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Background: Admissions for acute myocardial infarction (MI) have declined significantly during the COVID-19 pandemic. The changes in the presentation, management, and outcomes of MI during the pandemic period are not well recognized, and data from low- and middle-income countries are limited. Methods: In this two-timepoint cross-sectional study involving 187 hospitals across India, patients admitted with MI between 15th March to 15th June in 2020 were compared with those admitted during the corresponding period of 2019. We sought to determine the changes in the number of admissions, management practices, and outcomes. Findings: We included 41,832 consecutive adults with MI. Admissions during the pandemic period (n = 16414) decreased by 35·4% as compared to the corresponding period in 2019 (n = 25418). We observed significant heterogeneity in this decline across India with the North zone reporting greater decline (-44·8%) than the South zone (-27·7%). The weekly average decrease in MI admissions in 2020 which peaked around the mid- study period, correlated negatively with the number of COVID cases (r = -0·48; r 2 = 0·2), but strongly correlated with the stringency of lockdown index (r = 0·95; r 2 = 0·90). On a multi-level logistic regression, admissions were lower in 2020 with older age categories, tier 1 cities, and centers with high patient volume, and teaching programs. Adjusted utilization rate of coronary angiography, and percutaneous coronary intervention decreased by 11·3%, and 5·9% respectively. However, the in-hospital mortality rates did not differ. Interpretation: The magnitude of reduction in MI admissions across India was not uniform. The nature, time course, and the patient demographics were different compared to reports from other countries, suggesting a significant impact due to the lockdown. These findings have important implications in managing MI admissions during the pandemic. Funding Statement: The study is funded by cardiological society of India. Declaration of Interests: Nothing to declare for all the authors. Ethics Approval Statement: Individual participating centres either obtained an ethical approval from respective Institutional ethics committees or a no objection certificate from the administration.

Chronic obstructive pulmonary disease (COPD) is a major public health problem in India. Its magnitude is particularly high among the elderly. Old age and comorbidity may lead to misdiagnosis and under treatment of this condition. COPD is not curable; however, various forms of treatment can help control symptoms and improve the quality of life. Most of the earlier studies lacked uniformity in definitions, designs, methodology and reporting techniques. Studies based on spirometry are only a few. Understanding the current prevalence and associated factors of COPD is important for planning control strategies. Hence, this study was conducted to determine the prevalence of COPD and associated factors among the elderly.In this community-based study among 449 elderly persons in a rural area, information regarding socio-demographic details, selected health conditions and exposure to risk factors was recorded. The assessment of airway obstruction was done by using a portable spirometer (MIR Spirolab). The diagnosis of COPD was based on the GOLD criteria. The association of COPD with sociodemographic and other variables was analysed by the multivariate logistic regression.Acceptable spirometry findings were available for 392 (87.3%) participants. The prevalence of COPD was 42.9 per cent (95% confidence interval 37.9-47.7%). The prevalence was 54.5 per cent among men and 33.4 per cent among women. Smoking, higher age group and low body mass index were significantly associated with COPD.The prevalence of COPD was found to be high among the rural elderly in this study. Interventions aimed at cessation of smoking and preparedness of health systems for diagnosis and management of COPD are hence required.

Objective: To evaluate the role of shear wave elastography (SWE) of suspicious axillary lymph nodes and its combination with B-mode USG in predicting nodal metastasis in breast cancer patients. Methods: Prospective observational study was performed from June 2018 to August 2020 on breast cancer patients with suspicious axillary nodes on USG. B-mode features (cortical thickness, effacement of fatty hilum, non-hilar blood flow and round shape) and SWE parameters (Emax, Emin, Emean and ESD) of the node with the thickest cortex were evaluated. Diagnostic performances of USG, SWE and their combination were estimated using pathological status of the node on biopsy as the gold standard. Results: Of the 54 patients evaluated, optimal elasticity maps were obtained in 49 nodes of 49 patients (mean age, 46.3 ± 12.1 years; 48/49 (98%) females). On biopsy, 38 nodes (77.6%) had metastasis, while 11 (22.4%) had reactive hyperplasia. Emax, Emin, Emean and ESD of both cortex and hilum were significantly higher in metastatic than reactive nodes. Emax (cortex) ≥14.9 kPa had the best diagnostic performance (sensitivity, 73.7%; specificity, 81.8%). Cortical thickness ≥6.7 mm had the best diagnostic performance among B-mode features (sensitivity, 89.5%; specificity, 72.7%). Combining cortical thickness with effacement of fatty hilum and/or non-hilar blood flow yielded sensitivity of 89.5% and specificity of 90.9%. Addition of Emax (cortex) to cortical thickness and combination of ≥2 B-mode features increased their specificities to 90.9 and 100%, respectively. Conclusions: Metastatic axillary nodes are stiffer than reactive nodes on SWE in breast cancer patients. Emax (cortex) has the best diagnostic performance in differentiating between reactive hyperplasia and nodal metastasis. Combination of Emax (cortex) and cortical thickness increases the specificity for diagnosing metastasis, especially in nodes showing only cortical thickening. Advances in knowledge: Combination of SWE and B-mode USG is highly specific for differentiating metastasis from reactive hyperplasia in suspicious nodes of breast carcinoma patients, especially in nodes with only cortical thickening.

