Assessment of quality of life among stroke survivors: a longitudinal study

Background: Quality of life (QoL) among stroke survivors is a concern which has not received sufficient attention in India. The objective of the study was to assess the quality of life of stroke survivors in rural population of Chikkaballapur district, Karnataka.Methods: A community based longitudinal study was done amongst the 150 incident stroke cases registered during the period from March 2013 to November 2014 and who survived beyond 28 days. The cases were enrolled and interviewed using a semi-structured questionnaire and were followed up for 6th month period. QoL was assessed at baseline (at 28 days), at 3rd month and 6th Month using Stroke Specific QoL scale (SSQoL) and Barthel index (BI).Results: The mean age of the persons with stroke was 61.3±15 years with a majority being males (69.3%). Baseline median score (IQR) of SSQoL at 28th day was poor i.e. 131 (77-183). Among the 150 cases, 136 (91%) survived until the end of 6th month. The overall QOL gradually improved to 182 (133-213) and 185 (147-213) at 3rd and 6th month respectively and similar improvement was seen individually in physical, psychological and social domains as well and on multivariate logistic regression age <60 years and few disturbed consciousness among the stroke survivors during the 6th month follow up were found to be predictors for improved quality of life.Conclusions: QoL showed significant improvements in all physical, psychological and social domains by the end of the 6th month of follow up.

Depressive Disorders among People with Chronic Illness in an Urban Area of South India

Over the past decades, twin demographic and epidemiological transitions have been reflected an increase in the burden of chronic diseases. Although public health practitioners have recognized the increasing burden, the socioeconomic and overall health impact is to be adequately researched. Depressive disorders are considered an important correlate, for appropriate management of chronic disease but have been given relatively less importance. Hence, this study was taken up in an urban slum of Bengaluru city to explore the associations between depressive disorders and chronic diseases.Methodology: The cross-sectional community-based study was conducted in an urban slum of Bengaluru city using a modified cluster sampling technique. All persons who were ill or on long-term medication or were hospitalized for a period more than 3 weeks in the past 1 year were interviewed. A semi-structured pre-tested questionnaire incorporating Hamilton Depression Rating Scale was used. Results: He overall prevalence of chronic illness was 10% among the study population with 10.9% having mild depression, and 1.2% having mild-moderate depression, and none severe depression. None of them were taking any treatment for their depression. The mean age of those with mild depression was 53.9 years and was greater among females (males 5.0% and females 16.7%). The latter was highly statistically significant. Of the 91 persons with symptoms of mild depression, nearly two-thirds (58.2%) belonged to Class IV of Modified B G. Prasad’s classification. Factor analysis showed that HAM-D scores to have a significant relation with chronic illness. Discussion: Depressive disorders among those with chronic disorders are hitherto unrecognized in routine clinical practice. Middle ages, females and those lower down in the socioeconomic hierarchy are at greater risk. There is a need to establish a mechanism for appropriate management of these disorders.

Self-rated health as a measure of health status among people with chronic illness in an Urban area of South India.

Background: Rising burden of chronic illnesses across the globe necessitates the assessment of needs of persons suffering from these illnesses. Self-rated health has been found to be a valid and reliable tool in population health surveys. Material and methods: A cross-sectional study using modified cluster sampling technique was undertaken in the urban field practice area of M S Ramaiah Medical College, Bangalore. A semi-structured pre-tested questionnaire was used for data collection, which was done by interview method through house-house visits. Self- rated health was assessed using a 5-point scale ranging from Very Good -Good –Fair- Poor- Very poor. This rating was crosschecked by an assessment by the investigator. Descriptive statistics and factor analysis were used for the purpose of analysis of data and weighted kappa statistic was used to test agreement between self-rated health and health assessed by investigator. Results and Conclusions: Overall prevalence of chronic illness in the study population was 10.0% and significant difference was observed between males and females. In the study population, 72.0% (293) rated their health as fair. 13.0% rated their health as poor while the investigator assessed the health status of the study pop-ulation as fair in 72.0% of the study population and as poor in 4.9% of the study population. Weighted Kappa statistic showed 33% agreement between the two ratings. Factor analysis of 32 variables included in the study explained 67% of the total variance. Principal component analysis of these factors yielded 12 factors of which 3 were considered major depending on the number of variables included and percentage variance explained by that factor. Major factor 1 contained 11 variables including self-rated health and explained 14.3% of the variance, which signifies the role of self-rated health as a measure of health status.

