Accuracy of foot length measurement for gestational age assessment in neonates: a prospective observational study in Central India

Background: Gestational age (GA) is a critical-factors in the decision making and predicting mortality and morbidities of neonates. In low resource settings where affordability and availability of first trimester scan is limited, assessment is often done by postnatal methods like expanded new Ballard score (ENBS) which are often clinical skill dependent and complex. Hence, there is a need of a simple and cost-effective method which can be readily adopted by frontline health care workers at periphery. One such method is assessment of foot length (FL). Methods: This prospective cross-sectional study was conducted in the level 3 NICU of Central India over a period of 18 months. Included neonates were assessed for GA by measuring FL by vernier calliper within 48 hours of birth and its validity was tested against ENBS as reference standard. Other anthropometric measurements like birth weight, head circumference and length were obtained within 48 hours of birth. Results: Total 700 neonates were included in the study. For, determining preterm newborn, the potential cut-off of FL of ?6.86 cm, with a sensitivity of 94.6% and specificity of 73.8%. The area under ROC (receiver operating characteristic) curve is 0.92. Conclusions: FL measurement is a cost-effective and time-saving simple intervention that can facilitate early identification of preterm newborns as well as help in initiating timely interventions and hence improving neonatal outcomes in resource-poor settings

Factors Affecting Under-Five Mortality Rate (U5MR) in India- National Family Health Survey (NFHS) 5 Factsheet What It Speaks?

Introduction: In developing countries various factors lead to Under-5 Mortality and irreversible losses which can be prevented by proper measures take on factors affecting to it. Objective: This study was conducted to analyse the changing trends of Under-5 Mortality in India. The new National Family Health Survey (5th round) which was published recently came up with several new findings, which were both encouraging and disheartening and also one of the major Sustainable Development Goals.Method: A secondary data analysis was conducted of NFHS factsheets to study the U5MR in India. The indica-tors which had a correlation either positive or negative with the Under-five mortality rate were included.Result- When we look at the result, few states' performance is encouraging because they have shown some of the best declines. Correlation was found between dependant variable that is U5MR which is a dependent vari-able and several independent variables which concluded that factors like Women literacy, Men literacy, Breastfeeding, Nutritional insufficiencies, Caesarean delivery, ANC visits and IFA consumptions are negatively associated withU5MR. Conclusion: Various steps have been taken in order to improve our healthcare sector since independence, every government had their fair share of contribution, that’s the reason why we are this stage. Now it’s time to increase efforts with targeted interventions to solve this problem and complete our commitment towards the SDGs.

Predictors for Anterior Cruciate Ligament (ACL) Re-injury after Successful Primary ACL Reconstruction (ACLR)

@#Introduction: Few authors have addressed risk factors related to an ipsilateral graft rupture and contralateral anterior cruciate ligament (ACL) injury after return to sports (RTS) following primary ACL reconstruction. Material and Methods: Patients with ACL re-injury to either knee after successful primary ACLR were included in Group I and those with no further re-injury were included in Group II. Variables including age, gender, side, body mass index (BMI), thigh atrophy, anterior knee laxity difference between both knees measured by KT-1000 arthrometer, mean time of return to sports (RTS), graft type, type of game, mode of injury, Tegner Activity Score, hormone levels, femoral tunnel length (FTL), posterior tibial slope (PTS) and notch width index (NWI) were studied. Binary logistic regression was used to measure the relative association. Results: A total of 128 athletes were included with 64 in each group. Mean age in Group I and II were 24.90 and 26.47 years respectively. Mean follow-up of Group I and Group II were 24.5 and 20.11 months respectively. Significant correlation was present between ACL re-injury and following risk factors; PTS of >10º, KT difference of >3.0mm, thigh atrophy of >2.50cm and time to RTS <9.50 months P value <0.05). No correlation was found with age, sex, BMI, type of game, Tegner Activity Score, mode of injury, NWI, size of graft, FTL and hormone levels. Conclusion: Possible risk factors include PTS of ≥ 10º, KT difference of ≥ 3.0mm at 1 year follow-up, thigh atrophy of ≥ 2.50cm at 1 year follow-up and RTS <9.5 months after primary ACLR.

