HOME-BASED PULMONARY REHABILITATION: A NARRATIVE REVIEW

Pulmonary rehabilitation is a multidisciplinary, evidence based therapy wherein individually tailored therapies made to improve the physiological and psychological status of chronic respiratory disease patients. We searched 3 databases and term used “home-based pulmonary rehabilitation”. We identified 68 literatures and 8 of them met our inclusion criteria. Our review suggests that home-based pulmonary rehabilitation is effective in chronic respiratory disease patients, further research needed to standardise its quality and benefits.

Artificial intelligence–based stratification of demographic, ocular surface high-risk factors in progression of keratoconus

Purpose: The purpose of this study was to identify and analyze the clinical and ocular surface risk factors influencing the progression of keratoconus (KC) using an artificial intelligence (AI) model. Methods: This was a prospective analysis in which 450 KC patients were included. We used the random forest (RF) classifier model from our previous study (which evaluated longitudinal changes in tomographic parameters to predict “progression” and “no progression”) to classify these patients. Clinical and ocular surface risk factors were determined through a questionnaire, which included presence of eye rubbing, duration of indoor activity, usage of lubricants and immunomodulator topical medications, duration of computer use, hormonal disturbances, use of hand sanitizers, immunoglobulin E (IgE), and vitamins D and B12 from blood investigations. An AI model was then built to assess whether these risk factors were linked to the future progression versus no progression of KC. The area under the curve (AUC) and other metrics were evaluated. Results: The tomographic AI model classified 322 eyes as progression and 128 eyes as no progression. Also, 76% of the cases that were classified as progression (from tomographic changes) were correctly predicted as progression and 67% of cases that were classified as no progression were predicted as no progression based on clinical risk factors at the first visit. IgE had the highest information gain, followed by presence of systemic allergies, vitamin D, and eye rubbing. The clinical risk factors AI model achieved an AUC of 0.812. Conclusion: This study demonstrated the importance of using AI for risk stratification and profiling of patients based on clinical risk factors, which could impact the progression in KC eyes and help manage them better

Impact of crossplay between ocular aberrations and depth of focus in topo-guided laser-assisted in situ keratomileusis outcomes

Purpose: To develop a nomogram in cases with mismatch between subjective and Topolyzer cylinder, and based on the magnitude of the mismatch, customize a treatment plan to attain good visual outcomes post?laser?assisted in situ keratomileusis (LASIK) surgery. Methods: The patients were evaluated preoperatively using corneal tomography with Pentacam. Five optimal corneal topography scans were obtained from the Topolyzer Vario were used for planning the LASIK treatment. For the nomogram purpose, the patients were divided into three categories based on the difference between the subjective cylinder and Topolyzer (corneal) cylinder. The first group (group 1) consisted of eyes of patients, where the difference was less than or equal to 0.4 D. The second group (group 2) consisted of eyes, where the difference was more than 0.4 D and the subjective cylinder was lesser than the Topolyzer cylinder. The third group (group 3) included eyes where the difference was more than 0.4 D but the subjective cylinder was greater than the Topolyzer cylinder. LASIK was performed with the WaveLight FS 200 femtosecond laser and WaveLight EX500 excimer laser. Assessment of astigmatism correction for the three groups was done using Aplins vector analysis. For comparison of proportions, Chi?square test was used. A P value less than 0.05 was considered statistically significant. Results: The UDVA was statistically significantly different when compared between groups 1 and 2 (P = 0.02). However, the corrected distance visual acuity (CDVA) was similar among all the three groups (P = 0.1). Group 3 showed an increase of residual cylinder by ?0.25 D, which was significant at intermediate and near reading distances (P < 0.05). Group 3 showed significantly higher target?induced astigmatism (TIA) compared to groups 1 and 2 (P = 0.01). The mean surgically induced astigmatism (SIA) was the least in group 2, which was statistically significant (P < 0.01). Conclusion: The outcomes for distance vision using our nomogram postoperatively were excellent, but further refinement for improving the near vision outcomes is required

COVID-19: Time for a clinical classification?