Diffuse midline gliomas (DMGs) are rare and devastating tumors with limited therapeutic options. Programmed death-ligand 1 (PD-L1) expression represents a potential predictive biomarker for immunotherapy. One hundred and twenty-six DMGs (89 adult and 37 pediatric) were assessed for immune profile (PD-L1, cluster of differentiation (CD3, CD8) and genetic markers (mutation in 27th amino acid of histone H3 (H3K27M), alpha thalassemia/mental retardation syndrome X-linked (ATRX), isocitrate dehydrogenase 1 (IDH1), p53) by immunohistochemistry. Sanger sequencing was done for IDH1 and H3K27M. The thalamus was the commonest site. Four molecular subgroups of DMGs were identified. H3K27M mutation was more frequent in children (P = 0.0001). The difference in median overall survival (OS) was not significant in any of the four molecular subgroups (P 0.05). PD-L1 expression was significantly higher in H3K27M/IDH1 double-negative adult glioblastomas (GBMs) (P = 0.002). Strong PD-L1 expression was more frequent in grade IV tumors and thalamic location, although the difference was not significant (P = 0.14 and P = 0.19 respectively). Positive PD-L1 expression was significantly associated with high tumor-infiltrating lymphocytes count (P 0.05). There was no significant difference in median OS in PD-L1-positive versus negative cases among four genetic subgroups (P 0.05). On univariate analysis, there was no direct correlation of PD-L1 with any genetic alteration, except H3K27M mutation (P = 0.01). CD3 infiltration was similar in both adults and pediatric ages (84.3% and 78.4%, respectively) while CD8 expression was significantly greater in adults compared to children (74.1% vs 37.8%, P = 0.0001). This is the first comprehensive analysis highlighting molecular and immune profiles of DMGs. Despite molecular and clinicopathological diversity, overall survival in DMGs remains dismal. Multicentric studies with larger numbers of cases should be undertaken for stratifying DMGs according to their age, immune and molecular profiles, to develop effective immunotherapies.

Objective: Hypertension is the most important risk factor for cardiovascular morbidity and mortality. There is limited data on hypertension prevalence in India. This study was conducted to estimate the prevalence of hypertension among Indian adults. Methods: A national level survey was conducted with fixed one-day blood pressure measurement camps across 24 states and union territories of India. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or a diastolic BP ≥90 mmHg or on treatment for hypertension. The prevalence was age- and gender-standardized according to the 2011 census population of India. Results: Blood pressure was recorded for 180,335 participants (33.2% women; mean age 40.6 ± 14.9 years). Among them, 8,898 (4.9%), 99,791 (55.3%), 35,694 (11.9%), 23,084 (12.8%), 9,989 (5.5%), and 2,878 (1.6%) participants were of the age group 18–19, 20–44, 45–54, 55–64, 65–74, and ≥ 75 years, respectively. Overall prevalence of hypertension was 30.7% (95% confidence interval [CI]: 30.5, 30.9) and the prevalence among women was 23.7% (95% CI: 23.3, 24). Prevalence adjusted for 2011 census population and the WHO reference population was 29.7% and 32.8%, respectively. Conclusion: There is a high prevalence of hypertension, with almost one in every three Indian adult affected. Keywords: Hypertension, India, Prevalence

The aim was to compare the renal dynamic scan (RDS) performed with technetium-99-L,L-ethylene dicysteine (Tc-L,L-EC) and technetium-99-mercaptoacetyltriglycine (Tc-MAG3) in children with pelviureteric junction (PUJ) obstruction. A retrospective study was carried out and children with PUJ obstruction who had RDS performed with both Tc-L,L-EC and Tc-MAG3. Children with any intervention in between the two scans or a gap of more than 2 months in between renal scans were excluded. The dose of each radiotracer used was 0.1 mCi/kg (3.7 MBq/kg), with a minimum dose of 1 mCi (37 MBq). RDS was performed using the F+0 protocol. The differential renal function, Tmax, T1/2, drainage pattern, and hepatic uptake of the radiotracer were recorded and compared. A Bland-Altman plot was used to assess agreement between the two radiotracers. Sixteen children were included in the study. A total of 18 obstructed and 14 normal renal units were available to us for study. The values of differential renal function as well as Tmax and T1/2 of the two radiotracers were in agreement. In three obstructed kidneys in which T1/2 on Tc-MAG3 was greater than 20 min, Tc-L,L-EC showed T1/2 values of 13.3 min or less. Tc-L,L-EC showed nonobstructive drainage in three patients who had shown partial obstruction on Tc-MAG3 scan. The hepatic uptake of Tc-L,L-EC was also lower compared with Tc-MAG3. To conclude Tc-L,L-EC is a useful radiotracer for the evaluation of children with PUJ obstruction, with better assessment of drainage and lower hepatic uptake compared with Tc-MAG3.

Few studies have tried to assess prognostic variables in chronic obstructive pulmonary disease (COPD) patients requiring mechanical ventilation (MV). We evaluated serum C reactive protein, (CRP) pre-albumin (PA) and transferrin (TR) levels in AE-COPD patients requiring MV as prognostic markers of in hospital mortality. 93 AE-COPD patients on MV were evaluated. Detailed clinical evaluation was done daily. Serum CRPPA were measured on admission, 3rd, 8th and 16th day; TR was measured on admission, 8th and 16th day. Demographics, baseline parameters, CRP, PA and TR were correlated with mortality. Of 93 patients, 49 (52.69%) survived whereas 44 patients (47.31%) died. APACHE II, serum ureaalbumin were similar in survivorsnon-survivors. Baseline CRP (≥10.5 mg/dl) had sensitivity of 60.5%, specificity of 60.2%, with area under curve (AUC) of 0.62 as predictor of mortality. CRP (≥7 mg/dl) on day 3 had sensitivity (65.5%) and specificity (63.3%) with AUC 0.70 as predictor of mortality. Baseline serum prealbumin was 11.00 (0.09-29.26) mg/dl, and similar in survivorsnon-survivors (

Background: Falls are a common, disabling, and frequently fatal health concern among elderly persons. Assessment of the prevalence of falls and associated factors can lead to the identification of corrective measures, which can help in preventing falls and their consequent effects on health and well-being of the elderly. Objectives: The objective is to determine the prevalence of falls among elderly persons in a rural area and to study the association of falls with sociodemographic variables and selected health conditions. Methods: In a community-based, cross-sectional study conducted among 456 elderly persons in a rural area, information regarding sociodemographic details, selected health conditions, and history of falls in the past 12 months was recorded. Univariate analysis followed by stepwise multivariate logistic regression analysis was carried out. The effect of sociodemographic and various health conditions on falls was analyzed using logistic regression analysis. Results: Among the 456 study participants, the prevalence of falls in the past 12 months was 36.6% (95% confidence interval [CI] =32.1–40.0). The prevalence among women was 40.6% (95% CI = 34.5–46.7) and among men was 31.5% (95% CI = 25.0–37.9). Low socioeconomic status, urgency of micturition, knee pain, visual impairment, hearing impairment, functional disability, and depression were significantly associated with falls. Conclusions: Falls are common among elderly persons. Health programs for the elderly must include prevention of falls and rehabilitation of fall-related injuries.

