Executive Summary of the Recommendations on the Management of Asthma In Primary Care (2022) – New Updates

Background : Asthma is a heterogenous disease defined by the history of respiratory symptoms (shortness of breath, wheezing, cough, and chest tightness) that vary over time and in intensity, along with variable expiratory airflow limitation. Despite an ever-increasing prevalence of asthma across all age groups, this condition remains poorly managed in India. Majority of the Indian patients remain undiagnosed or wrongly diagnosed in general clinical practice and even those who get diagnosed, remain poorly or inadequately treated1,2. Since the last published 2020 Indian Medical Association (IMA) recommendations on the management of asthma in primary care, noteworthy critical changes have been recommended in relation to the diagnosis/management of asthma in international guidelines. Hence, there was a need to update the existing IMA recommendations. For the same, an expert group meeting was organized with family physicians having clinical experience in managing patients with asthma along with chest physicians and pediatricians. Important updates related to asthma diagnosis and its management were discussed and the final recommendation decisions were derived from the joint group discussion. Some of the key points derived from the discussion are mentioned below in the executive summary. For a detailed version of the new recommendations please click on the url.

Prevalence of depression and health related quality of life among patients with diabetes mellitus and hypertension attending a secondary care hospital in district Faridabad, Haryana

Background: Diabetes mellitus (DM) and hypertension (HT) have significant effect on the mental health of the patient. and. Objective: To estimate the prevalence of depression, and the quality of life among patients with diabetes mellitus and hypertension who attended a secondary care hospital. Methods: A cross-sectional study was carried out among 618 patients who had DM and/or HT. PHQ-9 and WHO-BREF QOL questionnaire were administered to assess depression and health related quality of life respectively. Results: More than 2/3rd of patients had depression. Among those who had depression, nearly half (46%) had moderate depression and 2.1% had severe depression. The proportion of severely depressed patients was higher in diabetes mellitus group compared to the hypertension group. Patients that were depressed had poorer quality of life compared to non-depressed, and the difference was statistically significant. Conclusion: Patients with diabetes mellitus and hypertension may be screened for depression and managed accordingly

Intravenous Iron sucrose and change in hemoglobin, ferritin, and oxidative stress markers among moderately anemic pregnant women attending a secondary care level Hospital in Northern India

Background: Intravenous iron is associated with oxidative stress, and very few studies have assessed change in oxidative stress markers post infusion. Objectives: The study aimed to measure the change in levels of hemoglobin (Hb), serum ferritin, and select oxidative stress markers (malondialdehyde [MDA], superoxide dismutase [SOD], and ferric reducing ability of plasma [FRAP]) 4 weeks following the administration of intravenous iron sucrose (IVIS) among moderately anemic pregnant women who were attending a secondary-level health-care facility, Haryana, North India. Methods: An observational study was conducted (May 2016 to Jan 2018) among pregnant women receiving intravenous iron sucrose i.e., IVIS (300 mg per dose) diluted in 300 mL of normal saline over 20� min and were followed up for a period of 4 weeks after the last dose of IVIS (end line). The study outcomes were measured in the levels of Hb, serum ferritin, MDA, SOD, and FRAP from the baseline to the end line. Results: The mean (95% confidence interval) change in the Hb and serum ferritin level 4 weeks after the last dose of IVIS was an increase of 2.5 (2.1�0) g/dL (P < 0.001) and 63.0 (44.7�.3) ng/mL (P < 0.001), respectively. There were no significant changes (baseline to end line) in mean (standard deviation [SD]) MDA level and mean (SD) FRAP level. The mean (SD) SOD level declined significantly (2.2 [0.4] U/mL to 1.6 [0.5] U/mL [P < 0.001]). No life-threatening adverse events were encountered during the study. Conclusion: IVIS was well tolerated and effective in treating moderate anemia in pregnancy. Body iron store was replenished following IVIS administration. There was no increase in oxidative stress following IVIS therapy.