Practice pattern of cataract surgeons when operating on seropositive patients

Purpose: The aim of this study is to know practice pattern of cataract surgeons when operating on patients, positive for blood-borne viral infections (BBVIs), namely, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. We also studied their awareness, knowledge, and attitude toward universal precautions and guidelines. Methods: The telephonic survey enrolled practicing cataract surgeons, who were interviewed to record responses pertaining to their practice using an open-ended questionnaire. We studied statistical significance of difference of frequency of prick injuries in topical versus peribulbar anesthesia, and phacoemulsification versus manual small incision cataract surgery by employing Chi-square test. Significance of proportion was calculated using z-test. For all statistical calculations, significance level was set at 0.05%. Results: Of 623 ophthalmologists contacted, responses of 479 (79%) ophthalmologists were analyzed. Maximum participants were in private practice (48%). During whole practicing carrier, 313 (65%; 95% confidence interval [CI]: 61–70) participants admitted having suffered injury with needle or sharp instruments; of these, 204 (65%; 95% CI: 60–70) participants did not report their injury. Wearing “double gloves” during cataract surgery was the most common barrier adopted by participants. Conclusion: We found high prevalence of occupational-related sharp injuries among ophthalmologists in this survey. Majority of them were aware of universal precautions, but adherence to postexposure prophylaxis was lacking.

Seroprevalence, risk associations, and cost analysis of screening for viral infections among patients of cataract surgery

Purpose: The purpose of this study was to estimate the prevalence of blood-borne viral infections (triple H: HBV-hepatitis B virus, HCV-hepatitis C virus, and HIV-human immunodeficiency virus) among cataract patients, sought possible risk associations and discuss feasibility of universal preoperative screening. Methods: This prospective, cross-sectional study enrolled consecutive patients of senile cataract. They were screened by immunoassay-based rapid diagnostic card tests for blood-borne viral infections. Positive cases were confirmed with confirmatory ELISA tests. Seropositive patients were enquired about the exposure to possible risk associations for acquiring these infections. Cost of card test per patient was calculated. Results: The prevalence of seropositivity for triple H viral infections (HBV, HCV, and HIV) among patients of senile cataract was 5.9% (95% confidence interval [CI]: 5.3–6.6), and HCV was most common viral infection. The dental extraction was most common (54%; 95% CI:48-60) possible risk association. The total cost of primary screening per patient for triple H infections(HBV, HCV, and HIV) was $0.93. Conclusion: The prevalence of blood-borne viral infection among cataract patients is high in this area. Awareness of the prevalence of blood-borne viral infections in service area, along with knowledge of rate of accidental exposure and risk of transmission would help to understand cost-effectiveness of universal preoperative screening before cataract surgery.

Role of Personality and Stress in the Genesis of Bipolar Disorder - Mixed States: "Could it be a solution to the Diagnostic confusion prevailing in this disorder? (Part II)" .

Role of temperamental predisposition in the development of Mixed States is a relevant factor. Mania seems to arise from a hyperthymic background and Mixed States seems to arise from a depressive disposition. Aims: To compare the personality pathology and distribution of stress of patients of mixed states distributed according to the number of standardized criteria fulfilled and with the pure manic group. Materials and methods: Out of 214 bipolar disorder- current episode manic patients diagnosed as per DSM IV TR ,admitted in psychiatry ward of P.B.M. Hospital, Bikaner from 1st Jan 2007 to 31st Dec 2007,64 patients were randomly selected. Young’s Mania Rating Scale and Montgomery Asberg Depression Rating Scale were applied to these patients and 32 patients were assigned to mixed states on displaying one or more depressive symptom on MADRS, excluding decreased sleep. Rest 32 patient were assigned to pure manic group displaying no depressive symptoms. Presumptive Stressful Life Event Scale was applied to find out any stress in the lifestyle of the sample and International Personality Disorder Examination was applied on the third follow up visit. Results: Patients with personality psychopathology and stress met 3 or more criteria as compared to those with personality psychopathology without stress (p<0.01). Disorder level personality psychopathology, especially anxious disorder level personality, was significantly higher in mixed group patients as compared to pure manic patients(p<0.02).Meeting more criteria for mixed mania also meant higher scores on MADRS(p<0.01) Also patients meeting more than 3 criteria for mixed states had a significantly higher duration of hospital stay than those meeting less than 3 criteria(p<0.02) Conclusion: Mixed states is a dimensional diagnosis, higher the vulnerability in terms of disorder level personality psychopathology higher is the MADRS scores and greater episode duration.

Major Depressive Disorder: Part-I: Personality and Phenomenology.

