Drug adherence to anti-tubercular treatment during COVID-19 lockdown in Haldwani block of Nainital district

Background: India saw one of the stringent lockdowns during the COVID-19 pandemic. In the wake of this period, the normal functioning of medical services was affected. People were reluctant to seek medical attention and notification of Tuberculosis dipped. The aim of the study was to estimate the proportion of non-adherence to anti-tubercular treatment and to identify the factors affecting the non-adherence to treatment. Methods: A retrospective community-based study was conducted among 284 tuberculosis patients. They were interviewed using a pre-designed questionnaire consisting of WHO dimensions of non-adherence and lockdown related questions. Results: The proportion of non-adherence to treatment was found to be 5.3%. Factors like chronic diseases, depression, without knowledge on how the disease is transmitted and that medication can be discontinued once the symptoms subsided, alcohol consumption, and trouble accessing medicine were found to be the determining factors in non-adherence to the treatment. Conclusions: Non-adherence to anti-tuberculosis treatment in our study was low but the various dimensions of adherence along with lockdown related factors had significant impact on it. To further minimize non-adherence during emergency like the lockdown due to COVID-19 pandemic, corrective measures must be explored and implemented.

Assessment of Health-Related Quality of Life in school-going adolescents: Validation of PedsQL instrument and comparison with WHOQOL-BREF

Background. Health-Related Quality of Life (HRQoL) studies are gaining importance. Yet there is a dearth of crossculturally validated generic HRQoL instruments for Indian adolescents. Two HRQoL instruments, namely World Health Organization Quality of Life-Brief (WHOQOL-BREF) and Pediatric Quality of Life inventoryTM 4.0 (PedsQL), are widely used internationally, with both measuring four domains (physical, psychological/emotional, social relations and environment/school) but each having different questions with 26 in the former and 23 in the latter. This study was done among adolescents in the city of Lucknow to evaluate the psychometric properties of PedsQL and compare its performance with previously validated and culturally revised WHOQOL-BREF. Methods. This cross-sectional study was conducted in February 2010 after institutional ethical approval. Data were collected by a self-administered, predesigned questionnaire in which items of PedsQL and revised WHOQOL-BREF were intermingled. Reliability, content and construct validity were evaluated for PedsQL. Convergent validity of PedsQL with revised WHOQOL-BREF was calculated for domains with similar questions. Results. Parents of 76.5% adolescents (385/503) provided consent. Mean age of adolescents was 13.6 years (1.6 SD and 44.7% were girls). PedsQL showed substantial reliability (Cronbach alpha=0.82, p<0.00001) but poor to fair validity as compared to revised WHOQOL-BREF. Conclusions. For Indian adolescents, PedsQL is a reliable and valid instrument. However, on comparison with revised WHOQOL-BREF, PedsQL has poor to fair validity. We conclude that revised WHOQOL-BREF is a better HRQoL instrument for Indian adolescents.

Clinical Profile and Prevalence of Rotavirus Infection in Children Presented with Acute Diarrhea at Tertiary Care Referral Hospital at Northern Part of India.

A prospective analysis of 90 clinically diagnosed cases with acute diarrhea over a period of one year was carried out to determine the prevalence of rotavirus infection in children between 2 months to 2 years of age. Enzyme Linked Immunosorbent Assay (ELISA) and Polyacrylamide Gel Electrophoresis (PAGE) were used for detection of rotavirus from stool sample. Fourteen (15.6%) of them were found to be positive for group A rotavirus, 9 (23%) cases were between 6 months to 1 year of age. Rotavirus excretion was highest (50%) when all three symptoms (diarrhea, vomiting and fever) occurred in the same child. A planned study for surveillance of rotavirus serotypes is required from this area.

Prevalence and risk factors associated with worm infestation in pre-school children (6-23 months) in selected blocks of Uttar Pradesh and Jharkhand, India.