Prevalence of anemia among elderly persons residing in old age homes in national capital territory, Delhi, India

Background: Anemia is a common morbidity in elderly persons (aged 60 years or above). In India, in recent years, the number of old age homes (OAHs) and the residents living in them has increased significantly. Objective: The aim of this study was to estimate the prevalence of anemia among elderly persons living in OAHs. Methods: This was a cross-sectional study among individuals living in OAH in Delhi, India. Using combination of location and type of OAH, 28 clusters of almost equal sizes were created, of which 13 clusters were randomly selected, and all elderly persons living therein were selected for the study. Sociodemographic profile was recorded using a self-designed, semistructured interview schedule. Hemoglobin (Hb) was estimated using HemoCue Hb 201+ system. Binary Logistic regression was used to assess the socioeconomic determinants of anemia. Results: The study included 334 elderly persons, with a mean (standard deviation [SD]) age of 75.2 (8.6) years and mean (SD) Hb of 11.6 (1.7) g/dL. The mean (SD) Hb in men was 12.1 (1.7) g/dL compared to 10.9 (1.5) g/dL among women (P < 0.0001). The overall prevalence of anemia was 68.7% (95% confidence interval 63.9, 73.4); among those who were anemic, 47.4% had mild anemia, 47.0% had moderate anemia, and 5.6% had severe anemia. The prevalence of mild anemia was 45% in men compared to 24.8% in women. The odds of anemia among ?80 years was 2 times that among 60–69 years (P < 0.029). Conclusions: The prevalence of anemia among elderly persons in OAHs is high in Delhi, India and increased with age.

Do we have a magic bullet to treat moderate and severe anemia in pregnant women?

A desperate situation may evoke a fundamental question or suggestion of a radical solution. Hence, let us first examine whether the current situation of maternal anemia in India is really desperate and therefore merits a search for a “magic bullet” as a cure.

ROS-1 re-arrangements and c-MET amplifications in adenocarcinoma lung: A tertiary care center study from North India

Background: C-ros oncogene 1, receptor tyrosine kinase (ROS 1) proto-oncogene 1, receptor tyrosine kinase (ROS-1) fusions are potent oncogenic drivers and these re-arrangements promote signal transduction programs leading to uninhibited cell survival and proliferation identified in 1–2% of cases of nonsmall-cell lung cancer. Mesenchymal epithelial transition factor (MET) receptor tyrosine kinase and its ligand are predominantly involved in epithelial mesenchymal transition and tissue regeneration. The MET amplification and overexpression is oncogenic in 3–7% cases. The objectives of this study were to identify the frequency of ROS-1 and c-MET protein expression in adenocarcinoma lung and to correlate it with the clinicopathological parameters and to analyze the histomorphology of cases that harbor the characteristic mutations (c-MET and ROS-1). Materials and Methods: Study group comprised a prospective cases series of 90 cases of adenocarcinoma lung. ROS-1 protein expression was determined by immunohistochemistry using the D4D6 rabbit monoclonal antibody (Cell Signaling, Danvers, MA) and c-MET protein expressed was analyzed using the SP-44 clone (Ventana Medical Systems). Results: c-MET protein expression was identified in 33.33% cases (n = 30/90) with statistically significant thyroid transcription factor-1 (TTF-1) positivity. ROS-1 protein expression was detected in 3.33% cases (n-3/90), in biopsies from the respiratory tree with TTF-1 expression. Conclusion: This is the first study from the Indian subcontinent to identify the frequency of ROS-1 re-arrangements and MET amplification in the Indian population. The availability of targeted therapy that has a significant impact on survival makes it essential to detect these less frequent mutations.