Objectives: To study the phenomenological variations in context of personality psychopathology in Major Depressive Disorder patients. Methods:36 indoor patients of psychiatry ward of tertiary level service out of total 168 admitted patients from Ist January 2008 to 31st Dec. 2008 diagnosed as Major Depressive Disorder (as per DSMIV TR) . Socio-demographic data on a self-designed Performa, Montgomery Asberg’s Depression Rating Scale (MADRS), Hamilton Anxiety rating scale (HARS)and Presumptive Stressful Life Event Scale(PSLE) were applied to these patients and they were observed every alternate day till discharge. International Personality Disorder Examination (IPDE) was applied on their third follow-up visit, which ranged from 6 to8 weeks. Results: Sociodemographic variables by enlarge didn’t make a difference in MADRS score. MADRS score was significantly higher with increasing episodes of illness. Personality disorder patients had significantly higher MADRS score than Double traits (t=3.47, df=27, p<0.01) and Single trait (t=4.056, df=23, p<0.001) personality psychopathology. Higher level of depression in Personality disorder patients in all components of depression like sadness, reduced sleep pessimistic and suicidal thought etc were reported. Presence of stress with personality psychopathology added greater severity to depression. Conclusion: Our study brings out constitutional vulnerability with adverse environmental conditions were associated with higher level of psychopathology.

Major Depressive Disorder: Part-II -Comorbid Anxiety Disorders.

Objective: To demonstrate that Anxiety Disorder comorbidity is reflection of underlying common risk factors (Anxiety proneness) in Major Depressive Disorder patients and may not be a separate disorder. We hypothesized that “Anxious personality traits or disorders under stress take the form of state that is Anxiety Disorders”. Methods:36 indoor patients of psychiatry ward of tertiary level services, out of total 168 admitted patients from Ist January 2008 to 31st Dec. 2008 diagnosed as Major Depressive Disorder (as per DSMIV TR). Socio-demographic data on a self-designed Performa, Montgomery Asberg’s Depression Rating Scale (MADRS), Hamilton Anxiety rating scale (HARS) and Presumptive Stressful Life Event Scale (PSLE) were applied to these patients and they were observed every alternate day till discharge. International Personality Disorder Examination (IPDE) was applied on their third follow-up visit, which ranged from 6 to8 weeks. Results: High level of co-existence of Anxiety disorder 29(80.5%) in the study sample, 11 patients (30.55%) of Major Depressive Disorder had personality disorder level of psychopathology and 18(50%) patient of Major Depressive Disorder had double or more personality traits psychopathology and there were 7(19.45%) patients of Major Depressive Disorder had only single trait personality psychopathology. Conclusion: This work support the gene environmental diathesis where vulnerable person under stress develop Axis I disorder which are considered currently as co morbid disorders.

Co-Morbidity of Personality Disorders and its Impact on Phenomenology and Treatment Response in Bipolar Disorder Patients.

Aim:To study the comorbidity of personality disorders and its impact on phenomenology and treatment response in bipolar patients. Methods:40 indoor patients of psychiatry ward of P.B.M. General Hospital out of total 437 admitted patients diagnosed as Bipolar Disorder – Manic or Mixed were randomly selected. Young’s Mania Rating Scale (YMRS), Montogomery Asberg Depression Rating Scale (MADRS) and Presumptive Stressful Life Event Scale (PSLE) were applied to these patients and they were observed every alternate day till discharge.. International Personality Disorder Examination (IPDE) was applied on their first follow-up visit after recovery. Since the major aim was to observe the routine response pattern of phenomenology in Bipolar I patients and considering wide variabilities in treatment strategies of clinicians, we decided to consider the naturalistic method, the response to the best treatment considered by the treating physician Results : Borderline disorder level personality psychopathology was noticed in 32.5% of the whole sample .Anxious and Impulsive traits came a close second with 30% of the sample demonstrating the combined trait. Anxious disorder was seen in 3 patients that is 7.5% of the sample and Anxious, Impulsive and Anti-social traits were seen in 3 patients (7.5%).5 patients (12.5%) demonstrated anxious traits,3 patients (7.5 %)had impulsive traits and 1 patient had histrionic traits. Hospital stay of patients with Borderline personality disorder versus others with trait level psychopathology was significantly higher. (t=9.40, d.f. =38, p<0.000) Electro- Convulsive Therapy was administered to a significantly higher number of patients with personality disorder level psychopathology than to trait level personality psychopathology (X2=6.856, d.f.=1, p<0.01). Borderline Disorder patients had significantly higher YMRS score than single (t=3.348, d.f.=20, p< 0.001) and double trait t=3.58, d.f.=26, p<0.001) patients.

Bipolar Disorder - Mixed States: A Diagnostic Dilemma (Part-I).