BACKGROUND: Intestinal worm infestation is widely prevalent in developing countries and can result in impaired nutrition and development. AIMS: To estimate prevalence of and risk factors for intestinal geohelminths and other intestinal parasites in children aged 6 to 23 months. SETTINGS AND DESIGN: Cross sectional study in rural India. MATERIALS AND METHODS: Proportionate population size sampling method was used to randomly select 15 villages per block. Thereafter, house-to-house survey was done to recruit eligible children and obtain fecal sample for microbiological examination. STATISTICAL ANALYSIS: Univariate distribution of variables was assessed and comparison between categorical variables and continuous variables was done using a Chi-square test and student's t-test, respectively. Odds ratio was calculated to assess associations. RESULTS: Overall 926 children were recruited and 909 fecal samples examined. Combined prevalence of infestation with intestinal geohelminths treatable by albendazole and other intestinal parasites non-treatable by albendazole was 50.3% (457/909) and 51.6% (469/909), respectively. Exclusive use of hand pump water (OR = 1.79, CI = 1.36-2.35, P CONCLUSION: Since almost half the children are infected with intestinal geohelminths treatable by albendazole, targeted deworming of population in this age group should be considered.

Chlamydia sp. in hospitalised children with community acquired pneumonia.

Our aim was to document the prevalence of chlamydial infection in children less than five years of age with Community Acquired Pneumonia (CAP). Seventy three children, 1 month to 5 years of age, hospitalized with CAP were enrolled over a period of one year. Microimmunofluorescence (MIF) was done to detect IgM antibodies against Chlamydia sp. in sera of all patients; PCR was performed to detect C. pneumoniae DNA in nasopharyngeal aspirates. The prevalence of Chlamydia species infection in CAP in children < 5 years of age was 5.5% (4/73). Two cases were positive for C. trachomatis antibodies; one case was positive for C. pneumoniae antibodies and one case was positive for C. pneumoniae DNA. Chlamydia sp. have an important role in CAP in children < 5 years and for early diagnosis of infection, use of more than one method i.e. PCR and serology both is advisable.

Six-monthly de-worming in infants to study effects on growth.

OBJECTIVE: The study was conducted to assess the effectiveness of six monthly albendazole (ABZ) for improving the weight and height of preschool children when initiated at 0.5-1 year of age in populations with a high transmission rate of intestinal roundworm, Ascaris lumbricoides. It was a cluster randomized trial in the urban slums of Lucknow, North India. METHODS: Control children received 2 ml (1 ml to infants) of Vitamin A every six month whereas those in the ABZ areas received, in addition, 400 mg of ABZ suspension (Zentel, SKB) every six month. Sixty-three and sixty-one slum areas were randomized to albendazole (ABZ) or to control groups, respectively. Children aged 0.5-1 year were recruited in April 1996 and followed up for 1.5 years. Of 1022 children recruited from control and 988 from ABZ areas, the loss to follow-up at 1.5 year was 15.6% and 14.6% respectively. Mean (+/- SE) weight gain in Kg in control versus ABZ areas was 3.04 (0.03) versus 3.22 (0.03), (p = 0.01). RESULTS: After controlling for the presence of weight-for age z-score < -2.00 at enrollment in the ordinary least square's regression model, the extra weight gain in 1.5 years in those who received ABZ plus vitamin A was 0.13 Kg (95% CI: 0.004 to 0.26 Kg., p value = 0.043) when compared to those who received only vitamin A; underweight children at enrollment benefiting more than the normal ones. CONCLUSION: It was concluded that there was an improvement in weight with six monthly ABZ over 1.5 years. However, a much larger trial would be needed to determine whether there is any net effect of improvement in weight on under five mortality rate.

Fundamentals of clinical economics in health interventions.

