Study to estimate impact of sudden lockdown due to COVID-19 pandemic at the household level: findings of cross-sectional study in Tamil Nadu

Background: In response to contain the spread of coronavirus disease 2019 (COVID-19) in India, the entire country was declared to be under lockdown from the midnight of 24 March 2020. In this study, we determined the economic impact and availability of health services during sudden lockdown. Methods: A cross sectional study was done in rural and urban health and training centres attached to rural medical college of Chengalpattu district of Tamil Nadu. Sample size was 424. Study participants were out patients, seeking health care services. Data was collected by trained medical social workers (MSW), using field tested semi-structured questionnaire. Percentages were calculated and for assessing difference between proportions, Pearson抯 chi-square test was used as a test of significance. Results: Out of 424 study participants, 223 (52.6%) were male and mean age of participants was 44 years. Socio economically, majority of them belonged to lower and lower middle-class families. 297 (70%) of households reported to have financial loss and 71.2% reported difference due to lockdown. In univariant analysis, the significant risk factors for difference in income were found to be type of house (0.029), loss of job (0.0001), loss of wages (0.0001), having bank loan (0.019) and issues in managing household expenses (0.0001), per capita income (0.008), farming business (0.018) and household with members having non-communicable diseases (0.013). Conclusions: Lockdown has huge economic cost. Underprivileged households were economically impacted. Most of the essential health services were available and accessible to the household even during the strict lockdown.

Effectiveness of lockdown to mitigate the spread of COVID-19 pandemic during its first wave in India

Background: Countries across the globe had adopted various prevention and control measures ranging from social distancing and isolation, to shutting down of nonessential services and countrywide lockdowns. The objective of the study was to assess the effectiveness of the nation-wide lockdown to prevent or delay the spread of COVID-19 in India. Methods: This was a cross sectional and descriptive study. We used the secondary data from WHO website, from 01 January to 30 October 2020. We calculated mean, median number of new cases, deaths reported per day and case fatality rate, using Microsoft excel spreadsheet. Results: There was a steady rise in number of cases and deaths in India, during the lockdown and unlock period from phase-1 to phase-4. Approximately 10-fold increase in death was reported in the duration of 68 days of lockdown from phase-1 to Phase 4. The number of cases reported in unlock phase-4 were approximately 6 times more compared to unlock phase 1. The case fatality rate per day had declined during the lockdown period, from 3 .4% to 2 .5% deaths per day. The case fatality rate was lowest during the peak of pandemic, 1.27% in September 2020. Indicating good care of hospitalized patients compared to initial stage of pandemic in India. Conclusions: Indian government had imposed complete sudden lockdown at the right time. The peak of pandemic was delayed or slowed down. Indicating the timing of lockdown is an essential step to save the lives in pandemic, in resource limited settings.

Comparison of lymphangiogenesis, lymphatic invasion, and axillary lymph node metastasis in breast carcinoma

Context: Lymphangiogenesis correlates with poor prognosis in Invasive Ductal Carcinoma (IDC) breast. D2-40 antibody, a specific marker for lymphatic endothelium, differentiates lymphatic from vascular endothelium. Therefore, the aims of this study were to estimate lymphangiogenesis using D2-40 antibody and correlate with lymphatic invasion (LI) and axillary lymph node (LN) status and compare lymphatic mean vessel density (LMVD) with Tumor (T) and Node (N) stages and grade of tumor. Methods and Material: The study was conducted on fifty consecutive cases of IDC breast who underwent modified radical mastectomy (MRM) from Jan 2009 to March 2011. Hematoxylin-eosin sections and Immunohistochemistry (IHC) slides were studied along with their LN status. LMVD was counted after D2-40 immunostaining (100x magnification) in three hot spots in peritumoral areas and averaged. LI as opposed to vascular invasion (BVI), and LN status for all cases were assessed. Statistical Analysis: Statistical analysis was done using SPSS software (version 14.0 for Windows). Pearson's correlations, χ2 tests and Mann-Whitney U test were used. Results: Lymphangiogenesis varied from 0 to 58 with mean LMVD of 11. Of 50 cases, five showed no lymphatic vessels in peritumoral areas; of these five, three had positive LNs. 21/50 cases had LI. No statistical significant association was seen between lymphangiogenesis and LI. 34/50 cases had positive LNs. Mean LMVD was higher in patients with N2/N3 stage as compared to N0/N1 stage and was statistically significant (P = 0.013). Conclusions: D2-40 is specific marker for lymphatic endothelium. LI and lymphangiogenesis, as opposed to BVI, are better prognostic indicators in IDC breast.

A morphometric and immunohistochemical study of melanocytes in periorbital hyperpigmentation.