COVID-19 pandemic caused by SARS-CoV-2 virus has been around for 2 years causing significant health-care catastrophes in most parts of the world. The understanding of COVID-19 continues to expand, with multiple newer developments such as the presence of asymptomatic cases, feco-oral transmission, and endothelial dysfunction. The existing classification was developed before this current understanding. With the availability of recent literature evidences, we have attempted a classification encompassing pathogenesis and clinical features for better understanding of the disease process. The pathogenesis of COVID-19 continues to evolve. The spiked protein of the SARS-CoV-2 virus binds to ACE2 receptors causes direct cytopathic damage and hyperinflammatory injury. In addition to alveolar cells, ACE2 is also distributed in gastrointestinal tract and vascular endothelium. ACE2–SARS-CoV-2 interaction engulfs the receptors leading to depletion. Accumulation of Ang2 via AT1 receptor (AT1R) binding causes upregulation of macrophage activity leading to pro-inflammatory cytokine release. Interleukin-6 (IL-6) has been attributed to cause hyperinflammatory syndrome in COVID-19. In addition, it also causes severe widespread endothelial injury through soluble IL-6 receptors. Thrombotic complications occur following the cleavage and activation of von Willebrand factor. Based on the above understanding, clinical features, organ involvement, risk stratification, and disease severity, we have classified COVID-19 patients into asymptomatic, pulmonary, GI, and systemic COVID-19 (S-COVID-19). Studies show that the infectivity and prognosis are different and distinct amongst these groups. Systemic-COVID-19 patients are more likely to be critically ill with multi-organ dysfunction and thrombo-embolic complications.

Suspecting and diagnosing transthyretin amyloid cardiomyopathy (ATTR-CM) in India: An Indian expert consensus

Transthyretin cardiac amyloidosis (ATTR-CM) is a rare and under-recognized disorder characterized by the aggregation of transthyretin-derived insoluble amyloid fibrils in the myocardium. Heterogeneity of symptoms at presentation, makes its diagnosis often delayed. An expert panel gathered on a virtual platform across India to conduct a meeting for developing a guiding tool for ATTR-CM diagnosis. The panel recommended younger age (40 years) for suspecting ATTR-CM and thick-walled non-dilated hypokinetic ventricle was considered as one of the important red flags. Electrocardiogram (ECG) and echocardiography (ECHO) findings were recommended as primary tests to raise the suspicion while nuclear scintigraphy and hematological tests were recommended to confirm the diagnosis and rule out amyloid light-chain (AL) amyloidosis. Cardiac magnetic resonance (CMR) and biopsy were recommended in case of ambiguity in the presence of red flags. Considering the lack of expert guidelines in the Indian scenario, a standardized diagnostic algorithm was also proposed.

Interventions in the diagnosis and adoption of pacemaker therapy in sinus node dysfunction patients: Results from the IMPROVE Brady study

Aims: IMPROVE Brady assessed whether a process improvement intervention could increase adoption of guideline-based therapy in sinus node dysfunction (SND) patients. Methods: /Results: IMPROVE Brady was a sequential, prospective, quality improvement initiative conducted in India and Bangladesh. Patients with symptomatic bradycardia were enrolled. In Phase I, physicians assessed and treated patients per standard care. Phase II began after implementing educational materials for physicians and patients. Primary objectives were to evaluate the impact of the intervention on SND diagnosis and pacemaker (PPM) implant. SF-12 quality of life (QoL) and Zarit burden surveys were collected pre- and post-PPM implant. A total of 978 patients were enrolled (57.7 ± 14.8 years, 75% male), 508 in Phase I and 470 in Phase II. The diagnosis of SND and implantation of PPM increased significantly from Phase I to Phase II (72% vs. 87%, P < 0.001 and 17% vs. 32%, P < 0.001, respectively). Pacemaker implantation was not feasible in 41% of patients due to insurance/cost barriers which was unaltered by the intervention. Both patient QoL and caregiver burden improved at 6-months post-PPM implant (P < 0.001). Conclusions: A process improvement initiative conducted at centers across India and Bangladesh significantly increased the diagnosis of SND and subsequent treatment with PPM therapy despite the socio-economic constraints.