Dietary factors and cancer chemoprevention: an overview of obesity-related malignancies.

Obesity is a growing health problem in developed nations and in countries that are in the process of westernization like India. Obesity is linked with several health disorders such as hypertension and cardiovascular diseases, Type 2 diabetes, dyslipidemia and certain cancers. Currently, obesity-related malignancies, e.g., cancers of the breast, prostate and colon are the leading cancers in the industrialized societies. An increased amount of fat or adipose tissue in an overweight or obese person probably influences the development of cancer by releasing several hormone-like factors or adipokines. The majority of adipokines are pro-inflammatory, which promote pathological conditions like insulin resistance and cancer. On the other hand, many recent studies have shown that adiponectin, an anti-inflammatory adipokine, has anti-cancer and insulin-sensitizing effects. Adiponectin exerts its physiological functions chiefly by activation of AMP kinase via adiponectin receptors. Interestingly, several fruits and vegetables may contain adiponectin-like molecules or may increase the biosynthesis of adiponectin in our body. Studies on adiponectin analogues or adiponectin receptor agonists are a promising area of cancer chemoprevention research. In general, fruits and vegetables contain various dietary substances such as vitamins, minerals (like calcium and selenium), fiber and phytochemicals or phenolic compounds (like flavonoids and vanilloids), which may act as anti-cancer agents. Similarly, several dietary constituents including phytochemicals may have anti-obesity effects. Consumption of such dietary compounds along with caloric restriction and physical activity may be helpful in preventing obesity-related cancers. For this review article, we searched PubMed primarily to get the relevant literature.

Study of social loss or gain from a particular cause: scope for the developing countries - a review with reference to cancer.

Incidence rates have long been used to assess the burden of different diseases in a population, whereas loss due to occurrence of diseases is studied using the death rates. Death rates however, are based on and therefore describe, only number of lives lost. There have been two approaches to arrive at the actual loss or gain from a particular cause viz. Person years of life lost (PYLL) approach and cause elimination life table (CELT) approach. This review covers these approaches and the competing risk theory and models focusing on the methodological developments. A summary of the conceptual and methodological developments on these concepts has also been presented. There are eight possible approaches in dealing with the loss in the presence or gain in the absence of a particular cause of death depending upon the preferences related to PYLL/CELT approach, modeling/descriptive approach, considering or without considering competing causes. A close look at the two basic approaches reveals that PYLL and cause elimination are just different terminologies used to address the same quantity, loss in the presence or gain in the absence. As far as descriptive vs. modeling approaches are concerned, all the descriptive procedures can be put in the form of models and all the models can be presented in a descriptive way. Regarding results using different models, no practical difference exists in the results based on different models for competing risks. However, exclusion of the competing risks may result in a considerable bias in the developing countries where general mortality is relatively higher. This review study suggests freedom in the selection of a modeling or a descriptive approach without any considerable loss of accuracy but at the same time emphasizes the consideration of the competing risks. An empirical study may be recommended to confirm the conclusions of this study.

Burden of cancer and projections for 2016, Indian scenario: gaps in the availability of radiotherapy treatment facilities.