National survey of infection control programmes in South Asian association for Regional Cooperation countries in the era of patient safety

Background: The implementation of hospital infection prevention and control (IPC) in south Asia is not well described. We aimed to assess IPC programmes in hospitals in this region and explore opportunities for improvement. Methods: Attendees from hospitals in the South Asian Association for Regional Cooperation (SAARC) region who were at one of four National Initiative for Patient Safety workshops organised by All India Institute of Medical Sciences (New Delhi) from 2009 to 2012 were invited to complete a semi-structured questionnaire. The survey addressed six main components of IPC programmes. Results: We received responses from 306 participants from 82 hospitals. Five key opportunities for improvement emerged: (1) lack of healthcare epidemiologists, (2) relative infrequency of antibiotic guidelines (53%) and prescribing audits (33%) (3) lack of awareness of needle stick injury rates (84%) (4) only 47% of hospitals were prepared for surge capacity for patients with infectious diseases, and (5) limited coordination of hospital infection control personnel with other support services (55%-66%). Conclusion: These results outline IPC challenges in the SAARC region and may be useful to guide future quality improvement initiatives.

Effect of directly observed oral iron supplementation during pregnancy on iron status in a rural population in Haryana: A randomized controlled trial

Background: In India, more than half of the pregnant women suffer from anemia. Low compliance to iron supplementation is one of the important reasons. Objectives: The objective of the study is to estimate the reduction in the prevalence of anemia, improvement in iron status, and to compare the compliance to oral iron supplementation during pregnancy between directly observed iron-folic acid (IFA) supplementation group and control group. Methods: This was a community-based open labeled parallel block-randomized controlled trial including 400 pregnant women in a rural setting of north India. In the intervention group, the first dose of IFA every week was supervised by ASHA and women were instructed to take the remaining tablets during the week as per the prescription. In control group, IFA tablets were supplemented without direct supervision. Results: After 100 days of IFA supplementation, the reduction in anemia in the intervention group was 6% higher as compared to control group (P = 0.219). The increase in the mean hemoglobin level over and above control group was 0.52 g/dl in intervention group (P < 0.001). However, the mean increase in serum ferritin level in the intervention group was similar to the control group. The mean percentage compliance in the intervention group was almost 9% higher than that of control group (P = 0.001). Conclusion: Directly supervised oral iron (IFA) supplementation improves compliance to oral iron (IFA) supplementation and also improves hemoglobin status among pregnant women. However, the mean increase in serum ferritin and reduction in the prevalence of anemia in the intervention group were not higher than the control group.

Anemia at the time of delivery and its association with pregnancy outcomes: A study from a secondary care hospital in Haryana, India

Maternal anemia has been reportedly associated with increased risk of maternal and fetal morbidity and mortality. Adverse pregnancy outcomes such as preterm birth, low birth weight, and stillbirth have been reported to be associated with anemia. However, different studies have shown inconsistent results. In the present study, we report the association between maternal hemoglobin levels at the time of delivery and outcomes among women at a secondary care hospital in northern India. Secondary analysis of routinely collected hospital data from January 2015 to December 2016 was carried out. Sociodemographic details, hemoglobin levels at the time of admission, and birth outcomes were retrieved from the records of women admitted for delivery. The outcomes were compared among anemic and nonanemic women. About 78% of the women were found to have anemia at the time of delivery. A significantly higher proportion of anemic women had preterm labor.

A prospective study of association of cancer stem cell marker aldehyde dehydrogenase 1 with clinicopathological profile in lung carcinoma patients

Context: In India, lung carcinoma is the fifth-most common tumor and second-most common tumor in the males as per the Indian Council of Medical Research registry of 2002. It has been seen that ALDH1 expression in non-small cell lung cancer (NSCLC) and the presence of marker was linked to a more tumorigenic potential in the in vivo assessment and shorter disease-free survival in NSCLC patients with platinum treatment. Aims: Hence, our objective was to detect association of cancer stem cell (CSC) marker aldehyde dehydrogenase 1 (ALDH1) with clinicopathological profile in lung carcinoma patients. Settings and Design: This is a Pilot study. Subjects and Methods: It was a Pilot study where biopsies from 55 fresh previously untreated lung cancer patients visiting the Pulmonary Medicine Department of Era's Lucknow Medical College and Hospital Lucknow and King George's Medical University were taken for 18 months November 2014–April 2016, after taking proper informed consent from them. Paraffin blocks were taken and stained by hematoxylin and eosin (Sigma) to make the histopathological diagnosis and immunohistochemistry was done for detection of CSC marker ALDH1 (Daco). Statistical Analysis Used: The statistical analysis was done using Statistical Package for Social Sciences Version 15.0 Statistical Analysis Software. The values were represented in number (%) and mean ± standard deviation. Results: Expression of stem cell marker ALDH1 with the staging of the tumor was observed in 62.5% of Stage I, 80% of Stage II, 94.1% of Stage III, and 100% of Stage IV cases. Statistically, there was a significant association between ALDH1expression and stage of disease (P < 0.001). Diagnostic efficacy of ALDH1 expression in the detection of any positive clinical stage, it was found to be 88.6% sensitive and 90.9% specific. Conclusions: Strong ALDH1 expression correlates with higher stage of lung carcinoma making it a prognostic marker needing in-depth study.