Feasibility and impact of screening for venous thromboembolism in treatment?naive lung cancer patients–Results of a prospective cohort study

Background: Venous thromboembolism (VTE) in cancer remains underdiagnosed. This prospective study aimed to evaluate the feasibility of screening for VTE in lung cancer (LC) patients. We assess the incidence of VTE, its risk factors, and effects on overall survival (OS). Methods: Consecutive treatment?naive LC patients were screened for deep venous thrombosis (DVT) with compression ultrasonography and pulmonary thromboembolism (PTE) with computed tomography pulmonary angiography (CTPA) at diagnosis and after 3 months of treatment. The incidence rate of VTE (DVT and/or PTE) was calculated. Risk factors associated with VTE were assessed using logistic regression analysis. All participants were followed?up to 1 year after enrollment. OS was compared in LC subjects with and without VTE, using the Cox proportional hazard analysis. Results: Around 301 subjects with LC (stages IIIB?IV accounted for 83.1%) were enrolled, of which 16 had VTE (5.3%). The incidence rate of VTE was 90 per 1000 person?years (PY). PTE was asymptomatic in 27.3% of cases while all DVT episodes were symptomatic. The incidence rate of asymptomatic PTE identified during the screening was 17 per 1000 PY. The median duration from LC diagnosis to the VTE event was 96.5 days. Median OS was significantly less in VTE patients [161 versus 311 days; P = 0.007] and death was attributable to VTE in 50%. After adjusting for covariates, VTE (hazard ratio [HR] = 2.1), smoking (HR = 1.7), and Eastern cooperative oncology group performance status ?2 (HR = 1.6) were independently associated with poor OS in LC. Conclusions: VTE occurs in approximately 1 in 20 newly?diagnosed patients with LC and is associated with decreased OS. Screening for PTE may be considered even in resource?limited settings

Identifying high risk patients post myocardial infarction with reduced left ventricular function using loop recorders INSPIRE-ELR clinical study

Aims: Sudden cardiac death (SCD) continues to be a devastating complication amongst survivors of myocardial infarction (MI). Mortality is high in the initial months after MI. The aims of the INSPIRE-ELR study were to assess the proportion of patients with significant arrhythmias early after MI and the association with mortality during 12 months of follow-up. Methods: The study included 249 patients within 14 days after MI with left ventricular ejection fraction (LVEF) _x0001_35% at discharge in 11 hospitals in India. Patients received a wearable external loop recorder (ELR) 5 ± 3 days after MI to monitor arrhythmias for 7 days. Results: Patients were predominantly male (86%) with a mean age of 56 ± 12 years. In 82%, reperfusion had been done and all received standard of care cardiovascular medications at discharge. LVEF was 32.2 ± 3.9%, measured 5.1 ± 3.0 days after MI. Of the 233 patients who completed monitoring (7.1 ± 1.5 days), 81 (35%) experienced significant arrhythmias, including Ventricular Tachycardia/Fibrillation (VT/ VF): 10 (4.3%); frequent Premature Ventricular Contractions (PVCs): 65 (28%); Atrial Fibrillation (AF): 8 (3.4%); chronic atrial flutter: 4 (1.7%); 2nd or 3rd degree Atrioventricular (AV) block: 4 (1.7%); and symptomatic bradycardia: 8 (3.4%). In total, 26 patients died. Mortality was higher in patients with clinically significant arrhythmia (at 12 months: 23.6% vs 4.8% with 19 vs 7 deaths, hazard ratio (HR) ¼ 5.5, 95% confidence interval (CI) 2.3 to 13.0, p < 0.0001). Excluding 7 deaths during ELR monitoring, HR ¼ 4.5, p < 0.001. Conclusion: ELR applied in patients with acute MI and LV dysfunction at the time of discharge identifies patients with high mortality risk.