There is a large difference in classifying Mixed States according to the prevailing standardized classifications because of the differential focus of the various criteria in identifying Mixed States. Aims: To assign the Mania With Depressive symptoms patients in different groups and to compare the phenomenology, personality profiles and psychiatric co-morbidities of these various groups so generated. Material and Methods: 64 patients were randomly selected from the 214 Bipolar Disorder – Current episode Manic (as per DSM IV TR9) patients admitted in Psychiatry ward of P.B.M. General Hospital,Bikaner from 1st Jan 2007 to 31st Dec. 2007. After recording socio-demographic data on a self-designed Performa, Young’s Mania Rating Scale (YMRS)and Montgomery Asberg Depression Rating Scale (MADRS) were administered on day 1,3,5,7 and 9 till discharge.32 patients were assigned to Mania with Depressive Symptoms on displaying 1 or more depressive symptom, excluding decreased sleep.32 patients were assigned to Pure Mania group who displayed no Depressive symptoms. Results: 30 patients(94%) could be assigned to Mixed states according to Vienna Criteria,25(78%) could reach the diagnosis of Mixed States as per Cincinnati criteria, another 17(53%) were assigned to Mixed States as per Pisa San Diego Criteria.ICD-10 could identify 5 patients(16%) and DSM IV TR appeared to identify the least that is 3 patients(9%) Conclusion: Concept of MS couldn’t be better explained with these existing criteria because some patients meeting one criterion are not meeting others.

Two-tier system of epilepsy evaluation: a useful method for developing countries.

PURPOSE: To test the usefulness of a simplified and clinically oriented, the Epidemiological Classification (EC), in determination of seizure types and appropriate drug selection in epileptic patients at the primary care level. METHODS: The EC was applied to all epileptic patients over 5 years then compared with the currently recommended international classifications of seizures and epilepsy (ICES/ICEES). RESULTS: A total of 1176 patients were enrolled with 2:1 male preponderance and 88% had onset of disease below 30 years of age. Based on EC, 682 (58%) had partial, 333 (28.3%) had generalized and 161 (13.7%) had undetermined seizures semiology. When ICES was applied, seizure typing was same in 86.2%, 68.5% and 26.7% patients of partial, generalized and unclassified seizures respectively. About 87% patients in generalized and partial seizure semiology had no change in selected antiepileptic drug even after the ICES, but 53.6% patients in undetermined group had change in selected AED. Only, 146 patients (12.5%) found to have symptomatic cause for seizure(s) on applying the EC system. After utilizing the ICEES on 1030 patients (87.5%) of "unknown etiology" cases after the EC system, almost 86.5% patients could be classified to a definite etiological class. CONCLUSION: The EC was found useful for determination of seizure type and appropriate AEDs selection at the primary care level. The ICES/ICEES works better at the tertiary care level. This "two-tier" system can be more effective for overall epilepsy management in developing countries with limited facilities.

"Poor man's risk factor": correlation between high sensitivity C-reactive protein and socio-economic class in patients of acute coronary syndrome.

OBJECTIVE: Inflammation has been proposed as one of the factors responsible for the development of coronary artery disease (CAD) and high sensitivity C-reactive protein (hs CRP) at present is the strongest marker of inflammation. We did a study to assess the correlation of hs-CRP with socio-economic status (SES) in patients of CAD presenting as acute coronary syndrome (ACS). METHODS: Baseline hs-CRP of 490 patients of ACS was estimated by turbidimetric immunoassay. Patients were stratified by levels of hs-CRP into low (<1 mg/L); intermediate (1-3 mg/L) or high (>3 mg/L) groups and in tertiles of 0-0.39 mg/L, 0.4-1.1 mg/L and >1.1 mg/L, respectively. Classification of patient into upper (21.4%), middle (45.37 percent) and lower (33.3%) SES was based on Kuppuswami Index which includes education, income and profession. Presence or absence of traditional risk factors for CAD diabetes, hypertension, dyslipidemia and smoking was recorded in each patient. RESULTS: Mean levels of hs-CRP in lower, middle and upper SES were 2.3 +/- 2.1 mg/L, 0.8 +/- 1.7 mg/L and 1.2 +/- 1.5 mg/L, respectively. hs-CRP levels were significantly higher in low SES compared with both upper SES (p = 0.033) and middle SES (p = 0.001). Prevalence of more than one traditional CAD risk factors was seen in 13.5%, 37.5% and 67.67 percent; in patient of lower, middle and upper SES. It was observed that multiple risk factors had a linear correlation with increasing SES. Of the four traditional risk factors of CAD, smoking was the only factor which was significantly higher in lower SES (73%) as compared to middle (51.67 percent;) and upper (39.4%) SES. We found that 62.3%, 20.8% and 26.5% patients of low, middle and upper SES had hs-CRP values in the highest tertile. Median value of the Framingham risk score in low, middle and upper SES as 11, 14 and 18, respectively. We observed that at each category of Framingham risk, low SES had higher hs-CRP. CONCLUSION: We conclude from our study that patient of lower SES have significantly higher levels of hs-CRP despite the fact that they have lesser traditional risk factors and lower Framingham risk. These findings add credit to our belief that inflammation may be an important link in the pathophysiology of atherosclerosis and its complications especially in patients of low SES who do not have traditional risk factors.