Nanoemulsion formulation of vitamin D3 have been shown to have better bioavailability than the coarse emulsion preparation in vitro and in vivo animal studies. In the absence of randomised trial in humans, comparing the efficacy of nanotechnology-based miscellised vitamin D3 over conventional vitamin D3, we undertook this study. A total of 180 healthy adults were randomised to receive either micellised (DePura, group A) or conventional vitamin D3 (Calcirol, group B) at a monthly dose of 60 000 IU (1500μg) for 6 months. The outcome parameters were serum 25-hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), Ca, phosphate, alkaline phosphatase and urinary Ca:creatinine ratio. A total of eighty-nine subjects in group A and seventy-seven in group B completed the trial. Subjects in both the groups had a significant increase in their serum 25(OH)D levels following supplementation (group A: 21·5 (sd 10·9) to 76·7 (sd 18·8) nmol/l (Psd 10·4) to 57·8 (sd 16·0) nmol/l (PPP3 appeared to be more efficacious in achieving higher levels of serum 25(OH)D.

The objective of this study was to evaluate endothelial function and carotid intima media thickness (CIMT) in moderate to severe obstructive sleep apnea (OSA) without comorbidities. It is an observational case control study in which endothelial function was assessed using flow-mediated dilatation (FMD) and peripheral arterial tonometry (PAT), and carotid artery ultrasound was used to measure CIMT in study group subjects that included 20 normotensive, non-diabetic, treatment naive, and moderate to severe OSA patients, and 20 normotensive, non-diabetic, and non-OSA subjects served as a control group. Study was conducted in Polysomnography Laboratory, Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS) Hospital, New Delhi. FMD was significantly lower in the moderate to severe OSA group compared to non-OSA group (mean ± SD, 8.3 ± 2.8 vs. 13.4 ± 4.1 %; p = 0.0001). Reactive hyperemia index (RHI) was also significantly lower in the OSA group (1.55 ± 0.27 vs. 2.01 ± 0.48, p = 0.0007). CIMT was observed to be significantly higher in the OSA group compared to the non-OSA group (0.54 ± 0.09 vs. 0.48 ± 0.08 mm; p = 0.049). In the OSA group, FMD, RHI, and CIMT did not show a significant correlation with OSA disease severity indices [apnea hypopnea index (AHI), oxygen desaturation index (ODI), and minimum O2 saturation]. Endothelial function in macrovascular and microvascular circulation is significantly impaired in moderate to severe OSA patients without comorbidities. These patients also show evidence of subclinical atherosclerosis, in the form of increased CIMT.

To assess the impact of corneal disease on vision-related quality of life (VR-QoL) in a rural North Indian population.Cross-sectional, population-based study.The Corneal Opacity Rural Epidemiological (CORE) study included 12 899 participants from 25 randomly selected clusters of rural Gurgaon, Haryana, India, with the primary objective of determining the prevalence of corneal disease in the general population during July 2011 to January 2013. VR-QoL was assessed through Indian Vision Function questionnaire (IND-VFQ-33) in adult participants (aged ≥18 years) detected with corneal opacity and equal number of healthy controls (no ocular pathology with visual acuity of 6/6 binocularly) selected from the same clusters. Scores of the three subscales of IND-VFQ-33 (vision-specific mobility, psychosocial impact and visual symptoms) were computed, analysed and compared separately across various groups.Overall, 12 113 participants of all ages underwent detailed ophthalmic examination and VR-QoL was assessed in 435 cases with corneal disease and 435 controls without any ophthalmic disease. The diseased population had significantly higher scores and hence poorer VR-QoL across all three domains of vision function (scores of 28 vs 22; 6 vs 5 and 14 vs 9, respectively; p0.0001) and the scores were inversely related with the level of visual impairment in patients with corneal disease. Patients with unilateral corneal disease also had poorer VR-QoL scores as compared with healthy controls (p0.0001).VR-QoL is impaired in patients with corneal disease, more so in patients with corneal blindness. This is the first population-based study to document VR-QoL through IND-VFQ-33 in the Indian population with corneal disease.

To study optic nerve head (ONH) characteristics using scanning laser ophthalmoscopy, Heidelberg retina tomograph (HRT), in an elderly population.A population-based, cross-sectional study included 1460 eyes of 1460 consecutive, subjects60 years, in North India. All subjects underwent a detailed ophthalmic evaluation and imaged on HRT. Stereometric parameters, Moorfields regression analysis (MRA) and discriminant function analysis were analyzed. Correlation between ONH parameters and disc area, age, sex, and intraocular pressure was analyzed.Disc size had a normal Gaussian distribution (2.22 ± 0.48 mm

To assess awareness, barriers, and misconceptions related to eye donation in people with corneal disease as compared to controls in a population setting.A population-based study was conducted in 25 randomly selected clusters of Rural Gurgaon, Haryana, India, as part of the CORE (Cornea Opacity Rural Epidemiological) study. In addition to ophthalmic examination, knowledge and perceptions regarding eye donation were assessed through a validated questionnaire. The questionnaire captured the sociodemographic factors influencing awareness regarding eye donation in participants with corneal disease and twice the number of age- and gender-matched controls recruited from the same study clusters. Descriptive statistics were computed along with multivariable logistic regression analysis to determine associated factors for awareness of eye donation.In the CORE study, 452 participants had corneal opacities on ocular examination. Of these, 442 were assessed for eye donation awareness. Additionally, 884 age- and gender-matched controls were recruited. The mean age of cases and controls was 60.9 ± 15.5 and 59.6 ± 14.3 years, respectively. Awareness of eye donation in cases and controls was 46.4% (n = 205 of 442) and 52.3% (n = 462 of 884), respectively (P = 0.044). Educational status was an important factor determining knowledge about eye donation in both cases and controls (P = 0.001). Major barriers reported for not pledging eyes were lack of willingness (36.7%) and ignorance (15.3%). Common misconceptions like eyes could be donated before death or even after 24 h of death and that any type of blindness could be treated with corneal transplantation were prevalent.The study demonstrated that although there is substantial awareness about eye donation, there are numerous barriers in this population that need to be resolved to improve donation rates. Additional efforts are needed to translate this awareness into actual eye donation in both cases with corneal disease and controls.