Prevalence, clinical profile, and stroke risk of atrial fibrillation in rural Andhra Pradesh, India (the AP-AF study)

The burden of atrial fibrillation (AF) is increasing worldwide. It is often asymptomatic, with stroke being the first manifestation in some. AF burden in the community and the practice of stroke prophylaxis has not been studied in India. The problem might be higher in rural regions due to poor health awareness and challenges to healthcare access. This study aimed to estimate the prevalence of AF, clinical profile and stroke risk in rural India. Methods: This is a community-based cross-sectional study done in rural Andhra Pradesh (AP). Adults from 40 villages formed the study population. We did a door-to door survey to collect information on demographics, and medical history. Electrocardiogram was recorded using a smart phone based Alivecor device. Participants diagnosed with AF underwent echocardiogram. Study cardiologists assessed the cardiovascular risk profile and collected detailed medical history. Results: Fourteen of the 4281 individuals screened had AF (0.3%). The mean age of the sampled population was 44 ± 16.5 years with 56% women. The mean age of participants with AF was 71 ±7.8 years; males were 71%. Except for one, all were non-valvular AF. Majority had a CHA2D2S2Vasc score of 2. Three had history of stroke. Two were on anticoagulant therapy but without INR monitoring. Conclusion: The prevalence of AF is lower in this study compared to studies from the developed countries. Non-rheumatic cardiovascular risk factors were primary causes for AF. Non-adherence to stroke prophylaxis is a major threat that needs to be addressed

Impact of Patient Counseling and Socioeconomic Factors on Initiation of Rehabilitation Program in Spinal Cord Injury Patients Presenting to a Tertiary Spine Unit in India

Study DesignProspective case series.PurposeThis study aimed to investigate the impact of education, financial income, occupation, and patient counseling on the timing of enrolment in a spinal cord injury (SCI) rehabilitation program.Overview of LiteratureA rehabilitation program following SCI is essential to improve functional outcomes. Socioeconomic factors can affect the timing of enrolment to a rehabilitation program. Literature on the effects of socioeconomic factors among patients with SCI in the Indian scenario is limited.MethodsA prospective, consecutive analysis of patients with SCI was performed with 1-year follow-up. Assessment of the timing of enrolment to a rehabilitation program was performed using the modified Kuppuswamy socioeconomic scores (MKSS). Patients admitted to the SCI unit (group A), underwent intensive individual, group, and family counseling sessions to encourage early enrolment into a rehabilitation program. Patients presenting directly for rehabilitation (group B) were analyzed for comparison.ResultsA total of 153 patients were recruited. Group A was composed of 122 patients who started the rehabilitation program after a mean of 28 days, compared with a mean of 149 days for 31 patients in group B. In group A, 104 patients (85%; mean MKSS, 14.02) and 18 patients (15%; mean MKSS, 15.61) enrolled for rehabilitation 0.05).Conclusions Early patient counseling in the acute care unit helps in the early enrolment of patients with poor socioeconomic demographic profile to a rehabilitation program.

Impact of Patient Counseling and Socioeconomic Factors on Initiation of Rehabilitation Program in Spinal Cord Injury Patients Presenting to a Tertiary Spine Unit in India

Study DesignProspective case series.PurposeThis study aimed to investigate the impact of education, financial income, occupation, and patient counseling on the timing of enrolment in a spinal cord injury (SCI) rehabilitation program.Overview of LiteratureA rehabilitation program following SCI is essential to improve functional outcomes. Socioeconomic factors can affect the timing of enrolment to a rehabilitation program. Literature on the effects of socioeconomic factors among patients with SCI in the Indian scenario is limited.MethodsA prospective, consecutive analysis of patients with SCI was performed with 1-year follow-up. Assessment of the timing of enrolment to a rehabilitation program was performed using the modified Kuppuswamy socioeconomic scores (MKSS). Patients admitted to the SCI unit (group A), underwent intensive individual, group, and family counseling sessions to encourage early enrolment into a rehabilitation program. Patients presenting directly for rehabilitation (group B) were analyzed for comparison.ResultsA total of 153 patients were recruited. Group A was composed of 122 patients who started the rehabilitation program after a mean of 28 days, compared with a mean of 149 days for 31 patients in group B. In group A, 104 patients (85%; mean MKSS, 14.02) and 18 patients (15%; mean MKSS, 15.61) enrolled for rehabilitation 0.05).Conclusions Early patient counseling in the acute care unit helps in the early enrolment of patients with poor socioeconomic demographic profile to a rehabilitation program.

