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To evaluate mitral-aortic flow velocity integral ratio (MAVIR) as an echocardiographic tool to differentiate between severe and nonsevere mitral regurgitation (MR), compared with regurgitant volume (RVol) and effective regurgitant orifice area (EROA), with subgroup analysis in patients with calcific mitral valve, both by transthoracic (TTE) and transesophageal (TEE) echocardiography. Also, whether MAVIR can be used as a screening tool for severe MR.Prospective, cross-sectional, observational.Cardiac operating room of a tertiary-care hospital.One hundred adult patients with chronic mitral regurgitation with at least mild MR by two-dimensional Doppler and with absence of mitral stenosis, aortic valve disease, and rhythm other than sinus scheduled for cardiac surgery. The subgroup (n = 24) consisted specifically of patients with a calcific mitral valve.Preinduction TTE and postinduction TEE in the operating room.MAVIR, RVol, and EROA were measured in all patients both by TTE and TEE. Cohen's kappa statistics was employed to quantify concordance among RVol, EROA, and MAVIR. Diagnostic indices of MAVIR toward diagnosis of severe MR also were quantified. The results showed a strong agreement, in differentiating severe from nonsevere MR, between MAVIR and both RVol and EROA in the whole cohort (n = 100) and the subgroup (n = 24), both by TTE and TEE. Diagnostic indices were high for MAVIR compared with RVol and EROA in detecting severe MR, both by TTE and TEE.MAVIR may be used as an echocardiographic tool to differentiate between severe and nonsevere MR, even in patients with calcific valves. It also can be used to screen patients for severe MR.

Background: In 2018, the Government of India launched Ayushman Bharat – Pradhan Mantri Jan Aarogya Yojana (AB - PMJAY), a large tax-funded health insurance scheme. Provider payment rates for the AB-PMJAY health benefit packages (HBPs) were determined through consultative process and review of existing publicly financed health insurance (PFHI) schemes. In this paper, we present findings of the Costing of Health Services in India (CHSI) study and the process of price revision in 2019. Methods: Reference costs were generated from first phase of CHSI study which sampled 11 tertiary public hospitals from 11 Indian states. Economic costs were estimated using mixed (top-down & bottom-up) micro-costing methods. Based on stakeholder consultations, the cost of HBPs were analysed with different combinations of fixed and variable costs. The HBP cost was compared with AB-PMJAY prices of 2018 and 2019 and the budgetary impact was estimated. Finding: Only 13% of the HBPs in 2018, were close to (± 10%) to the actual cost of providing care. More than one-third (42%) of the HBPs had price less than 50% of the cost. After revision of prices in 2019, the latter decreased to 20%. The evidence-informed revision of HBP prices is estimated to increase claims amount by 200 million (0·7%). Interpretation: Strategic purchasing and price-setting of HBPs require creation of systems of evidence generation on the cost of providing services. Further, research is recommended to develop a cost-function for unit cost estimation with changes in time, region, prices, skill-mix and other factors. Funding Department of Health Research. Funding Statement: The study is funded by Department of Health Research (DHR), Ministry of Health & Family Welfare, Government of India. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: The present study was approved by the Institutional Ethics Committee (IEC) vide letter no. PGI/IEC/2018/00125A and Institutional Collaborative Committee (ICC) vide letter no. 79/30-Edu-13/111273 of Postgraduate Institute of Medical Education & Research, Chandigarh, India.

Active pulmonary tuberculosis (APTB) is associated with a failure of the host immune system to control the invading Mycobacterium tuberculosis (Mtb). The objective of this study was to quantify and assess the role of serum inflammatory cytokines in active pulmonary tuberculosis patients following anti-tuberculosis drug (ATD) therapy. Blood samples were collected from APTB patients and normal healthy subjects (NHS) (total n = 204) at baseline and 2, 4 and 6 months post-therapy and the abundance of serum inflammatory cytokines were measured by cytokine specific ELISA. Compared to NHS, APTB patients at baseline had higher levels of serum pro-inflammatory cytokines IL-12p40 (P < 0.001), IFN-γ (P < 0.001), TNF-α (P < 0.01), IL-1β (P < 0.001) and IL-6 (P < 0.001) and anti-inflammatory cytokines IL-10 (P < 0.001) and TGF-β1 (P < 0.001) while there was no change in the level of IL-4. In APTB patients, the serum levels of IFN-γ, TNF-α, IL-6 and TGF-β1 directly relate to the bacterial load while the TNF-α, IL-1β, IL-6 and TGF-β1 relate to radiological severity. At baseline, the IL-6 level in NHS and APTB patients differed most and following ATD therapy, this level rapidly decreased and stabilized by 4-month in APTB patients. It is concluded that a subtle reduction in the serum level of IL-6 of the APTB patients following ATD therapy might play a vital role in immune-protection of the host against Mtb infection and hence the serum IL-6 level can be a useful marker to diagnose the effectiveness of therapy in the patients.