Plausible projections of future burden of cancer in terms of incident cases and requirement of radiotherapy treatment facilities at the national and state level are useful aids in planning of cancer control activities. The present communication attempts to provide a scenario for cancer in India during the year 2001 and its likely change by 2016 for all sites of cancer as well for selected leading sites. Further, a study was made of: (i) the state-wise distribution of radiotherapy treatment facilities and short falls; and (ii) pattern of investment of finances through central assistance by Government of India for cancer control activities during the various plan periods. The age, sex and site-wise cancer incidence data along with populations covered by 12 Indian population based cancer registries were obtained from the eighth volume of Cancer Incidence in Five Continents (CIV-VIII) and other published reports. Pooled age sex, site specific cancer incidence rates for twelve registries were estimated by taking weighted average of these registries with respective registry population as weight. Population of the country and states according to age and sex for different calendar years viz. 2001, 2006, 2011 and 2016 were obtained from the report of Registrar General of India. Population forecasts were combined with the pooled incidence rates of cancer to estimate the number of cancer cases by age, sex and site of cancer for the above 5-yearly periods. The existing radiotherapy facilities available in the country for cancer treatment during the year 2006 was based on the published reports and updated through personal communication from the Ministry of Health of India. During the year 2001, nearly 0.80 million new cancer cases were estimated in the country and this can be expected to increase to 1.22 million by 2016 as a result of change in size and composition of population. The estimated numbers were greater for females (0.406 millions, 2001) than males (0.392 millions, 2001). Lung, esophagus, stomach, oral and pharyngeal cancers are much higher in men while in women, cancers of cervix and breast are predominant forms followed by those of oral cavity, stomach and esophagus. Considering all the sources, it was noted that during the year 2006, there were 347 teletherapy units in the country as against a requirement of 1059. The state-wise analysis of the distribution of RCCs, and radio-therapy units shows wide gaps in the availability of facilities. The existing treatment facilities for cancer control in-terms of radiotherapy and financial allocation are woefully inadequate to take care of even the present load. The only way to fight this scourge under such circumstances is to have pragmatic programmes and policies based on currently available scientific information and sound public health principles.

An indirect study of cancer survival in the context of developing countries.

With classical approaches, survival refers to the life of a person after diagnosis of disease, and survival studies deal with measurement of the same to evaluate overall performance of a group of patients in terms of quality and quantity of life after diagnosis/treatment. There are numerous difficulties in the conduct of a population-based survival study in the context of developing countries, including India. Loss to follow-up is a typical problem encountered, causing biased estimates. In view of this difficulty with the classical approach, the objective of this study was to propose an indirect methodology for the study of survival. The proposed methodology is based on life table techniques and uses current data on incidence and mortality from the disease. It involves the estimation of person years free of disease (PYFD), person years with disease (PYWD), person years of life lost (PYLL) and average duration of disease (ADD) and their comparison over a time period. Empirical application was carried out for mouth and lung cancers in males and cancers of breast and cervix in females as well as for all sites combined together in each sex. Cancer incidence and mortality data by age and sex for the years 1989, 1993, 1997 and 2001 were obtained from published reports of Mumbai Cancer Registry, India. All causes of deaths for these years were obtained from Mumbai Municipal Corporation. Three life tables were constructed by applying various attrition factors: (a) risk of death from all causes; (b) risk of incidence and that of death from other causes; and (c) risk of death from other causes only. The expectation of life from the second life table gave PYFD. PYWD and PYLL were calculated by suitable subtractions among three expectations of life. ADD was calculated by dividing person years lived with disease by number developing the disease. It was noted that during 1993-2001, PYFD for all sites increased from 59.4 to 62.1 and from 63.8 to 66 years in males and females respectively. PYLL was about 0.8 year in males and 1 year in females. Similarly, PYWD was 0.6 and 1 year in males and females. ADD for all sites varied from 4 to 4.7 years in both sexes. It was about 6 years for mouth cancers and 2 years for lung cancers in males and 4-5 years for breast and cervical cancers in females. Validation of the ADD was carried out by comparison with published data for calculating median duration of disease. Given the difficulties in conduct of classical survival studies, the proposed method may provide a useful tool for having a regular audit of prognostic factors in the community.

Maternal thyroid hormonal status in preeclampsia.