Use of Point of Care Testing (POCT) in measurement of hemoglobin

Point of care tests (POCT) are critical to success of public health programs like anemia control program which involve measurement of biomarkers; as they help in prompt decision making during first (and in many scenario the only) contact with the targeted beneficiary. There are many methods currently in use for point of care testing for hemoglobin estimation and include manual methods like Sahli’s method, Indirect cyanmethemoglobin method, WHO Hemoglobin Color Scale method; digital hemoglobinometers including the newer non-invasive devices. The current background paper reviewed available published literature regarding performance of different POCT methods for hemoglobin estimation. Available literature indicates that invasive digital hemoglobinometers have shown a reasonable performance for use as POCT in facility and community settings both for clinical diagnosis as well as surveys. Adequate training of front line workers for use of digital hemoglobinometers and adherence to standard operating procedures (SOPs) is essential to reduce errors/biases. Non-invasive digital hemoglobinometers seem to be promising new option for POCT which obviates the need for drawing blood sample (either by venous or capillary method) but further research and development is required before their use in programs.

Use of GenoType® MTBDRplus assay to assess drug resistance and mutation patterns of multidrug-resistant tuberculosis isolates in northern India.

Purpose: The emergence and spread of multidrug-resistant tuberculosis (MDR-TB) is a major public health problem. The diagnosis of MDR-TB is of paramount importance in establishing appropriate clinical management and infection control measures. The aim of this study was to evaluate drug resistance and mutational patterns in clinical isolates MDR-TB by GenoType® MTBDRplus assay. Material and Methods: A total of 350 non-repeated sputum specimens were collected from highly suspected drug-resistant pulmonary tuberculosis (PTB) cases; which were processed by microscopy, culture, differentiation and first line drug susceptibility testing (DST) using BacT/ALERT 3D system. Results: Among a total of 125 mycobacterium tuberculosis complex (MTBC) strains, readable results were obtained from 120 (96%) strains by GenoType® MTBDRplus assay. Only 45 MDR-TB isolates were analysed for the performance, frequency and mutational patterns by GenoType® MTBDRplus assay. The sensitivity of the GenoType® MDRTBplus assay for detecting individual resistance to rifampicin (RIF), isoniazid (INH) and multidrug resistance was found to be 95.8%, 96.3% and 97.7%, respectively. Mutation in codon S531L of the rpoB gene and codon S315T1 of katG genes were dominated in MDR-TB strains, respectively (P < 0.05). Conclusions: The GenoType® MTBDRplus assay is highly sensitive with short turnaround times and a rapid test for the detection of the most common mutations conferring resistance in MDR-TB strains that can readily be included in a routine laboratory workflow.

Changing patterns and trends of multidrug-resistant tuberculosis at referral centre in Northern India: A 4-year experience.