Objective Post-stroke depression (PSD) is a disabling entity among stroke survivors (SS). Longitudinal studies on PSD, essential to determine its prognosis, are lacking from developing countries. This prospective study was undertaken to assess the prevalence, natural history, and correlates of depression among SS in an Indian community. Methods From a community based stroke registry, SS were assessed annually for cognition, disability, and depression using Bengali validated scales. PSD was diagnosed if score on geriatric depression scale was greater than or equal to 21. Complex sample strategy was considered when calculating prevalence of post stroke depression. An age- and sex-matched case–control study was undertaken to determine the odds of depression in SS. Results Prevalence of PSD was 36.98% (95% confidence interval [CI]: 31.89%–42.06%) among 241 patients assessed at baseline. About 17% developed depression annually and a similar proportion had spontaneous improvement. Peak rate of PSD was beyond 3 months and continued up to 18 months after stroke. Compared to the non-depressed group, PSD subjects were significantly older, had higher age at first stroke, less education, lower socioeconomic status, and greater cognitive impairment and disability. Education had a protective role. Mortality in PSD was nearly twice that in non-depressed patients, though not significant statistically (hazard ratio: 1.84; 95% CI: 0.90–3.77). Compared with controls, odds ratio of PSD was 19.95 (95% CI: 10.09–39.47). Conclusions Approximately one-third of SS develop PSD, similar to developed countries. Prevalence remains stable annually. Delayed peak of PSD suggested later realization of underlying disability. Predictors of PSD have been described and higher literacy was protective in this study.

There is no previously published well-designed study on long-term outcome of stroke from India. The present study has examined the case fatality rate and survival pattern in patients with stroke in a stratified, randomly selected sample from a large Indian metropolitan area. This prospective study was conducted over 7 years (March 2003 to February 2010) using a validated questionnaire administered by a field team and headed by a neurologist. A cross-sectional house-to-house survey was repeated twice yearly. A verbal autopsy was performed to assess cases of death. The Kaplan-Meier method was applied for survival analysis. A cohort of 763 stroke cases were followed up. The overall stroke fatality was approximately 59% at 5 years and 61% at 7 years. Early fatality was 33% within 7 days and 42% within 30 days. Men were at greater risk of death than women. Logistic regression analysis revealed male sex and diabetes to be important predictors of fatality. The majority of deaths were attributable to the index stroke (70%), followed by recurrent stroke (19%) and cardiovascular causes (7%). Beyond the first year, recurrent stroke was by far the most common cause of death. Median survival time exceeded the 84-month observation period when 30-day fatalities were excluded. Early stroke fatality is higher in this study compared with reports from developed countries, but long-term survival is similar. Beyond 1 year, the causes of stroke fatality are similar to that reported in other Asian populations. Access to acute stroke care and appropriate preventive strategy are urgently needed to reduce early stroke fatality in India.

Objective The route of delivery in eclampsia is controversial. We hypothesized that adverse maternal and perinatal outcomes may not be improved by early cesarean delivery. Study Design This was a randomized controlled exploratory trial carried out in a rural teaching institution. In all, 200 eclampsia cases, carrying ≥34 weeks, were allocated to either cesarean or vaginal delivery. Composite maternal and perinatal event rates (death and severe morbidity) were compared by intention-to-treat principle. Results Groups were comparable at baseline with respect to age and key clinical parameters. Maternal event rate was similar: 10.89% in the cesarean arm vs 7.07% for vaginal delivery (relative risk, 1.54; 95% confidence interval, 0.62–3.81). Although the neonatal event rate was less in cesarean delivery–9.90% vs 19.19% (relative risk, 0.52; 95% confidence interval, 0.25–1.05)–the difference was not significant statistically. Conclusion A policy of early cesarean delivery in eclampsia, carrying ≥34 weeks, is not associated with better outcomes.