Lumpy Bumpy Weepy Face - A Rare Case Report of a Frequently Misdiagnosed Disease

.Infectious clinical conditions that can present with swellings and sinuses more commonly, include cutaneous tuberculosis, and subcutaneous and deep fungal infections. One of the differentials that should be considered in such a scenario is actinomycosis. Actinomyces are filamentous gram-positive bacteria that are facultative anaerobes which can form endospores. The individual bacterium is rod shaped filamentous organism. After its discovery in 1890, a misconception was that it is a mycosis that affected individuals who chewed grass or straw. The pathogen is still known as the ‘great masquerader’.1Many entities can mimic cutaneous mycobacterial infections and deep cutaneous mycosis. One such great mimicker is actinomycosis – a bacterial infection caused by Actinomyces israelii. Though it is sensitive to many antibiotics, the duration of treatment for effective clearance of the lesions is long.

Low incidence of GIPC3 variants among the prelingual hearing impaired from southern India

The broad spectrum of causal variants in the newly discovered GIPC3 gene is well reflected in worldwide studies. Except for one missense variant, none of the reported variants had reoccurred, thus reflecting the intragenic heterogeneity. We screened all the six coding exons of GIPC3 gene in a large cohort of 177 unrelated prelingual hearing impaired after excluding the common GJB2, GJB6 nuclear and A1555G mitochondrial variants. We observed a single homozygous pathogenic frameshift variant c.685dupG (p.A229GfsX10), accounting for a low incidence (0.56%) of GIPC3 variants in south Indian population. GIPC3 being a rare gene as a causative for deafness, the allelic spectra perhaps became much more diverse from population to population, thus resulting in a minimal recurrence of the variants in our study, that were reported by authors from other parts of the globe.

Analysis of Temporal parameters in the Speech of the Children with Hearing Loss

The surge of literature indicates that the to develop more effective speech training procedures for the subjects with hearingloss, it is necessary to study the deviation in their speech from that of the normal-hearing subjects and hence, the analysis ofspeech of the subjects with hearing loss becomes essential. The current investigation aimed at studying the temporalparameters of vowel and consonants in the speech in children with hearing loss. Sixteen bisyllabic words with stopconsonants and vowels, uttered by participants with severe sensorineural hearing loss and age and gender-matched normalhearing participants in the age range of eight to ten years were recorded and the temporal parameters namely vowel duration,closure duration, consonant duration, voice onset time, burst duration, and word duration were analysed acoustically. Resultsof statistical analyses revealed that there were significant differences in vowel duration, voice onset time, closure durationand consonant duration between the participants of two groups. No differences in burst duration were observed between theparticipants of both groups.

Effects of Vowel and Consonant Duration Transformation on the Speech Intelligibility in Children with Hearing Loss

The present study aimed at investigating the effects of transformation of vowel and consonant duration on the intelligibility ofspeech in children with hearing loss. Sixteen bisyllabic words with stop consonants and vowels, uttered by participants withsevere sensorineural hearing loss and normal hearing participants in the age range of eight to ten years were recorded, and thevowel duration and consonant duration were analysed acoustically. Results of statistical analyses revealed that there weresignificant differences in both the vowel duration and consonant duration between the participants of two groups. The meanvalues of both vowel duration and consonant duration of the participants with normal hearing were used to transform (toapproximate the normal values) the vowel and consonant duration (individually and in combination) in the speech of theparticipants with hearing loss. The results of perceptual analysis showed significantly higher speech intelligibility scores forthe transformed words compared to the unaltered words spoken by the children with hearing loss. Combined transformationsresulted in the highest improvement in speech intelligibility compared to the individual transformations of vowel duration andconsonant duration.