Purpose: India has a high burden of drug-resistant tuberculosis (TB), although there is little data on multidrug-resistant tuberculosis (MDR-TB). Although MDR-TB has existed for long time in India, very few diagnostic laboratories are well-equipped to test drug sensitivity. The objectives of this study were to determine the prevalence of MDR-TB, first-line drug resistance patterns and its changing trends in northern India in the 4 years. Materials and Methods: This was a prospective study from July 2007 to December 2010. Microscopy, culture by Bactec460 and p-nitro-α-acetylamino-β-hydroxypropiophenone (NAP) test was performed to isolate and identify Mycobacterium tuberculosis (M. tb) complex (MTBC). Drug sensitivity testing (DST) was performed by 1% proportional method (Bactec460) for four drugs: Rifampicin, isoniazid, ethambutol and streptomycin. Various clinical and demographical profiles were evaluated to analyse risk factors for development of drug resistance. Results: We found the overall prevalence rate of MDR-TB to be 38.8%, increasing from 36.4% in 2007 to 40.8% in 2010. we found that the prevalence of MDR-TB in new and previously treated cases was 29.1% and 43.3% ( P < 0.05; CI 95%). The increasing trend of MDR-TB was more likely in pulmonary TB when compared with extra-pulmonary TB ( P < 0.05; CI 95%). Conclusions: we found a high prevalence (38.8%) of MDR-TB both in new cases (29.1%) and previously treated cases (43.3%).This study strongly highlights the need to make strategies for testing, surveillance, monitoring and management of such drug-resistant cases.

Detection of 123 bp fragment of insertion element IS6110 Mycobacterium tuberculosis for diagnosis of extrapulmonary tuberculosis.

Purpose: Extrapulmonary tuberculosis (EPTB) is emerging problem in developing and developed countries. The diagnosis of EPTB in its different clinical presentations remains a true challenge. IS6110-based polymerase chain reaction (PCR) is used for rapid identification and positivity rate of the Mycobacterium tuberculosis complex in clinical isolates of different sites of EPTB. The present study was carried out to study the prevalence of M. tuberculosis complex in clinical isolates of EPTB at tertiary care centres in Lucknow. Materials and Methods: Seven hundred fifty-six specimens were collected from the suspected cases of EPTB which were processed for Mycobacteria by Ziehl Neelson (ZN) staining and BACTEC culture. All the specimens were also processed for IS6110-based PCR amplification with primers targeting 123 bp fragment of insertion element IS6110 of the M. tuberculosis complex. Results: Of these 756 specimens, 71(9.3%) were positive for acid fast bacilli (AFB) by ZN staining, 227(30.1%) were positive for mycobacteria by BACTEC culture and IS6110 PCR were positive for M. tuberculosis complex in 165 (20.7%) isolates. We found a significant difference in sensitivities of different tests (P<0.05). Conclusions: This study reveals the positivity of M. tuberculosis complex in clinical isolates of EPTB case in tertiary care hospitals in Northern India. 72.7% of M. tuberculosis complex was confirmed by IS6110-PCR in culture isolates from different sites of EPTB. The high prevalence of the M. tuberculosis complex was seen in lymph node aspirate and synovial fluid. However, utility of PCR may play a potentially significant role in strengthening the diagnosis of EPTB especially targeting IS6110.

Sunlight exposure and development of rickets in indian toddlers.

Objective. To study the role of sunlight exposure in determining the vitamin D status of underprivileged toddlers. Methods. Height and weight were measured, clinical examination was performed, Food Frequency Questionnaire was administered and history of sunlight exposure was obtained in all (61) toddlers attending daytime crèche (Group B). Ionised calcium (iCa), inorganic Phosphorous (iP), alkaline phosphatase activity (ALP), serum parathyroid hormone (PTH) and 25 Hydroxy vitamin D (25OHD) were measured. Data were compared with results of a survey measuring similar parameters in 51 (of 251 eligible) toddlers from the same slum (Group A). Results. 111 children (mean age 2.6 yr (0.7), boys 56) were studied. Prevalence of hypovitaminosis D was 77% in group B toddlers (46 of 60) and 16.4% (10 of 61) had rickets, while none of the group A toddlers had 25OHD levels below 30nmol/L. Four children (7.8%) from Group A as against 24 (42.9%) from Group B, had sunshine exposure of < 30 minutes per day. Conclusion. Underprivileged toddlers who were deprived of sunlight had a much greater incidence of hypovitaminosis D and frank rickets. The study has important public health implications and underscores the necessity for sunlight exposure in young children.

Circadian rhythm of peak expiratory flow rate in healthy north Indian men.