BACKGROUND: The physiological changes in the thyroid gland during pregnancy are well understood but only a few reports provide information about thyroid function in complicated pregnancies. AIMS: The present study evaluates thyroid hormonal levels in cases of preeclampsia in the third trimester of pregnancy. SETTINGS & DESIGN: A case-control study was conducted in the antenatal clinic of a public hospital of Delhi. METHOD & MATERIALS: Thyroid hormones, namely triiodothyronine (Free T3), thyroxine (Free T4) and thyroid stimulating hormone (TSH) were evaluated at the time of diagnosis of preeclampsia in 82 pregnant women and equal number of matched controls. STATISTICAL ANALYSIS: The demographic data and hormone levels were analyzed using students' t test, Mann-Whitney test and chi-square test. Pearson two-tailed analysis was used for correlation. RESULTS: Mean TSH levels were significantly higher in preeclamptic group as compared to controls (p< 0.001). However, mean values of thyroid hormones were in the normal range. Approximately 40% preeclamptic women had TSH titres > 5 mIU/ml in the study group as compared to 12.2% in the controls. Approximately 76.7% of 43 pregnant women with abnormal TSH titres and 40% of 121 pregnant women with normal TSH titres belonged to the study group (p< 0.001). The odd ratio corresponding to TSH titres > 5 mIU/ml in preeclamptic women was 4.85 (95% CI 2.19-10.74). CONCLUSIONS: Mean serum TSH levels were significantly increased without concomitant changes in free T3 and T4, in preeclampsia compared to normal pregnancy. Abnormal TSH titres might be associated with a risk for occurrence of preeclampsia.

Adrenocorticotropic hormone and growth factor receptors in breast cancer.

Tissues from 100 cases of breast cancer were analysed immunohistochemically for the presence of adrenocorticotropic hormone (ACTH) or ACTH-like peptides and expression of c-erbB-2 oncoprotein, epidermal growth factor receptor (EGF-R) as well as oestrogen receptor (ER). Immunopositivity for ACTH was found in 15% cases of infiltrating duct carcinoma of the breast, whereas 38% and 36% breast tumours were positive for c-erbB-2 and EGF-R respectively. While 27% cases were positive for ER. The immunoexpressions of all parameters were higher in breast cancer cases with upper age group (45 years or above) than the patients below 45 years of age. A significant correlation was observed between the tumour grade and the expression of c-erbB-2 oncoprotein. Further, a positive association between the immunoexpression of c-erbB-2 and EGF-R was noticed. Interestingly, a statistically significant relationship was found between the immunopositivity of ACTH and ER. The study reflects a probable association of ACTH or ACTH-like peptides in pathological process of breast cancer.

Screening for cancer of uterine cervix and approaches adopted in India.

Cervical cancer is the leading malignancy among Indian women. It has been estimated that in the absence of any control programme, the incident number of cervical cancer cases in the country would rise to 140 thousand by the turn of this century. Cytology screening remains the main stay for the control of cervix cancer. In the present communication the evidence available for screening for cancer of cervix has been presented. Difficulties in organising cervical cancer screening programmes in India and the alternative approach have been discussed.

A step towards quality medical research.

Only well planned and conducted research can answer questions that arise in day-to-day clinical practice. Unfortunately, most studies in India are deficient in design or execution. The results thus obtained are biased and cannot be extrapolated to the population studied. Some important questions which arise during the statistical design of investigations are selection of subjects on which observations are to be made, number of observations falling into different groups, allocation of subjects among different groups, etc. Besides planning and execution, appropriate methods need to be chosen for data analysis beforehand. If the study has been well designed and correctly analysed, the interpretation of results can be fairly simple. The present communication focuses on some issues relating to the planning of investigations in medical research with emphasis on statistical design.

Biological behaviour of moderate dysplasia--a prospective study.

The present communication reports the biological behaviour of women with moderate dysplastic lesions of uterine cervix based on a long term prospective study. Two hundred and thirty nine women with moderate dysplasia by cervical cytology who satisfied the criteria for registration were longitudinally followed up at 3 +/- 1 monthly intervals along with age and parity matched controls for a period ranging from 4 to 132 months. The cumulative rate of progression from moderate dysplasia to malignancy (CIS) was observed to be 23.0% at the end of 72 months of follow up with mean transition interval of 24.2 months. Out of 239 cases, 142 women who had more than 24 months of follow up were considered for studying the biological behaviour of the lesion. It was observed that during a follow up of 132 months, 14(9.9%) and 15(10.6%) women progressed to carcinoma in-situ and severe dysplasia respectively. The persistence of lesion was observed in 21(14.8%) women while 11(7.3%) and 81(57.0%) regressed to mild dysplasia and normalcy respectively.