Vertebral artery occlusion with lateral medullary syndrome and cervical cord infarct

@#Wallenberg syndrome (lateral medullary syndrome) is a type of posterior circulation stroke resulting in brainstem infarction which is most often caused by occlusion of vertebral artery or posterior inferior cerebellar artery or both.1 Here we report a case of right lateral medullary syndrome secondary to vertebral artery occlusion with associated left cerebellar and cervical cord infarct resulting in quadriparesis.

Permanent HIS bundle Pacing Feasibility in Routine Clinical Practice: Experience from an Indian Center

There is a paucity of experience regarding His bundle pacing (HBP) at laboratories initially attempting the procedure, especially in the Indian scenario. Patient who underwent HBP were selected for pacing therapy or in lieu of cardiac resynchronization therapy (CRT) at a single center. Among 22 patients attempted, 19 patients underwent successful implant, achieving selective HBP in 14 patients. There was a significant improvement in left ventricular ejection fraction (LVEF) (49.3 ± 9.3 vs. 36.7 ± 9.2) in the LV dysfunction subgroup (n = 6). Over a follow-up of 15 ± 6.5 months, thresholds were stable in all except one patient, and there was no requirement of lead revision. In summary, we found that HBP is a feasible option for achieving physiological pacing.

Vanishing Headache In A Young Female: An Interesting Case Report

Headache is one of the most common neurological symptom occurring worldwide. Here, we present a unique case of secondary headache in a young female which got reversed with appropriate treatment. A young female who presented with a severe subacute unilateral left-sided intractable headache with papilledema and obstructive hydrocephalus was found to have 4th ventricular neurocysticercosis causing obstruction of the foramen of Magendi and Luschka, relieved on timely surgical excision and with medical management. This case is reported to highlight the rare causes of secondary headache and various presentations of neurocysticercosis, in endemic areas like India as it causes neurological morbidity which can be alleviated on appropriate treatment, thereby preventing economic hardship and improving the quality of life.

Cognitive Impairment in Renal Transplant Recipient: A Prospective Study

Introduction: Kidney transplant recipients, like patients on dialysis, have several risk factors for developing cognitive impairmentsuch as comorbid illness, depression, and lower level of physical activity.Materials and Methods: A total of 25 patients were included to analyze the cognitive status in chronic kidney disease patientbefore and after renal transplant (RT) (6–9 months after renal transplant). Demographic and clinical variables associated withcognitive impairment were also examined.Results: The mean hemoglobin (Hb) before RT was 8.44 g, significant increase after RT 11.56 mgs. The mean blood ureadecreased from 115.60 mgs to 31.60 mgs after RT. Serum creatinine significantly decreased after RT from 8.10 mgs to 1.30 mgs.Blood pressure (BP) after RT decreased to 123.6/80.40 mmHg. Statistically significant changes in attention, anterogradememory, verbal fluency, and word recognition after renal transplant, but there is no statistically significant in language domain.Conclusion: There is a statistically significant increase in Hb level, decrease in serum creatinine and blood urea, and BPcontrol after the renal transplant. Statistically significant changes in attention, anterograde memory, verbal fluency, and wordrecognition after renal transplant, but there is no statistically significant in language domain

An Interesting Case Of Metastatic Brain Abscess

Klebsiella pneumoniae is a Gram-negative, non-motile, lactose fermenting, aerobic rod-shaped bacterium with three different subspecies, K. pneumoniae, Klebsiella ozaenae, and Klebsiella rhinoscleromatis. Here, we report the case of a 32-year-old male, chronic alcoholic presented with fever, hemoptysis, and headache of 20 days duration. Over a period of 4 days, the patient worsened with the development of altered sensorium and respiratory distress, connected to a mechanical ventilator. Computed tomography and chest X-ray showed consolidation involving the left lower lobe with an air-fluid level. Magnetic resonance imaging brain showed multiple metastatic brain abscess involving cerebrum and cerebellum and culture reports of sputum and blood showed K. pneumoniae. The patient was started on antibiotics along with anti-tubercular drugs. In spite of effective management, the patient developed recurrent episodes of hemoptysis and died of respiratory failure. For the concomitant involvement of both cerebrum and cerebellum for the first time.