Background: The mechanism of development of atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) has not been clearly defined, and the involvement of multiple factors such as advanced age, withdrawal of β-blockers, inadequate atrial protection, and electrolyte imbalance, particularly hypomagnesemia has been documented by several authors. Despite all the available pharmacologic prophylaxis, incidence of AF still remains high in this group of patients. This unexplained cause could be genetic inheritance of endothelin-1 (ET-1) gene which is thought to have a pro-arrhythmogenic effect. Aim: This study aims to investigate the relationship between plasma ET-1 concentrations, ET-1 gene polymorphisms in loci -1370 T/G, -134 (3A/4A) Ins/del, Lys198Asn (G/T), and occurrence of AF in patients undergoing CABG. Methodology: Ninety-eight nonrelated, nondiabetic patients over a period of 4 years undergoing routine CABG were selected for the present study. All patients were genotyped for three single nucleotide polymorphisms (SNPs) in loci -1370 T/G, -134 (3A/4A) Ins/del, and Lys198Asn (G/T) in the ET-1 gene by gene sequencing. The plasma ET-1 concentrations were measured using an ET immunoassay. Results: Plasma ET-1 concentrations were higher in AF+ group ( P = 0.001) as compared to AF− group. The allele frequencies between AF+ and AF− group were significantly different only with respect to the Lys198Asn (G/T) SNP of the ET-1 gene. Conclusion: The study described the possible correlation of polymorphism of ET gene in CABG population from India. The ET-1 gene might play a disease-modifying role in atrial fibrillation.

Objectives Rheumatic heart disease (RHD) continues to be major public health burden in developing world. Echocardiographic screening in school children has shown that subclinical RHD cases are several times more than clinical cases. Recent reports have used World Heart Federation (WHF) criteria. Objective of present study was to determine RHD prevalence using WHF criteria in Indian children. Methods Children (5–15years) from randomly selected schools across four sites were included. After focused clinical evaluation, echocardiography was performed using WHF criteria in all children. Images/loops of abnormal cases were analyzed independently by an additional experienced cardiologist. Children with murmur and confirmatory echocardiography were categorized ‘clinical RHD'; those with abnormal echocardiography alone were labeled ‘subclinical RHD'. Results Among 16,294 children included, mean age was 10.8 ± 2.9years; 55.1% were males; 11,405 (70%) were from rural areas and 3978 (24.4%) were from government schools. We detected RHD by echocardiography in 125 children [prevalence: 7.7/1000 (95% CI 6.3, 9.0)]. Borderline RHD was present in 93 children (5.7/1000, 95% CI 4.6, 6.9), definite RHD in 32 (2/1000, 95% CI 1.2, 2.6), and clinical RHD in six [0.36/1000, 95% CI: 0.1–0.7]. On univariate analysis, older age, female gender, and higher waist circumference were associated while on multivariate analysis, older age (OR 1.18, 95% CI: 1.09, 1.26) and female gender (OR 1.61, 95% CI: 1.13, 2.3) were associated with RHD. Conclusion RHD prevalence varies in different parts of India. Echocardiographic prevalence is several times higher than clinical and underscores importance of echocardiographic screening in community.

Background Nutritional modulation remains central to the management of metabolic syndrome. Intervention with cinnamon in individuals with metabolic syndrome remains sparsely researched. Methods We investigated the effect of oral cinnamon consumption on body composition and metabolic parameters of Asian Indians with metabolic syndrome. In this 16-week double blind randomized control trial, 116 individuals with metabolic syndrome were randomized to two dietary intervention groups, cinnamon [6 capsules (3 g) daily] or wheat flour [6 capsules (2.5 g) daily]. Body composition, blood pressure and metabolic parameters were assessed. Results Significantly greater decrease [difference between means, (95% CI)] in fasting blood glucose (mmol/L) [0.3 (0.2, 0.5) p = 0.001], glycosylated haemoglobin (mmol/mol) [2.6 (0.4, 4.9) p = 0.023], waist circumference (cm) [4.8 (1.9, 7.7) p = 0.002] and body mass index (kg/m2 ) [1.3 (0.9, 1.5) p = 0.001] was observed in the cinnamon group compared to placebo group. Other parameters which showed significantly greater improvement were: waist-hip ratio, blood pressure, serum total cholesterol, low-density lipoprotein cholesterol, serum triglycerides, and high-density lipoprotein cholesterol. Prevalence of defined metabolic syndrome was significantly reduced in the intervention group (34.5%) vs. the placebo group (5.2%). Conclusion A single supplement intervention with 3 g cinnamon for 16 weeks resulted in significant improvements in all components of metabolic syndrome in a sample of Asian Indians in north India. Trial registration The clinical trial was retrospectively registered (after the recruitment of the participants) in ClinicalTrial.gov under the identification number: NCT02455778 on 25th May 2015.

Background Chronic liver disease questionnaire (CLDQ) is an established disease specific tool to assess the health related quality of life (HRQOL) in patients with CLD irrespective of the etiology and severity. The objective of the study was to develop the Hindi language version of CLDQ and to assess the validity of the Hindi CLDQ. Methods CLDQ was adapted into Hindi language by following a standard method of forward and back-translation by two bilingual translators, revision by expert panel and formulation of a consensual version followed by pilot testing and appropriate modifications before final administration. Hindi CLDQ along with short form 36 (SF-36) were administered in 494 patients with chronic liver disease (CLD) and 103 healthy controls (HC). To assess reproducibility, Hindi CLDQ was re-administered in a subsample of 20 patients. Internal consistency was assessed by Cronbach’s alpha coefficient. Structural validity was assessed by exploratory factor analysis and construct validity was assessed with help of correlation of SF-36 scores and CLDQ pattern across disease severity groups. Results The Cronbach’s alpha coefficient was 0.93 and intra class coefficient correlation was 0.88 for the average CLDQ score, suggestive of good reliability. An inverse relationship of the average CLDQ score with the disease severity (CLDQ score of Child A vs. B vs. C = 5.2±1.10 vs. 4.73±1.24 vs. 4.15±1.19 respectively; p