Health economics is a science of efficient use of medical resources. Economic evaluation deals with both inputs or costs and outputs or consequences and is done when there are choices. The inputs or costs can be direct, indirect or intangible. The consequences can be measured as natural health units or utilities which aggregate multiple health units or quality adjusted life years. In the current health care scenario in India the cost data is usually lacking. An exact way for estimating the cost is elicitation of opportunity cost which is the value of time or input at its highest. The total cost is the cost of producing a particular quantity of the output and is made up of fixed and variable costs. Fixed costs do not vary with the quantity of output but variable costs do. In India, the total cost of health care provided by a multidisciplinary team can be estimated either by the 'per diem' approach which assumes no cost sharing by the departments, or by the allocation method which takes into account the quantity of service provided by each department and costs them individually. Cost effectiveness or utility and cost-benefit analysis are considered complete economic evaluation. Analyses are done from a pre-specified perspective which could be patients', payers', providers' or societal. Costs incurred at a later time are discounted. Such evaluations help us make informed decision to choose between various health interventions. Their increasing use in health research in the developing countries is needed.

Effectiveness and cost-effectiveness of albendazole in improving nutritional status of pre-school children in urban slums.

OBJECTIVE: To study the clinical efficacy and the incremental cost-effectiveness of albendazole in improving the nutritional status of pre-school children. DESIGN: Single blind, placebo-controlled trial with child as the unit of randomization. SETTING: In the Anganwadi centers of the Integrated Child Development Services situated in the urban slums of Lucknow, North India. METHODS: Thirty-two Anganwadi centers were randomly selected for the trial. Included were registered resident children between 1.5 to 3.5 years of age with informed and written parental consent. The intervention group received 600 mg of albendazole powder every six months while the placebo group received same quantity of calcium powder. Enrolled children were contacted once in six months from January 1995 to 1997 and given treatment. The outcome measure were change in the proportion of underweight (weight for age <-2.00z), stunted (height for age <-2.00z) children and the cost per child prevented from becoming stunted. RESULTS: There were 610 and 451 children in the albendazole and placebo groups, respectively. Mean age at recruitment was 31.8 months (SD: 9.7). Follow-up and compliance in both the groups was >95%. During the 2 year follow-up, the proportion of stunted children increased by 11.44% and 2.06% in the placebo and albendazole groups, respectively, and the difference was 9.38% (95% CI 6.01% to 12.75%; p value <0.0001). Direct fecal smear was positive for the ova of ascaris in 41.2% and 55.3% children in the albendazole and placebo groups, respectively at the end of the study (p value <0.001). The annual family expenditure on illness in the recruited child was Rs. 743 (SD: 662) and Rs. 625 (SD: 609) in the albendazole and the placebo groups, respectively. The incremental cost-effectiveness ratio was Rs 543.00 for each case of stunting prevented with albendazole. There was no difference in the various morbidity or cognitive performance, as judged by the revised Denver prescreening questionnaire, in both the groups at enrollment as well as at the end of the study. CONCLUSIONS: Six monthly albendazole reduces the risk of stunting with a small increase in the expenditure on health care from the payer's perspective. Larger trials are needed to study the effect of albendazole on prevention of stunting, cognitive functions and all-cause childhood mortality.

Effectiveness of BCG vaccination against tuberculous meningitis.

OBJECTIVE: To assess the protective effectiveness of BCG vaccination against tuberculous meningitis, while controlling for age, nutrition and socio-economic status, in children 1 month to 12 years of age. DESIGN: Case-control study. SETTING: Secondary care referral and teaching hospital. METHODS: Cases were those conforming to the definition of tuberculous meningitis and controls were patients admitted after every third consecutive case included in the study from September 1995 till the end of August 1997 and who did not suffer from any central nervous system disorder. RESULTS: Among the 192 cases and 70 controls, BCG scar was present in 57.8% and 75.7%, respectively. The crude odd's ratio (OR)for tuberculosis meningitis with a BCG scar was 0.44 (95% CI, .24-0.81; p = 0.008), while the adjusted OR was 0.53 (95% CI, 0.26-1.06; p value = 0.07) after controlling for weight, age, sex and place of residence. Higher weight for age and urban residence were associated with a decreased risk of tuberculous meningitis in the logistic model. CONCLUSIONS: BCG vaccination offers protection against tuberculous meningitis. Since improvement in weight for age was associated with a decreased risk of disease, further studies are needed to evaluate the association, if any, between nutritional status and vaccine efficacy.

