Frailty and chronic kidney disease: associations and implications / Fragilidade e doença renal crônica: associações e implicações

ABSTRACT Introduction: Frailty and its association with chronic kidney disease (CKD) has been established previously. The present study examined this association further by studying the distribution of frailty among groups defined by different stages of the disease. It also identified associated health deficits and explored their association with estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (UACR). Methods: A cross-sectional survey was conducted on 90 non-dialysis dependent CKD Stage 1-4 patients, recruited in three stratified groups of 30 participants each based on the stage of disease. Frailty was assessed using Fried's frailty criteria and associated health deficits were recorded using a pre-determined list. Depression was screened using a 4-point depression scale. Results: 21.1% of the participants were frail and 43.3% were pre-frail. The proportion of frailty in CKD groups A (Stages 1 and 2), B (Stage 3a), and C (Stages 3b and 4) was 10%, 13.3%, and 40%, respectively. The association of health deficits including co-morbidities, physical parameters, mental status, daily activities, etc. with UACR, eGFR, and CKD stages was not statistically significant. Nearly one in two frail participants was depressed compared with 14% among non-frail participants. Conclusion: The skewed distribution of 21% frail subjects identified in our study indicates an association between frailty and advancing kidney disease. Frail individuals had a lower eGFR, higher UACR, were more likely to be depressed, and had higher count of health deficits and poorer performance on Barthel Index of Activities of Daily Living and WHOQOL. Early identification of depression would improve care in these patients.

RESUMO Introdução: Fragilidade e sua associação com DRC foram estabelecidas anteriormente. O presente estudo aprofundou esta associação, estudando distribuição da fragilidade entre grupos definidos por diferentes estágios da doença. Também identificou déficits de saúde associados e explorou sua associação com taxa de filtração glomerular estimada (TFGe) e relação albumina/creatinina urinária (RAC). Métodos: Realizou-se uma pesquisa transversal em 90 pacientes com DRC Estágios 1-4 não dependentes de diálise, recrutados em três grupos estratificados de 30 participantes cada, conforme estágio da doença. Avaliou-se fragilidade usando os critérios de fragilidade de Fried e registraram-se os déficits de saúde associados usando uma lista pré-determinada. A depressão foi verificada utilizando a escala de depressão de 4 pontos. Resultados: 21,1% dos participantes eram frágeis e 43,3% eram pré-frágeis. A proporção de fragilidade nos grupos de DRC A (Estágios 1 e 2), B (Estágio 3a), e C (Estágios 3b e 4) foi de 10%, 13,3%, 40% respectivamente. A associação de déficits de saúde, incluindo comorbidades, parâmetros físicos, estado mental, atividades diárias etc. com RAC, TFGe e estágios da DRC não foi estatisticamente significativa. Cerca de um em cada dois participantes frágeis estava depressivo comparados com 14% entre não frágeis. Conclusão: A distribuição enviesada de 21% dos indivíduos frágeis identificados em nosso estudo indica associação entre fragilidade e doença renal progressiva. Indivíduos frágeis apresentaram menor TFGe, maior RAC, eram mais propensos a depressão, tinham maior índice de déficits de saúde e desempenho inferior no Índice de Atividades da Vida Diária de Barthel e WHOQOL. A identificação precoce da depressão melhoraria o atendimento desses pacientes.

Variation in COVID Mortality with Different Demographic Factors in Districts of India

Background : Descriptive data suggests significant disparity in the COVID-19 related deaths across different demographic zones. Several studies have examined these factors at the intra-country or intrastate level. Our study analyzed the data at a District level. Methods : This cross-sectional study analyzed the association between Socio-demographic factors and COVID19 Mortality at a District level using Univariate and Multivariate linear regression models. Data for sixty randomly selected Districts was collected and compiled from free sources available in the public domain. Linear regression models were built and factors that were found to be significant were used in the model. Results : Univariate analysis revealed that COVID Mortality has a positive correlation with the literacy rate and a negative correlation with the percentage Rural population of the District. No significant relation was found with primary Health Center accessibility, Sex Ratio and the percentage of chronic illness. On Multivariate analysis, it was negatively correlated to only the percentage of the Rural population. Conclusion and Relevance : Our study concluded that as the rural population increased in a district, COVID 19 mortality decreased. There was no significant association with other sociodemographic variables.