Objective To evaluate body fat patterning and phenotype including hepatic fat and pancreatic volume of non-obese (BMI: < 25 kg/m2) Asian Indians with type 2 diabetes residing in North India. Methods Non-obese patients with type 2 diabetes (n = 93) and non-obese, normo-glycemic subjects (n = 40) were recruited. BMI, waist & hip circumferences, skinfold thickness at 8 sites, body fat, lean mass and detailed abdominal fat evaluation [total abdominal fat, total subcutaneous fat (superficial, deep, anterior, and posterior), total intra-abdominal fat (intra-peritoneal, retroperitoneal)], liver span, grades of fatty liver and pancreatic volume were compared. Results Waist circumference, subscapular skinfolds and total truncal fat (on DEXA) were higher whereas calf, total peripheral skinfolds and total leg fat (on DEXA) lower in patients. Specifically, the following volumes were higher in cases as compared to controls; total abdominal fat (19.4%), total intra-abdominal fat (49.7%), intra-peritoneal fat (47.7%), retroperitoneal fat (70.7%), pancreatic volume (26.6%), pancreatic volume index (21.3%) and liver span (10.8%). In cases, significant positive correlations were observed for pancreatic volume with BMI, waist and hip circumferences, W-HR, subscapular, abdominal and total truncal skinfolds, truncal, total subcutaneous, total intra-abdominal, intra-peritoneal, retroperitoneal fat depots, liver span and fatty liver. Conclusions In non-obese Asian Indians with type 2 diabetes, subcutaneous and intra-abdominal obesity, including fatty liver, and pancreatic volume were higher and peripheral subcutaneous adiposity was lower than BMI matched non-diabetic subjects. Importantly, increased pancreatic volume in patients was highly correlated with multiple measures of abdominal obesity and liver fat.

We undertook this study to characterize peak bone density and evaluate its determinants in a healthy cohort of young adult male paramilitary personnel. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry in 473 healthy men aged 21-40 yr. The effect of anthropometry and biochemical parameters on BMD was determined. Mean BMD values of L1-L4, forearm, total hip, and femoral neck were 1.170+/-0.137, 0.755+/-0.089, 1.129+/-0.130, and 1.115+/-0.133 g/cm(2), respectively. BMD values for 31- to 40-yr age group were lower than those of 20- to 30-yr age group except for forearm, which was higher in the former. Significant positive correlation was observed between height, weight, and body mass index with BMD. On multivariate regression analysis, weight was the most consistent contributor to variance in the BMD. Compared with age-matched US males, BMD of total hip and femoral neck were higher for Indian paramilitary personnel by 3.58% and 4.2%, whereas lumbar spine BMD was lower by 4.1%. In conclusion, peak BMD in healthy Indian males was achieved by 30 yr of age at lumbar spine and hip, with weight being the most consistent contributor to variance in BMD. Peak BMD in this population was comparable to that reported in white US males.

Aim: To evaluate if supplementing iron at 2 weeks of age improves serum ferritin and/or haematological parameters at 2 months of life in very low birth weight (VLBW) infants. Methods: Preterm VLBW infants who received at least 100 mL/kg/day of oral feeds by day 14 of life were randomized to either ‘early iron’ (3–4 mg/kg/day orally from 2 weeks) or ‘control’ (no iron until 60 days) groups. Infants were followed up fortnightly and all morbidities were prospectively recorded. Serum ferritin was measured at 60 days by enzyme immunoassay method. Results: Forty-six infants were included in the study; primary outcome was available for 42 infants. There was no difference in either serum ferritin (mean: 50.8 vs. 45.3 μg/L; adjusted difference in means: 5.8, 95% CI: −3.0, 14.6; p = 0.19) or haematocrit (32.5 ± 5.3 vs. 30.8 ± 6.3%; p = 0.35) at 60 days between the early iron and control groups. The magnitude of fall in serum ferritin from baseline to the end of study period was also not different between the groups (4.9 vs. 13.8 μg/L; difference in means: 8.8; 95% CI: −0.3, 17.9; p = 0.06). The requirement of blood transfusions (9.5 vs. 13%; p = 0.63) and a composite outcome of common neonatal morbidities (19% vs. 21.7%; p = 0.55) were also not different between the two groups. Conclusion: Supplementing iron at 2 weeks of age in preterm VLBW infants did not improve either serum ferritin or the haematological parameters at 2 months when compared to the standard practice of starting iron from 8 weeks of age.

We assessed the iodine nutrition of upper socioeconomic strata school children from Delhi to identify its association with goiter, thyroid autoimmunity or thyroid function. After informed consent of parents, all assenting students (n=997) from one randomly selected section of each class from five private schools representing all the zones of Delhi) were evaluated for goiter, urinary iodine excretion, thyroid function and antibody status. Median urinary iodine was 35.28 microg/dL. Goiter was present in 123 (12.3%) and positive anti-TPO antibodies in 17 (2.6%). Increased urinary iodine was associated with thyroid dysfunction, though not with goiter.

The present population-based study was undertaken to estimate the prevalence, determinants and causes of corneal morbidity and blindness in a rural North Indian population.Population-based study in India with 12 899 participants of all ages.Participants were recruited from 25 village clusters of district Gurgaon, Haryana, India using random cluster sampling strategy. All individuals were examined in detail with a portable slit lamp for evidence of any corneal disease during the door-to-door examination. Comprehensive ocular examination including logMar visual acuity, slit lamp biomicroscopy, non-contact tonometry and dilated retinal evaluation was performed at a central clinic site in the respective villages.Overall, 12 113 of 12 899 people (93.9% response rate) were examined during the household visits. Prevalence of corneal disease was 3.7% (95% CI 3.4% to 4.1%) and that of corneal blindness was 0.12% (95% CI 0.05% to 0.17%). Multivariable analysis demonstrated that corneal disease was significantly higher in the elderly (p0.0001) and illiterates (p0.0001). Common causes of corneal opacity in the study population were pterygium (34.5%), ocular trauma (22.3%) and infectious keratitis (14.9%). Corneal diseases contributing to blindness were post-surgical bullous keratopathy (46.2%) and corneal degenerations (23.1%).The study findings demonstrate that currently ocular trauma, infectious keratitis, post-surgical bullous keratopathy, and corneal degenerations are responsible for the major burden of corneal blindness and morbidity in the Indian population. The prevalence of corneal morbidity due to vitamin A deficiency and trachoma was low in this rural population.