Early prediction of neonatal hyperbilirubinemia.

The study aim was to predict, using serum bilirubin level measured 18 to 24 hours (SB, 18-24) after birth, the occurrence of peak serum bilirubin level > 15 mg/dL (hyperbilirubinemia) or the requirement of phototherapy, any time from the second to fifth postnatal day. The study was conducted on a prospective cohort of 274 neonates born in north India. The main outcome measures were (a) hyperbilirubinemia and (b) phototherapy. Serum bilirubin level was estimated at 18-24 hours of age and then daily from second to fifth postnatal day. Exclusion criteria were Rh incompatibility, asphyxia and life threatening congenital malformations; and neonates of women with gestational diabetes or history intake of drugs affecting the fetal liver. Hyperbilirubinemia was found in 12.8%; and 19.3% neonates received phototherapy. Dichotomous SB 18-24, using a cut-off of > 3.99 mg/dL, as the "prediction test" had the following sensitivity and specificity for predicting (a) hyperbilirubinemia: 67% and 67%, respectively, and (b) the treatment with phototherapy: 64% and 68%, respectively. We concluded that by using SB 18-24 as the "prediction test", approximately two-thirds of neonates were test negative and had about one in ten chances of re-admission for treatment of hyperbilirubinemia, if discharged. After further validation, our results will be of benefit to neonates delivered in developing countries.

Seasonal pattern of morbidities in preschool slum children in Lucknow, north India.

OBJECTIVE: To quantify the burden of common morbidities for each month in one year, in preschool children. SETTING: Anganwadi centers under the Integrated Child Development Services Scheme (ICDS) in Lucknow, North India. DESIGN: Prospective cohort study, METHODS: From 153 anganwadi centers in urban Lucknow, 32 were selected by random draw. All eligible children registered with the anganwadi worker were enrolled over a period of six months from July 1995 to January 1996. All the subjects were then contacted a second time six months later. SUBJECTS: There were 1061 children (48.3% girls and 51.7% boys) between the ages of 1.5 to 3.5 years. RESULTS: The annual incidence rate (IR) per 100 child-years for respiratory, diarrhea and skin diseases and pneumonia were 167, 79.9, 30.6 and 9.6, respectively. When compared to other seasons, the IR of pneumonia was lowest in the winter months (October to February) while those of diarrhea and skin diseases were the highest in summer (March-June) and monsoon (July to September) months, respectively. Season specific diseases were measles in summer, and fever as the isolated symptom in monsoon. The IR for combined morbidities was the highest in the monsoon as compared to winter months. CONCLUSIONS: Season specific intensification of existing health care resources for these morbidities can be considered. Similar studies are needed from other parts of the country.

Modified Glasgow Coma Scale to predict mortality in children with acute infections of the central nervous system.

BACKGROUND: This study aimed to identify the predictors of hospital mortality in children with acute infective disorders of the central nervous system using an aggregate Modified Glasgow Coma Scale (MGCS) score and other clinical variables assessed within 24 hours of hospitalization. METHODS: We did a prospective cohort study in a teaching and referral hospital in Lucknow, North India. Consecutive children aged 1 month to 12 years of age admitted with acute infective disorders of the central nervous system were included in the study. The diagnosis was based on the presence of symptoms of fever, headache or irritability with or without vomiting, and either altered sensorium or first episode of seizures or both. The main outcome measure was hospital-based mortality. RESULTS: Of the 230 patients included in the study, 42.2% had pyogenic meningitis, 36.9% had tuberculous basal meningitis and 20.9% had meningo-encephalitis. There were 43 (18.7%) deaths of which 44.2% were within 3 days of admission. Death was associated with the day 1 aggregate MGCS score only. The area under the curve of four strata of aggregate MGCS was 0.63 (SE 0.05). The likelihood ratio for discharge with an aggregate MGCS score of < 5 was 0.52 (95% CI:0.29-0.95) and > 10 was 5.52 (9% CI:1.02-31.96). CONCLUSION: The MGCS can be used to predict discharge in patients with acute infective disorders of the central nervous system within 24 hours of hospitalization. The scale is simple, can be applied at the bedside and does not depend on any investigations. In developing countries with limited investigative facilities it can be used for identification and selective referral of patients with a higher risk of death to specialized centres. This study validates the predictive value of the MGCS.