Peak expiratory flow rate (PEFR) variability follows a specific pattern in asthmatics as well as in healthy individuals. There is scarcity of data for Indian healthy subjects. The PEFR (L/min.) was measured with Wright's portable peak flow meter at 05:00, 8:00, 11:00, 14:00, 17:00, 20:00 and 23:00 hours in 42 healthy, non-smoking adults of age group between 18-26 years. The variability of PEFR revealed a circadian pattern. PEFR levels tend to increase from morning at 5:00 hours till evening at 17:00 hours, with peak PEFR in evening at 17:00 hours, after which there was a progressive fall in PEFR levels, till morning 5:00 hours. This study provides the preliminary reference data of circadian pattern of PEFR in healthy individuals.

Morbidity profile of paediatric inpatents at a community health centre and a nearby [correction of near by] district hospital in northern India.

The study was conducted to ascertain the morbidity profile among children by retrospective review of inpatient data of children admitted to Comprehensive Rural Health Services Project (CRHSP), Ballabgarh, a model CHC and Badshah Khan (B.K.) hospital, Faridabad, a district hospital over a period of one year. Diarrhea and pneumonia comprised 64% of all admissions at the model CHC and 30% at the district hospital. Thalassemics requiring blood transfusion formed 21% of inpatients at the district hospital. Common paediatric ailments can be managed appropriately at CHC level, provided the infrastructure as recommended by Indian Public Health sandards for CHC under National Rural Health Mission (NRHM) is available. The blood bank or blood storage facility at a CHC is desirable.

Quality assurance of annual HIV sentinel surveillance 2006: experience of regional institute, central zone.

National AIDS Control Organisation (NACO) identified five regional institutes (RIs) to monitor and supervise the 2006 round of annual HIV sentinel surveillance. The task mandated was quality control of both epidemiological data collection and HIV testing. The team at RI consisted of epidemiologist and microbiologist. We describe here the process of quality control and the quality of surveillance in the states of Uttar Pradesh, Uttarakhand, Bihar, Jharkand, and Delhi. The supervisors visited almost 90% of the sentinel sites. Performance of vast majority of the sentinel sites (92%) was satisfactory. The testing laboratories were found to be adhering to standard operating procedures. Concordance rate of test results between testing laboratory and the designated reference laboratory was high. Overall, the quality of sentinel surveillance was good. The lacunae found during the visit have been enumerated along with the recommendations for future surveillance round.

Passive malaria surveillance in a low endemic area of India: validation of a clinical case definition.

BACKGROUND: In India, 2.55 million cases of malaria were reported during 1997; roughly one-third were due to Plasmodium falciparum. Malaria cases are identified by passive and active surveillance and all patients with fever are treated with chloroquine (10 mg/kg body weight). Since all fevers are not malaria, this results in overtreatment and has a bearing in terms of the parasites developing resistance. We aimed to test the validity of a clinical algorithm for passive malaria surveillance by primary care doctors (fever with pallor or splenomegaly) in a low endemic, Plasmodium vivax-predominant area of Ballabgarh block in Faridabad District, Haryana. METHODS: Passive surveillance was carried out at the general and paediatric outpatient departments (OPDs) of Ballabgarh hospital. All persons with fever attending the OPD were examined for the presence of fever, pallor and splenomegaly by the treating doctor. A blood smear was prepared and examined in all these cases. RESULTS: A total of 3119 slides for malaria were made at Ballabgarh hospital but clinical details in the requisition form were available for only 2616 patients who form the subjects of this analysis. A total of 59 malaria cases (30 P. vivax cases and 29 P. falciparum) were diagnosed. The presence of fever with pallor or splenomegaly had a sensitivity of 28.8% (95% CI: 18.1-42.3); specificity of 88.6% (95% CI: 87.3-89.8), positive predictive value of 5.5% (95% CI: 3.3-8.8) and negative predictive value of 98.2% (95% CI: 97.5-98.7). CONCLUSION: The algorithm did not have sufficient sensitivity to detect malaria cases by passive surveillance.