Successful diabetes management depends on patient behaviour. Diabetes is a significant risk factor for depression which itself is a risk factor for poor metabolic control. Data on this association is scarce from India--which is fast becoming the diabetes capital of the world. This study was done to see the prevalence of depression in adult patients with type 2 diabetes diagnosed within the previous 5 years and treated with oral hypoglycaemic agents compared to healthy persons without diabetes. Also, to evaluate Becks depression inventory (BDI) in terms of Mini International Neuropsychiatric Interview (MINI) as a tool to assess depression in diabetes.Patients with diabetes within 5 year of diagnosis and on oral anti-diabetic drugs were included. Controls were healthy relatives of these patients without diabetes. These patients underwent clinical examination, biochemical tests, assessment of depression by BDI and MINI BDI and MINI were used to assess depression in controls as well. Prevalence of depression was found in both groups and compared. BDI was evaluated considering the MINI as gold standard in detecting depression in diabetes.The prevalence of co-morbid depression was 27.05% according to the MINI. In the non-diabetic healthy patient relatives, this was 11.11%. Those having depression had a lower educational attainment and a higher prevalence of retinopathy, compared to subjects without depression. The relative risk for the diabetics to have co-morbid depression was 2.97 (95% confidence interval 1.41-6.24). The BDI score with best sensitivity and specificity for diagnosing depression in diabetes wasor = 21. For healthy controls, a score ofor = 14 had best sensitivity and specificity. Diabetic patients had a higher score of BDI even without a diagnosis of depression on the MINI.Prevalence of depression was 27.05% diabetic patients and 11.11% healthy controls. A BDI score of 21 had the best sensitivity and specificity for diagnosing depression in adult type 2 diabetic patients. BDI can be used as a simple screening tool for the detection of depression in diabetic patients.

Background Tuberculosis (TB), caused by Mycobacterium tuberculosis, is one of the leading causes of mortality and morbidity across all age groups throughout the world, especially in developing countries. Methodology/Principal Findings In this study, we have included 432 open index cases with their 1608 household contacts in a prospective cohort study conducted from May 2007 to March 2009. The follow-up period was 2 years. All Index cases were diagnosed on the basis of suggestive signs and symptoms and sputum being AFB positive. Among the 432 index patients, 250 (57.9%) were males and 182 (42.1%) females; with mean age of 34±14.4 yr and 26±11.1 yr, respectively. Out of 1608 household contacts, 866 (53.9%) were males and 742 (46.1%) females; with mean age of 26.5±15.8 and 26.5±16.0 yr, respectively. Of the total 432 households, 304 (70.4%) had ≤4 members and 128 (29.6%) had ≥5 members. The median size of the family was four. Of the 1608 contacts, 1206 were able to provide sputum samples, of whom 83 (6.9%) were found MTB culture positive. Household contacts belonging to adult age group were predominantly (74, 89.2%) infected as compared to the children (9, 10.8%). On screening the contact relationship status with index patients, 52 (62.7%) were first-degree relatives, 18 (34.6%) second-degree relatives and 12 (14.5%) spouses who got infected from their respective index patients. Co-prevalent and incident tuberculosis was found in 52 (4.3%) and 31 (2.6%) contacts, respectively. In incident cases, the diagnosis could be made between 4 to 24 months of follow-up, after their baseline evaluation. Conclusion Active household contact investigation is a powerful tool to detect and treat tuberculosis at early stages and the only method to control TB in high-TB-burden countries.

There are few large-scale studies on the utility of peripheral dual energy X-ray absorptiometry (pDXA) in children. As central dual energy X-ray absorptiometry (cDXA) equipment is not commonly available in the developing world, we assessed the correlation of bone mineral density (BMD) with cDXA and pDXA in children to determine the optimal Z-score thresholds of pDXA for predicting two predefined Z-score cutoffs (≤-1, ≤-2) of cDXA in 844 subjects (441 boys, 403 girls) aged 10-18 years. The BMD of antero-posterior lumbar spine (L1-L4), proximal femur and forearm was measured by cDXA, while the peripheral BMD of forearm and calcaneus was estimated using pDXA. The correlation was statistically significant at all sites (p

Background Delayed or missed diagnosis of TB continues to fuel the global TB epidemic, especially in resource limited settings. Use of serology for the diagnosis of tuberculosis, commonly used in India, is another factor. In the present study a commercially available serodiagnostic assay was assessed for its diagnostic value in combination with smear, culture and clinical manifestations. Methodology/Principal Findings A total of 2300 subjects were recruited for the study, but 1041 subjects were excluded for various reasons. Thus 1259 subjects were included in the study of which 470 were pulmonary tuberculosis cases (440 of 470 were culture-positive) and 789 were their asymptomatic contacts. A house-to-house survey method was used. Blood samples were tested for IgM, IgA, and IgG antibodies using the Pathozyme Myco M (IgM), Myco A (IgA) and Myco G (IgG) enzyme immunoassay (EIA). Out of 470 PTB cases, BCG scar was positive in 82.34%. The Mantoux test and smear positivity rates in PTB cases were 94.3% (430/456), and 65.32% (307/470), respectively. Among the asymptomatic contacts, BCG scar was positive in 95.3% and Mantoux test was positive in 80.66% (442/548) contacts. No contact was found falsely smear positive. The sensitivity of IgM, IgA, and IgG EIA tests was 48.7%, 25.7% and 24.4%, respectively, while the specificity was 71.5%, 80.5%, 76.6%, respectively. Performance of EIAs was not affected by the previous BCG vaccination. However, prior BCG vaccination was statistically significantly (p = 0.005) associated with Mantoux test positivity in PTB cases but not in contacts (p = 0.127). The agreement between serology and Mantoux test was not significant. Conclusion The commercial serological test evaluated showed poor sensitivity and specificity and suggests no utility for detection of pulmonary tuberculosis.