Prevalence of malnutrition and intestinal parasites in preschool slum children in Lucknow.

OBJECTIVE: To assess the point prevalence of intestinal parasites and their association with nutritional parameters. SETTING: Anganwadi centers under the Integrated Child Development Scheme (ICDS) in Lucknow, North India. DESIGN: Cross-sectional survey. METHODS: By random draw, 32 out of 153 Anganwadi centers were selected. All eligible subjects registered with the Anganwadi worker were enrolled. These were 1061 children (48.3% girls and 51.7% boys) between the ages of 1.5 to 3.5 years. RESULTS: Of these, 67.6% were underweight (weight for age < -2 SD), 62.8% were stunted (height for age < -2 SD) and 26.5% were wasted (weight for height < -2 SD). Parasites were detected in 17.5% (95% CI 15.3%-19.9%) children by a single direct fecal smear examination. Of these, Ascaris lumbricoides was found in 124 (68.1%) and Giardia lamblia in 60 (32.9%). There was no association between weight or height and parasite positivity. The mean hemoglobin levels for children who were smear positive versus smear negative for ascaris or giardia were 9.1 g/dl and 9.6 g/dl, respectively (p < 0.0001). CONCLUSION: In the urban slums the point prevalence of intestinal parasites is 17.5% in the preschool children. Malnutrition and low hemoglobin levels are also widely prevalent. Urgent remedial steps are needed on community basis to improve their nutritional status and control parasitic infestation.

Cardiovascular responses to treadmill exercise testing in anemia.

OBJECTIVE: To study exercise performance on a treadmill in anemic children. DESIGN: Prospective case control study. SETTING: Department of Pediatrics and Intensive Care Unit, Department of Medicine, King George's Medical College, Lucknow. SUBJECTS: The study population consisted of 41 cases of anemia (10 mild, 21 moderate and 10 severe) and 11 normal age and height matched children aged between 7-12 years. METHODS: These subjects were exercise tested on Quinton Model Q5000 treadmill using Modified Naughton Q5000 protocol. Heart rate, systolic blood pressure, double product, ECG changes, exercise duration and metabolic equivalents achieved during peak exercise were studied. Statistical analysis was performed using analysis of variance (ANOVA) test. RESULTS: No significant difference was observed in values of resting heart rate, heart rate at peak exercise, recovery heart rate, blood pressure response, resting double product, double product at peak exercise, recovery double product and ECG changes in any of the study groups (p > 0.05). However, the gain in heart rate at peak exercise compared to basal value, and double product, total exercise duration and metabolic equivalent (MET) values at peak exercise were significantly low in anemic children on comparison to normal controls (p < 0.001). CONCLUSIONS: Cardiovascular responses are blunted in anemia, mainly because of depleted cardiac reserve.

Carcinoma gallbladder: atypical presentations and unusual associations.

Patients with carcinoma of the gall bladder (CaGB) may have atypical presentations and unusual associations. Out of 324 patients with CaGB seen at a tertiary referral center in northern India, 26 (8%) had atypical clinical presentations and 34 (10%) had unusual associations. The atypical presentations were empyema (5), acute cholecystitis (3), post-cholecystectomy benign biliary stricture (3), carcinoma of the head of pancreas (3), gastric outlet obstructions (2) and liver abscess (1). Unusual associations were common bile duct stones (18), left supraclavicular lymph node metastasis (11), Mirizzi's syndrome (3), inguinal lymph node metastasis (1) and umbilical metastasis (1). Majority of these patients had advanced disease and curative resection was not possible; a worthwhile palliation was however possible in the majority.