma (NSCLC), and to compare the treatment responses and outcomes among single common, single uncommon, and compound mutations. The study was of combined retrospective (January 2010–December 2015) and prospective (January 2016–February 2020) design spanning 10 years. Tumor samples from TKI-naive NSCLC patients were tested for EGFR mutations by a qPCR-based method. Objective response rates (ORRs) and survival outcomes were analyzed. In total, 1227 tumor samples were tested. EGFR mutations were detected in 391 samples (31.8 %), and included 79.5 % (311/391) single common (exon19del/L858R), 6.6 % (26/391) single uncommon (non-exon19del/L858R), and 13.8 % (54/391) compound mutations. Exon 20 T790M mutations were most prevalent among uncommon/compound mutations (40/391, 10.2 %). Overall, patients with single uncommon/compound mutations responded poorly to both EGFR TKI (47 % ORR) and chemotherapy (43 % ORR), with significantly shorter time to progression (median 7 months) compared to those with exon19del/L858R mutations (median 14.7 months). Patients with baseline T790M mutations (single/compound) were least responsive to EGFR TKIs (11 % ORR) and chemotherapy (27 % ORR) and showed the shortest progression-free survival compared to other uncommon and compound mutations. Approximately one fifth of EGFR- mutant patients harbor uncommon and compound mutations. Unlike those with exon19del/L858R, these patients—particularly those with baseline T790M mutations—show significantly inferior response rates to treatment (EGFR TKI or chemotherapy) and early disease progression. [ABSTRACT FROM AUTHOR]

Background: The prevalence of autism spectrum disorder (ASD) is on the rise. Apart from the core behavioral issues of impaired communication, impaired social interaction, and restricted and/or repeated behavioral phenotype, comorbidities like sleep problems are increasingly getting recognized as important determinants of management and overall quality of life.Methods: This study was conducted in a tertiary care teaching hospital in northern India over a two year period. Children diagnosed with ASD and normally developing children (control subjects) aged 3 to 10 years were enrolled in the study. Both groups underwent sleep evaluation based on the Children's Sleep Habit Questionnaire. Children with ASD also underwent polysomnography, Childhood Autism Rating Scale, Childhood Behavioral Checklist, and Developmental Profile 3 assessments.Results: The prevalence of poor sleepers among children with ASD and control subjects was 77.5% (confidence interval 66 to 86.5). and 29.2% (confidence interval 18.6 to 41.5), respectively (P < 0.001). The salient findings on polysomnography were reduced sleep efficiency, decreased rapid eye movement and slow wave sleep duration, and desaturation index>1. The Childhood Behavioral Checklist score was significantly high in poor sleepers compared with good sleepers on Children's Sleep Habit Questionnaire (P = 0.004). There was no correlation of Childhood Autism Rating Scale or Developmental Profile 3 score with sleep problems in children with ASD.Conclusions: Nearly three fourths of children with ASD have sleep abnormalities with a possible effect on the behavioral phenotype. The polysomnographic findings provide further insight with opportunity for pharmacological interventions. Screening for sleep problems is imperative for the appropriate management and overall improvement in quality of life in children with ASD. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The objective of this randomized single blind (outcome assessor) controlled trial was to evaluate the efficacy of 4weeks of modified constraint induced movement therapy (mCIMT) in improving upper limb function in 3–8years old children with hemiplegic cerebral palsy. Methods: Thirty-one children were randomly assigned to receive the mCIMT (N =16) with conventional therapy or conventional therapy alone (N =15). Children were evaluated three times (at enrollment, follow up at 4weeks and 12weeks). The primary outcome measure was difference in “change in mean total QUEST scores” at 4weeks of intervention between the intervention and the control arm. Results: After 4weeks of intervention, mCIMT group showed significant change in the affected upper limb in QUEST scores (10.7±5.2 vs 1.4±1.7, p <0.001) and time (s) to complete nine-hole-pegboard test compared with control group [60(0–130) vs 5(−12 to 30), p <0.001]. The improvement observed in upper limb function after 4weeks of intervention persisted 8weeks after discontinuation of intervention in mCIMT group. Conclusion: The modified constraint induced movement therapy appears to be effective in improving upper limb function in 3–8years old hemiplegic cerebral palsy children. [Copyright &y& Elsevier]

Abstract: Background: Genetics of non-alcoholic fatty liver (NAFLD) in Asian Indians has been inadequately studied. We investigated the association of polymorphisms C161T and Pro12Ala of peroxisome proliferator-activated receptor gamma (PPARγ) with clinical and biochemical parameters in Asian Indians with NAFLD. Methods: In this case–control study, 162 NAFLD cases and 173 controls were recruited. Abdominal ultrasound, clinical and biochemical profiles, fasting insulin levels and value of homeostasis model assessment of insulin resistance were determined. Polymerase chain reaction–restriction fragment length polymorphisms of two polymorphisms were performed. The association of these polymorphisms with clinical and biochemical parameters was analysed. Results: Higher frequency of Ala and T alleles of PPARγ was obtained in cases. Ala/Ala genotype of PPARγ (Pro12Ala) was associated with significantly higher serum triglycerides (TG), alkaline phosphatase (ALK) and waist–hip ratio in cases as compared to controls. In C161T polymorphism, TT genotype was significantly increased TG (p =0.04), total cholesterol (p =0.01), ALK (p =0.04) and gamma-glutamyl transpeptidase (p =0.007) in cases. The linkage disequilibrium for these two single-nucleotide polymorphisms of PPARγ was differed in cases (D1=0.1; p =0.006) and controls (D1=0.07; p =0.1). Using a multivariate analysis after adjusting for age, sex and body mass index, the presence of NAFLD was linked to these two polymorphisms (odds ratio 1.64 (95% CI: 1.09–2.45, p =0.05)]. Conclusion: Asian Indians in north India carrying the alleles Ala and T of PPARγ (Pro12Ala and C161T) polymorphisms are predisposed to develop NAFLD. [Copyright &y& Elsevier]