This study aimed to determine the noninferiority of early enteral feeding through nasogastric (NG) compared to nasojejunal (NJ) route on infectious complications in patients with severe acute pancreatitis (SAP).Patients with SAP were fed via NG (candidate) or NJ (comparative) route. The primary outcome was the occurrence of any infectious complication in blood, pancreatic tissue, bile, or tracheal aspirate. Secondary end points were pain in refeeding, duration of hospital stay, intestinal permeability assessed by lactulose/mannitol excretion, and endotoxemia assessed by endotoxin core antibody types immunoglobulin G and M.Seventy-eight patients were randomized to feeding by either the NG or the NJ route. During the hospital stay, the presence of any infectious complication in the NG and NJ groups was 23.1% and 35.9% (significantly different), respectively. The effect size of the difference of infectious complications was -12.8 (95% confidence interval, -29.6 to 4.0). The upper limit of the 95% confidence interval was 4.0 and was within the 5% limit set for noninferiority. The value of 8.0 for the number needed to treat implies that 8 patients should be treated with NG compared with the NJ group to prevent 1 patient from any of the infectious complications.Early enteral feeding through NG was not inferior to NJ in patients with SAP. Infectious complications were within the noninferiority limit. Pain in refeeding, intestinal permeability, and endotoxemia were comparable in both groups.

Vitamin D nutrition has a profound effect on the development of an infant. Vitamin D status of mothers and their infants are closely correlated. While hypovitaminosis D has emerged as a significant public health problem across all age groups, there is limited information of this condition in lactating mothers and their breast fed infants.To evaluate the vitamin D status of lactating mothers and their breast fed infants.180 healthy lactating mothers and exclusively breast fed infants, 2-24 weeks old, were recruited for the study. The mother-infant pairs underwent concurrent clinical, biochemical and hormonal evaluation for calcium-vitamin D-PTH axis.The mean serum 25(OH)D values in lactating mothers was 27.2 +/- 14.6 nmol/l (10.9 +/- 5.8 ng/ml), while that of their infants was 28.9 +/- 20.8 nmol/l (11.6 +/- 8.3 ng/ml). Serum 25(OH)D levels25 nmol/l (10 ng/ml) were found in 47.8% of the mothers and 43.2% of the infants. Among these, elevated PTH levels (54 pg/ml) were seen in 59.3% of the mothers and 69.6% of the infants. A highly significant negative correlation was found between serum 25(OH)D and PTH in mothers (r = -0.480, p = 0.01) and their infants (r = -0.431, p = 0.01). A strong positive correlation was seen of 25(OH)D levels in mother-infant pairs (r = 0.324, p = 0.001).A high prevalence of vitamin D deficiency was found in lactating mothers and their exclusively breast fed infants. Infants born to mothers with hypovitaminosis D had 3.8 times higher risk of developing hypovitaminosis D as compared to those born to mothers with normal vitamin D levels.

Objective This study was planned to obtain normative data of thyroid functions in school-age children from different regions of India. Design and methods Students from 36 schools involving 13 states across four geographical zones of India were evaluated for goiter. Subjects who consented, underwent evaluation for serum FT3, FT4, TSH, anti-TPO antibodies and thyroid ultrasound. From this, a “reference population” was obtained by excluding those with personal or family history of thyroid disease, use of thyroid medications, goiter, hypoechogenicity or nodularity on ultrasound or positive anti-thyroid antibodies. Results Of 24,685 students clinically evaluated, 8665 formed part of the study. The reference population comprised 5343 subjects. The mean, median, 3rd and 97th percentiles of FT3, FT4 and TSH for each year (6–17 years) were obtained. Conclusions This community based study in Indian school-age children provides reference intervals for thyroid hormones and evidence against narrowing the TSH reference range.

Ultrasound assessment of thyroid volume is considered a more objective method than clinical palpation for the diagnosis of goitre. We used ultrasonography to establish normal reference cut-off points of thyroid volume in schoolchildren of different socioecomonic groups in India and compared the results with international norms.In a cross-sectional study, we clinically examined 27,250 children from the lower and higher socioeconomic strata (SES) from all over India to determine their goitre staging. A single sonologist, using ultrasonography, assessed the thyroid volume in a subset of 15,986 children (8463 from the lower and 7523 from the higher SES). Students were recruited from at least one school each representing the higher and the lower SES, from cities located in 5 zones of India. Children with known thyroid disorders were excluded from the study.Clinical evaluation revealed a mean goitre prevalence of 19.9% (23.2% in girls; 16.5% in boys; 17.1% in the higher SES; 23.5% in the lower SES). The thyroid volume as assessed by ultrasonography was significantly higher in children from the lower SES (mean 5.65 ml, SE 0.02) compared with those from the higher SES (mean 5.02 ml, SE 0.02) after adjusting for the imbalance in body surface area (p0.001). Using international norms (WHO 2004), the prevalence of goitre in various body surface area categories among children who had no goitre on clinical examination ranged from 48.2% to 75.1% for boys and 23.2% to 67.4% for girls.The striking discrepancy in the prevalence of goitre assessed by using clinical examination and ultrasound techniques suggests that the norms recommended by WHO based on ultrasound techniques are not appropriate for India.

To evaluate the role of thyroid ultrasound in children with autoimmune thyroiditis diagnosed either on cytopathology or by the presence of thyroid peroxidase antibodies.Children presenting for the first time to the Thyroid Clinic at the Institute of Nuclear Medicine and Allied Sciences for the complaint of goiter over a two year period (January 2005-December 2006) were studied.695 school children (244 boys and 451 girls) aged 5-18 year were studied.Children were subjected to thyroid ultrasound, cytopathology, thyroid peroxidase antibody and thyroid function tests.Overall, 16% of goitrous children had hypoechogenicity on ultrasound, 15.2% had cytopathological evidence of thyroiditis, 10.6% had positive thyroid peroxidase antibodies and 25.2% had abnormal thyroid function tests. Subjects with hypoechogenicity had higher percentage of thyroiditis on cytopathology (41.4% vs. 10.3%; P0.01), thyroid peroxidase antibody positivity (30.6% vs. 6.8%; P0.01) and thyroid dysfunction (46.8% vs. 21.2%; P0.01) than those with normal echogenicity.Thyroid USG has a useful, though limited, role in excluding thyroid disease in children. The sensitivity of echogenicity for the diagnosis of autoimmune thyroiditis in children is less than that reported in adults.