Clostridium Difficile is associated with High Mortality among Cirrhotics in India

Background: To assess the prevalence and impact of Clostridium difficile infection (CDI) in hospitalized patients with cirrhosis in India. Methods: In this prospective observational study from June 2015 to March 2016, all hospitalized patients with cirrhosis and acute diarrhea at the time of admission or during hospitalization were included. We studied hospitalized patients with cirrhosis without diarrhea during the same period to detect asymptomatic colonizers.Stool samples were tested for CDI, bacterial cultures, and parasite microscopy in patients with diarrhea.CDI was detected using a stool PCR test that detects the pathogenicity locus of toxigenic Clostridium difficile gene. We analysed the impact of CDI on hospital outcomes and also assessed the risk factors for acquiring CDI. Result: Among 92 hospitalized cirrhotic patients with acute diarrhea [male: 74; median age: 50 (range 19 to 80) years; Child’s class A: B: C: 8:41:43; median MELD score: 18 (range 6 to 44)], 6 (6.5%) had CDI by positive stool PCR. Use of antibiotics (100% CDI Vs 55.8% non-CDI, p= 0.04) and steroids (50% CDI vs 10.5% non-CDI, p =0.028) emerged as risk factors for CDI among cirrhosis patients. Two of the 6 patients (33.3%) with CDI as compared to 6/86 patients (7%) with no CDI died (p-value: 0.08).There were no asymptomatic colonizers amongst 35 hospitalized cirrhosis patients without diarrhea.Conclusions: C. difficile, although uncommon, was an important cause of mortality in cirrhosis patients hospitalized with diarrhea in India.Prior use of antibiotics or steroids were identified as risk factors for CDI.

Lessons from the Pandemic and Healthcare Service Delivery for the Senior Citizens

Background : The healthcare delivery system is an important indicator of the quality of life in a society. The advent of the Corona Virus pandemic led to an unfortunate and unforeseen disruption in the healthcare services Globally. The older persons were impacted on multiple counts including limitations in healthcare service availability, access and social marginalization. As we gain more insight into the full impact of the Pandemic on the health quality indicators and look to resume Medical service delivery in Postpandemic times, it’s important to ensure that the older population is not neglected. Discussions : Small transitions in the delivery models but larger modifications in the mind-set may be needed to provide continued, effective and seamless healthcare services to the older Indian population. Planned interventions at each level of the system can ensure a smooth transition into the modified systems. Integration of modern telecommunication technology into the medical practice and extensive research in the area can make telemedicine a more accessible and acceptable option to the elderly patients with chronic ailments. The full extent of the impact of the Pandemic on healthcare will be revealed in the coming times requiring constant adaptation of each element of the system to cope with it.

Shiitake flagellate dermatitis (toxicoderma): A case report

We report a patient with flagellate dermatitis (shiitake dermatitis) appearing 48 hours after consumption of shiitake mushrooms in a previously healthy 37-year-old man. The skin lesion resolved completely within a week following treatment with antihistamine and topical steroid cream (dexamethasone 0.1%).

A Comparative Study of Autonomic Cardiovascular Parameters in Obese and Non-Obese Adults

Globally, the epidemic of obesity in children and young adults is on a constant rise over the past decade. Obesity makes individual highly susceptible to a variety of chronic diseases and their complications. An altered autonomic response in the form of enhanced baseline sympathetic activity, feeble response to sympathetic stimuli and compromised parasympathetic activity is observed in obesity. We have assessed potentially perturbed autonomic responses in young overweight/obese first year medical students. Methods: This cross sectional analytical study was undertaken in the research lab of the Department of Physiology, M.K.C.G. Medical College over a period of 12 months on 300 students (both males and females) to determine sympathetic and parasympathetic responses to stress using hand-grip dynamometer and sinus arrhythmia test respectively. Independent ‘t’ test, Pearson’s correlation coefficient and multiple linear regression analysis in SPSS 20.0 was used to statistically ascertain the differences for the aforementioned parameters between obese and non-obese adults. Results: Weight, Body mass index (BMI), waist hip ratio (WHR), Pulse rate (PR), baseline systolic blood pressure (BSBP) & baseline diastolic blood pressure (BDBP) is significantly greater in obese than in non-obese. BMI shows positive correlation with BSBP & BDBP (r=0.660**; p<0.001 & 640**; p<0.001) and negative correlation with ΔDBP, and E/I Ratio. A negative correlation is appreciated amongst ΔDBP and BMI (R2 = 39.6). A similar negative correlation is again seen between E/I ratio and BMI (R2 = 37.2). Conclusion: Obesity potentially alters autonomic balance with increased sympathetic and reduced parasympathetic tone posing elevated risk of cardiovascular and cerebrovascular accidents.