Summary: Purpose: The ketogenic (lipid to non-lipid) ratio may play an important role in the efficacy and tolerability of ketogenic diets (KD). This study was planned to compare the efficacy and tolerability of 2.5:1 versus 4:1 lipid:non-lipid ratio KD in young children with refractory epilepsy. Methods: Children aged 6 months to 5 years with refractory epilepsy were enrolled. They were randomized to receive either a 4:1 or 2.5:1 ketogenic ratio diet, which was introduced using a non-fasting protocol. Seizure frequency, biochemical profile (liver and kidney function tests, fasting lipid profile, and spot urinary calcium–creatinine ratio), and adverse effects were recorded at three months in both groups. Results: Thirty eight children were enrolled, 19 in each group. At three months, 11 children (58%) in the 4:1 group and 12 (63%) in the 2.5:1 group had more than 50% reduction in seizures (p =0.78). Five children (26%) in the 4:1 group and four (21%) in 2.5:1 group became seizure free. There was no significant difference in the biochemical parameters between the two groups. Conclusion: 2.5:1 ratio KD is possibly as effective as 4:1 KD in controlling seizures and has fewer adverse effects. [Copyright &y& Elsevier]

Summary: Background: Epilepsy is associated with imbalance of sympathetic and parasympathetic activity which may lead to sudden unexplained death in epilepsy (SUDEP). Well-controlled (WcE) and intractable epilepsy (IE) subjects may present different autonomic profiles, which can be helpful in explaining the predisposition of the latter to SUDEP. Purpose: To compare inter-ictal cardiovascular autonomic function in subjects with partial WcE and IE. Methods: Thirty WcE and 31 IE subjects underwent a battery of autonomic function tests: deep breathing, Valsalva maneuver, isometric exercise, cold pressor and tilt-table. Autonomic tone was assessed by heart rate variability (HRV). Their autonomic severity score and anxiety status was also assessed. Results: IE subjects had elevated low frequency component (52.0 vs. 37.6, p =0.047) and decremented high frequency component (114 vs. 397, p =0.013) of HRV and higher diastolic BP (75.62±9.77 vs. 68.64±0.43, p =0.036). In deep breathing test, they had lesser HR changes (20±10.18 vs. 29.68±11.23, p =0.007) and lower E:I (1.29±0.16 vs. 1.43±0.21, p =0.008). IE subjects had higher dysautonomia (chi square 165.0, p <0.0001). Conclusions: We observed a higher vasomotor tone, higher sympathetic tone, lower parasympathetic tone, lower parasympathetic reactivity and more severe dysautonomia in the IE subjects. Refractoriness may lead to an alteration in cardiovascular autonomic regulation, which might be a predisposing factor for SUDEP. [Copyright &y& Elsevier]

Besides hyperglycemia and hypertension, a recently recognized risk factor for diabetic retinopathy (DR) appears to be hyperlipidemia. While studies using earlier generation lipid lowering agents in DR were disappointing, a randomized trial using HMG-CoA Reductase Inhibitors has strong rationale, though hitherto not attempted. The aim of the present study was to compare the HMG-CoA Reductase Inhibitor, simvastatin, with placebo in patients having DR in a double-blind randomized placebo-controlled trial. Fifty patients with diabetes mellitus (Type 1 and 2) with good glycemic control and hypercholesterolemia and having DR (non-clinically significant macular edema and visual acuity 6/24 or better) in either or both eyes were randomized to simvastatin 20-mg per day or placebo, and were followed up for 180 days. On simvastatin therapy, total cholesterol and low-density lipoprotein cholesterol (LDL-C) decreased (P<0.001, respectively), and the level of high-density lipoprotein cholesterol (HDL-C) increased (P<0.001). VA improved in four patients using simvastatin, (not statistically different from placebo group) and worsening of VA occurred in seven patients in the placebo group and none in the simvastatin group (P=0.009). Fundus fluorescein angiography and color fundus photograph showed improvement in one patient in the simvastatin group, while seven patients showed worsening in the placebo group (P=0.009). The observations of the current study suggest that the HMG-CoA Reductase Inhibitor simvastatin significantly retards the progression of retinopathy in diabetic patients with hypercholesterolemia. The potential of this class of drugs for the primary prevention of DR and other microvascular complications needs to be explored further. [Copyright &y& Elsevier]

Abstract: Aims: The metabolic syndrome (MS) and type 2 diabetes mellitus (T2DM) are common in Asian Indians. Simple yet reliable phenotypic markers are needed for early detection of the MS in Asian Indians. Methods: In this cross-sectional study, 126 subjects either with of without the MS were compared. Anthropometric measurements (including assessment of novel phenotypic markers) and metabolic profile were done. Results: On univariate analysis, age more than 35 year, female gender, presence of buffalo hump and double chin and family history of T2DM were significantly associated with the MS. A metabolic syndrome screening (MSS) score (1.0×double chin+1.2×buffalo hump+1.3×gender+1.4×age category) was generated with a cutoff value of 3.5 out of total points of 4.9, with sensitivity and specificity 82% and 71% [area under the curve=0.83; 95% confidence Interval (0.76–0.90)], respectively in detecting individuals with the MS. Conclusion: We describe buffalo hump and double chin as novel phenotypic markers for detection of MS for the first time. The MSS score generated by us may be a useful tool for detection of MS in adult Asian Indians; however, it needs further validation in a larger sample of Asian Indians and in other ethnic groups. [Copyright &y& Elsevier]