Summary Objective There is an ongoing debate on narrowing the TSH reference range in adults. In view of the scarce data on normal values of thyroid function tests in children from India, we planned to establish a reference range for thyroid hormones in school-age children. Design and subjects All children (N = 9527; 6–19 years) from six schools representing various zones of Delhi were evaluated for clinical evidence of goitre, thyroid ultrasound, serum free T3 (FT3), free T4 (FT4) and TSH and anti-thyroid peroxidase (anti-TPO) antibodies. From this sample, a reference population (N = 5122) was obtained by excluding those with a personal or family history of thyroid disease, use of thyroid medications, goitre, hypoechogenicity/nodularity on ultrasound or serum anti-TPO antibodies. Measurements Thyroid hormone (FT3, FT4 and TSH) reference ranges were established for each year of life for the total and reference populations. Results In the reference population, mean serum FT3 was in the range 4·19–4·84 pm/l for boys and 4·03–4·47 pm/l for girls, mean serum FT4 14·69–17·36 pm/l for boys and 14·32–15·88 pm/l for girls, and mean serum TSH 2·57–3·6 mIU/l for boys and 1·83–3·58 mIU/l for girls. For TSH, the 97th percentile was in the range 6·01–8·4 mIU/l for boys and 5·28–8·04 mIU/l for girls, suggesting that at least in children there may not be a need to reduce the upper limit of normal for serum TSH. Conclusions This study provides mean reference intervals for FT3, FT4 and TSH for each year of life for both the sexes separately using strict exclusion criteria.

PurposeAssess prevalence of myopia and identify associated risk factors in urban school children.MethodsThis was a cross-sectional study screening children for sub-normal vision and refractive errors in Delhi. Vision was tested by trained health workers using ETDRS charts. Risk factor questionnaire was filled for children with vision ResultsA total number of 9884 children were screened with mean age of 11.6 + 2.2 years and 66.8% boys. Prevalence of myopia was 13.1% with only 320 children (24.7%) wearing appropriate spectacles. Mean myopic spherical error was -1.86 + 1.4 diopters. Prevalence of myopia was higher in private schools compared to government schools (p 11 years) children (p 5 hours per day (p < 0.001), watching television > 2 hours / day (p < 0.001) and with playing computer/video/mobile games (p < 0.001). An inverse association with outdoor activities/playing was observed with children playing > 2 hours in a day.ConclusionMyopia is a major health problem in Indian school children. It is important to identify modifiable risk factors associated with its development and try to develop cost effective intervention strategies.

(1) To assess the height, weight and body mass index (BMI) of school children from Delhi and generate percentile charts as appropriate for age, gender and socio-economic status. (2) To determine the prevalence of overweight and obesity in school children from low and upper socioeconomic status (LSES and USES respectively).Cross sectional evaluation of anthropometric parameters in Delhi school children (5-18 years) from different geographical zones.Government schools (non-fee paying) and Private Schools (fee paying) in Delhi.21485 children, 8840 (3566 boys, 5274 girls) from government schools and 12645 (6197 boys, 6448 girls) from private schools.Subjects underwent assessment of height and weight and calculation of BMI. Children were classified as normal, overweight and obese as per IOTF guidelines. Height, weight and BMI percentile charts specific for the socioeconomic status were generated using the LMS method. Prevalence of overweight and obesity was assessed and compared between the two socio-economic groups.A significant difference was noted in height, weight and BMI between LSES and USES. The prevalence of overweight and obesity in USES children was 16.75 % and 5.59 % in boys and 19.01 % and 5.03 % in girls respectively.There is a significant disparity in anthropometric parameters between children from USES and LSES, with a high prevalence of overweight and obesity in USES children.

The objective of the present study was to evaluate the efficacy and safety of Prostina, a multi-ingredient herbal formulation in benign prostatic hyperplasia (BPH) in comparison with terazosin. A randomised, open, parallel, controlled clinical trial was carried out in ambulatory men aged between 40-80 years suffering from BPH, with American Urological Association (AUA) symptom index score of at least 8 or more at recruitment. One group received 2 Prostina capsules twice daily for 12 weeks; the other received terazosin 2 mg at bedtime for 12 weeks. Urodynamic parameters, AUA score, biochemical and clinical adverse effects were assessed. Twenty subjects completed the study in Prostina group and 20 in terazosin group. The groups were comparable at baseline in age and assessment criteria. Majority of urodynamic parameters showed improving trends in both the groups. AUA symptom score declined significantly from 19.50 +/- 1.40 (mean +/- standard error) to 1.04 +/- 0.68 in Prostina group and from 16.95 +/- 1.23 to 4.14 +/- 0.88 in terazosin group. The AUA symptom score in 12 weeks follow-up was significantly lower in Prostina group than terazosin group (p = 0.005). Other laboratory-parameters remained unaltered in both the groups. Prostina is as effective as terazosin in providing symptomatic relief in BPH.

Background: The number and proportion of elderly persons is increasing, in India, as well as the world. Disability is an important indicator to measure disease burden in this group. While some chronic conditions may not be amenable to complete cure, their functional disabilities can be improved with timely and appropriate management. Objectives: The objective of the following study is to estimate the prevalence of functional disability and study its association with socio-demographic variables and self-reported chronic conditions among elderly persons in a rural area of Haryana. Materials and Methods: All persons aged 60 years and above in the randomly selected six clusters were included in this community-based cross-sectional study. Information was collected on socio-demographic variables and self-reported chronic conditions. Functional disability was defined as having disability in activities of daily living, or blindness or hearing impairment, or a combination of these. In multivariate analysis, backward stepwise logistic regression was carried out to study the association between the independent and dependent variables, after adjusting for confounding variables. Results: Among the 836 participants studied, the prevalence of functional disability was estimated to be 37.4% (95% confidence interval: 34.2, 40.7). The prevalence was less among men (35.9%) than women (38.8%). The prevalence increased with age, was more common among persons who were not currently married, had diabetes and chronic obstructive pulmonary disease. Conclusion: Functional disability is common among elderly persons in the rural area. Community-based interventions are needed to address them. Management of chronic conditions should include prevention and control of associated disability.