Sleep seizures versus wake seizures: A comparative hospital study on clinical, electroencephalographic and radiological profile.

Background: Epileptic seizures, predominantly or exclusively during sleep had been the focus of attention for many electroencephalographers. Though few epileptic syndromes are associated with sleep seizures (SS) its frequencies in Indian patients is still unknown. Aim: To find out the patterns of epilepsies in patients having SS and compare them with patients having wake seizures (WS). Setting and Design : Open label hospital based study. Materials and Methods: One hundred and forty-four (13%) patients having predominantly SS were compared with 976 (87%) patients of WS by various clinical, electrophysiological and radiological factors. Statistical Analysis: Chi square test and student T test, using software SPSS (version 10, 1999) was applied to compare various parameters. Relative risk was calculated by 2 x 2 contingency table. Results: The seizure semiology was better defined in patients with WS and GTCS was more common in SS ( P = 0.001). Wake-electroencephalogram (EEG) was abnormal in significantly ( P = 0.001) higher number of patients with WS. Symptomatic etiologies were found in more than half patients. Left lobe involvement was more common in patients having SS ( P = 0.000). After symptomatic, idiopathic generalized and frontal lobe epilepsy were most frequent with SS. Undetermined epilepsy was found in 37 (25.7%) patients with SS. Conclusion: Epilepsies associated with SS were less frequent and had symptomatic cause in most cases. Left hemispherical and frontal lobe lesion were more commonly associated with SS. Frontal lobe and idiopathic generalized epilepsy was most frequent in patients of SS. Sleep EEG should always be done in patients with sleep seizures.

Peak expiratory flow rate of children working in lock factories.

Peak expiratory flow rate (PEFR) of 106 children working in different units of lock factory was measured and compared with age and sex matched control group of same socio-economic status children. All the children worked for about ten hours per day. It was observed that there was a significant decrease in PEFR of children working in the different units of lock factories i.e. Hand press, Polishing, Lock fitting, Lock packing units as compared to control group (P>0.001). The reduction percentage of PEFR was maximum in children working in polishing unit (25.48%).

Apnea in the newborn.

Apnea, defined as cessation of breathing resulting in pathological changes in heart rate and oxygen saturation, is a common occurrence in sick neonates. Apnea is a common manifestation of various etiologies in sick neonates. In preterm children it may be related to the immaturity of the central nervous system. Secondary causes of apnea should be excluded before a diagnosis of apnea of prematurity is made. Methylaxanthines and Continuous Positive Airway Pressure form the mainstay of treatment of apnea in neonates. Mechanical ventilation is reserved for apnea resistant to above therapy. An approach to the management of apnea in neonates has been described.

Poisoning in children: Indian scenario.

The retrospective data on childhood poisoning from eight regional hospitals in India has been reviewed. The demographic features and types of poisonings encountered have been compared. The analysis of the data indicated that pediatric poisonings constituted 0.23-3.3% of the total poisoning. The mortality ranged from 0.64-11.6% with highest being from Shimla. Accidental poisoning was common involving 50-90% of children below 5 years of age and males outnumbered the females. Suicidal poisoning was seen after 13 years of age and was due to drugs and household chemicals. One of the hospitals in Delhi recorded a very high incidence (66.6%) of drug poisoning in children. The drugs consumed belonged to phenothiazines, antiepileptics and antipyretics. Iron poisoning was seen in younger children. Kerosene was one of the causes of accidental poisoning at all hospitals except Shimla and rural Maharashtra were probably wood charcoal is widely used. Pesticide poisoning was more prevalent in Punjab and West Bengal whereas plant poisoning was very common in Shimla. Significant number of snake envenomation has been recorded from rural Maharashtra. Other less common accidental poisonings in children included alcohol, corrosives, heavy metals, rodenticides, detergents and disinfectants. Thus various regions in the country showed some variation in types and frequency of childhood poisoning which could be attributed to different geographical and socio-economic background.