Interobserver agreement in the diagnosis of cervical smears.

The present study was carried out to reveal the magnitude of individual variation in the diagnosis of Pap smears between two cytoscreeners and their compatability with cytopathologists and subsequent final diagnostic comparison with biopsy in 1,17411 cervical smears collected from different hospitals of Delhi during ten-year period. Smears diagnosed as dysplasia at initial level by any one of the cytoscreeners were screened by cytopathologists for confirmation of diagnosis. An overall agreement of 94.9 percent was observed between two screens. 79.5 percent was agreement between screeners and cytopathologists. An agreement between cytology and histology in the diagnosis of dysplasia and malignancy were found to be 61.9 percent and dysplasia and malignancy were found to be 61.9 percent and 40.1 percent respectively. From the above study, it was observed that consistency among the two screeners was fairly acceptable. Keeping this observation in view, we can possibly practice two tier screening in place of three.

Urinary calcium creatinine ratio and hypercalciuria.

Random urine samples of 352 children in the age group of 5-12 yrs were studied for urinary calcium-creatinine ratio (Uca/Ucr mg/mg). None had any predisposing factor for secondary hypercalciuria. Calcium and creatinine both were estimated by colorimetric method. We observed that Uca/Ucr in the general pediatric population was skewed, the pattern was similar to that described in western children and it was independent of age and sex. The mean and standard deviation (SD) of Uca/Ucr was 0.10 +/- 0.094. Considering mean +2SD as the upper limit of normal, which was 0.29 in this series, the prevalence of hypercalciuria was 6.5%.

Cancer projection by the turn of century-Indian science.

This is an attempt to understand the magnitude of cancer problem in India. The incidence data generated by the three population based cancer registries at Bangalore, Bombay and Madras and the population projections of country have been utilised for estimating the present and future load of new cancer cases. It is estimated that the total number of incident cases in males increased from 0.29 million to 0.43 million by the turn of the century as a result of change in size and composition of population and when adjusted for tobacco habits the estimates increased to 0.49 million. In females the incident cases of cancer for three registries increased from 0.32 to 0.42 million by 2001, with cancer of uterine cervix and breast being the major problems. The above results show an urgent need for strengthening and augmenting the existing diagnostic/treatment facilities which are vow fully inadequate to tackle even the present load.

Tuberculous lymphadenitis: correlation of cellular components and necrosis in lymph-node aspirate with A.F.B. positivity and bacillary count.

Cytomorphologic features of tuberculous lymphadenitis cases as observed in lymph-node aspirates were analysed and correlated with AFB positivity and bacillary count. Cytologic features were categorized under three major groups, viz. epithelioid granuloma without necrosis, epithelioid granuloma with necrosis and necrosis without epithelioid granulomas. These three major groups showed a distinct trend in respect of their cellular constituents. While cases with appreciable lymphocytic and multinucleated giant cells component showed a significant decreasing trend, cases with neutrophilic infiltration showed an increasing trend (P less than 0.001). In the above three groups, 9.1 percent, 64.7 percent and 77.4 percent respectively showed AFB positivity, the difference being highly significant (P less than 0.001). All 14 cases with very high bacillary count (greater than 50 bacilli per 500 oil immersion field) were associated with necrosis and 71.4% of them neutrophilic infiltration. A univariate analysis revealed that in presence of lymphocytes, epithelioid cells and Langhan's giant cells, AFB positivity was significantly lower while the picture was just the reverse in presence of necrosis and neutrophilic infiltration (P less than 0.001). The odd's rations for all these variables were highly significant (P less than 0.001). However, a multivariate regression analysis revealed that necrosis was the only independent contributing factor towards AFB positivity.