Background: An increase in number of melanocytes in the basal cell layer of the epidermis is an important feature in many disorders of hyperpigmentation. In this study, we attempted an objective evaluation of the linear density of melanocytes and keratinocytes, along with other epidermal characteristics, in periorbital hyperpigmentation using immunohistochemistry and morphometric techniques. Methods: Melanocytes and epidermal parameters were assessed by digital morphometry in 30 newly diagnosed cases of periorbital hyperpigmentation and 14 controls from the post-auricular region. Melanocytes were labelled with the immunohistochemical stains, Melan-A and tyrosinase. We studied the linear keratinocyte density, mean linear melanocyte density, ratio of melanocytes to keratinocytes, the ratio between inner and outer epidermal length, maximum epidermal thickness and minimum epidermal thickness. Results: Melan-A expression of melanocytes showed strong positive correlation (r = 0.883) with the tyrosinase expression. Mean linear melanocyte density was 24/mm (range: 13–30/ mm) in cases and 17/mm (13–21/mm) in controls and this difference was statistically signifi cant (P < 0.001). The mean ratio of melanocyte to keratinocyte was 0.22 (0.12– 0.29) in cases and 0.16 (0.12–0.21) in controls; again, this difference was statistically signifi cant (P < 0.001). There was a mild negative correlation with linear keratinocyte density (r = −0.302) and the ratio between inner and outer epidermal length (r = −0.456). However, there were no differences in epidermal thicknesses. Limitations: There were fewer control biopsies than optimal, and they were not taken from the uninvolved periorbital region. Conclusion: Mean linear melanocyte density and the ratio of melanocytes to keratinocytes is increased in cases with periorbital hyperpigmentation. It is, therefore, likely that increased melanocyte density may be the key factor in the pathogenesis of periorbital hyperpigmentation.

Bilateral benign non functional struma ovarii with Pseudo-Meigs' syndrome.

Bilateral presentation of benign Struma ovarii is rare and has not been reported frequently in published literature. A 70-year-old postmenopausal female presented with progressive ascites, bilateral pleural effusion and elevated CA-125 levels. The contrast-enhanced computed tomography (CECT) of the abdomen and pelvis revealed a heterogenous mass in the left adnexa. These findings were suspicious for an ovarian malignancy. After surgery the diagnosis of non functional, bilateral benign Struma ovarii was made. Struma ovarii is a specialized ovarian teratoma composed predominantly of mature thyroid tissue. It is associated with pleural effusion and ascites (Pseudo-Meigs' syndrome) in 5% of cases. The combination of struma ovarii and elevated CA-125 levels has been reported infrequently. This is a rare case of bilateral benign struma ovarii associated with Pseudo-Meigs' syndrome and elevated CA-125 levels. Surgical excision of the ovarian masses induced immediate resolution of the ascites and pleural effusion and a reduction of the serum CA-125 level.

Observational sickness assessment by the NICU staff nurses.

OBJECTIVE: To see the level of agreement on subjectively assessed sickness by NICU staff nurse with doctor. METHODS: Prospective study in NICU for three months. The nurses were asked to assess whether a baby is sick or not on the basis of observed physical variables. Both the nurses and the attending physician made their assessment on a progress sheet separately. Statistical analysis was carried out to see the agreement of the nurses with the doctors in respect to the sickness assessment, treatment, final outcome and the agreement between the symptoms picked up by the nurses and the doctors. RESULTS: Out of 112 babies admitted, 90 were observed to be sick by the nurses out of which 85 were observed to be sick by the doctors (Kappa=0.4098). Considerable accuracy was noted on comparing symptoms picked up by the nurses and the doctors'. The Kappa value for respiratory, GI and neurological system was 0.4278,0.401 and 0.59 respectively. A significant correlation was seen between the two groups with regard to the treatment given (p value=0.0456). CONCLUSION: Trained NICU staff nurse can identify sick neonate on observation.

Three dimensional conformal radiation therapy in prostate adenocarcinoma: survival and rectal toxicity.

Technological advances in radiation beam planning and linear accelerator based radiation delivery have led to the development of three dimensional conformal radiation therapy (3D-CRT). The 3D-CRT clinical treatment in our hospital was started in September 1998 and till December 2002, 51 patients with M(0) stage prostate carcinoma were treated. Treatment method consisted of pelvis and leg immobilization, planning CT scan, marking of planning target volume and organs at risk and 3D beam plan using multileaf collimated beam shaping through beam's eye view display. Network controlled 3D conformal radiation therapy was delivered with portal image verification. The median 3D-CRT dose was 72 Gy. Of the 51 patients, 35 were followed-up till December 2002 (minimum follow-up 2 years) in whom 32 were disease free and 3 had progressive disease. Eleven patients died, 8 of progressive disease, one due to second malignancy and two of intercurrent illness. Five patients were lost for follow up during 0 - 29 months period, after 3D-CRT. The acute rectal reaction (RTOG criteria) in 51 patients was grade 0 in 4, grade I in 31 and grade II in 16. None had greater than grade II rectal toxicity. The late rectal toxicity in 49 patients who had a minimum 6 months follow-up was grade 0 in 41, grade I in 3 and grade II in 5. Our experience suggests that a dose of 72 Gy by 3D-CRT can be safely delivered to the prostate and gastrointestinal tolerance during treatment and follow-up period was excellent.

Prediction of mortality by application of PRISM score in intensive care unit.

OBJECTIVE: Prediction of mortality by application of Pediatric Risk of Mortality (PRISM) score in Pediatric Intensive Care Unit (PICU) patients under Indian circumstances. DESIGN: Prospective study. SETTING: PICU of a tertiary care multi-specialty hospital. METHODS: 100 sick pediatric patients admitted consecutively in PICU were taken for this study. PRISM score was calculated. Hospital outcome was recorded as (died/survived). The predicted death was calculated by the formula: RESULTS: Of 100 patients, 18 died and 82 survived. By PRISM score 49 children had the score of 1-9. The expected death in this group was 10.3% (n = 5.03) and the observed death was 8.2% (n = 4). Among 45 children with the score of 10-19, the expected mortality was 21.2% (n = 9.6) and observed was 24.4% (n = 11). There were 3 patients with the score of 20-29, the expected mortality in this group was 39.3% (n = 1.18) and observed mortality 33.3% (n = 1). There were 3 patients with score > or = 30, observed death 66.3% (n = 2) and expected mortality was 74.7% (n = 2.24). There was no significant difference between expected and observed mortality in any group. (p > 0.5). ROC analysis showed area under the curve of 72%. CONCLUSION: PRISM score has good predictive value in assessing the probability of mortality in relation to children admitted to a PICU under Indian circumstances.

Chilaiditi syndrome with hypertension.

Chilaiditi syndrome is interposition of the intestine between liver and diaphragm. It is often asymptomatic but there were cases presented as acute pain in the abdomen, needing corrective surgical procedure; or as mistaken renal colic, or as suspected subphrenic abscess, or as pneumoperitonium. The interposition of proximal transverse colon was found to be more common than the small intestine. Chilaiditi syndrome was associated with colonic volvulus. The colonic interposition then progressed from mild abdominal discomfort to intermittent bowel obstruction. Some patients needed surgical operation like hepatic extraperitonealization, after replacement of the dislocated gastroenteric tract, bringing the superior surface of the liver again into direct contact with the related diaphragmatic dome. A rare case of Chilaiditi syndrome incidentally associated with hypertension and ischaemic heart disease, in a male aged 50 years is reported.

Endosulfan poisoning--a clinical profile.

OBJECTIVES: The objective of the study is to identify the clinical profile of endosulfan poisoning and also to recognise any biochemical parameters which indicate clinical or subclinical dysfunction of organs so that the offending agent can be easily identified in a given case of poisoning and appropriate treatment instituted promptly. METHODS: Forty four individuals who consumed food which was accidentally contaminated by endosulfan in a rural area were the subjects of the present study. Except the one who died, rest 43 were examined by the authors. A details history, regarding the item of food taken and quantity consumed was noted. Routine bio-chemical parameters like CBC, blood urea, serum creatinine, serum electrolytes, LFT, S Calcium, S Phosporus, were estimated, in fourteen of the patients who were admitted into this hospital. In seven of the patients who were available for follow up, laboratory parameters which were abnormal initially were repeated. RESULTS: Examination revealed that vital signs were stable. There was no jaundice, central nervous system examination showed varying grades of altered sensorium, normal sized pupils briskly reacting to light, normal oculocephalic reflex. There were no lateralising signs like hemiparesis. Plantars were bilateral extensor. There were no signs of meningeal irritation. Complete blood counts, blood sugar, urea, serum creatinine, serum electrolytes were all normal. Liver function tests in the form of SGPT, SGOT were abnormal. Serum bilirubin levels were normal. The values of SGOT and SGPT returned to normal at the end of six weeks. All patients were treated symptomatically. A postmortem examination carried out on the individual who died due to status epilepticus confirmed that the death was due to asphyxia. CONCLUSIONS: Endosulfan poisoning can be suspected by the primary CNS manifestations with or without clinical or laboratory evidence of other organ dysfunction like liver, kidney and muscle.

A case control study of senile cataract in a hospital based population.

A case-control study (244 cases and 264 controls) was done during 1986-89 on a hospital based population to evaluate the risk factors associated with the etiology of senile cataract. Patient with age between 40-60 years, visual acuity of 6/9 or less, and presence of lenticular opacity of senile origin were included as cases. Age matched individuals with absence of lenticular opacity made up the controls. Multivariate logistic regression analysis revealed that higher systolic BP and number of meals were significantly (P < or = 0.05) associated with presence of senile cataract; whereas higher weight, education and income, and utilization of cooking water had a significant protective effect against senile cataract. The present study helps the clinician to understand the possible risk factors associated with the development of senile cataract and could be helpful in designing a intervention strategy in future.