Variations and Anomalies of Coronary Artery System in Cadaveric Human Hearts.

Background: Knowledge of the normal and variant anatomy and anomalies of coronary circulation is an increasingly vital component in the management of congenital and acquired heart disease. Anatomical variations in relation to coronary artery and its branches will help cardiac surgeons for refining imaging techniques and coronary artery bypass grafting. The current study is aimed at understanding the normal patterns of coronary arteries with reference to its predominance, branching pattern, variations and anomalies. Methods: Heart specimen for this study were obtained from Department of Anatomy, SIMS Hapur and GFIMSR Ballabhgarh. The cadaveric human hearts were dissected to observe the coronary arteries and its branches. Results: The diameter of right and left coronary orifices were measured. The distance of the orifices from the supravalvular ridge was also measured. The length and the diameter of the coronary arteries and its branches were measured and statistical significance was determined. Conclusion: The present study revealed that, ostium diameter of left coronary artery is larger than the right coronary artery. The outer diameter of the left coronary artery is larger than the right coronary artery. The mean lumen circumference of left coronary artery, anterior interventricular artery, right coronary artery and circumflex artery is more in males as compared to female. This knowledge is important for interpretation of the coronary angiography and surgical myocardial revascularization and paramount to cardiac surgeons for proper diagnosis and treatment of cardiac ailments and radiologists to refine image interpretation.

Effect of Capparis spinosa Linn. extract on lipopolysaccharide-induced cognitive impairment in rats.

Cognitive disorders in mankind are not uncommon. Apart from neurodegenerative diseases such as Alzheimer’s (AD), various stresses also affect cognitive functions. Plants are known to be potential source of compounds that ameliorate several diseases including cognitive impairment. Here, we evaluated effect of aqueous extract of caper (Capparis spinosa) buds on lipopolysaccharide-induced cognitive impairment in rats using two different oral doses i.e. 10 (pre-treatment) and 30 mg/rat(post-treatment) through assessment of behavioural (Morris Water maze test and Y maze test), biochemical (Cholinesterase assay) and histopathological (H&E staining) parameters. Lipopolysaccharide (from E. coli) administration resulted in an increased neurodegeneration and time taken to reach the platform (in Morris water maze). The increased neurodegeneration in CA1 region of hippocampus was significantly reduced in animals which received caper bud extract; they showedmarked reduction in time taken to reach the platform at both the dose levels. The experiment demonstrated that caper bud extract exhibits potential protective effect against learning and memory damage induced by chronic administration of lipopolysaccharide (175 µg/kg) for 7 days. The results suggest that the caper bud extract could be explored for its use in the treatment of cognitive disorders.

Comparative Assessment of Motor Nerve Conduction Velocity among Non-Diabetic, Diabetic Non-Smoker and Sub Groups of Diabetic Smoker.

Background: Neuropathy is one of the most common complications affecting individuals with diabetes mellitus. The best evidence indicates that the etiology of neuropathy is multifactorial and is a key area of current research. Hence, this study was undertaken to test the hypothesis of alteration in MNCV (motor nerve conduction velocity) of nerves before the actual manifestation of neuropathy in type II diabetic patients and also to analyze the effect of smoking on MNCV in diabetic subjects. Methods: In the present study, 120 diagnosed diabetics were taken as cases while 30 non diabetic healthy subjects were taken as controls. Case group was divided into diabetic non-smokers and diabetic smokers. Diabetic smokers were further subdivided into light, moderate and heavy smokers, according to smoking index. After detailed history and physical examination MNCV of median and ulnar nerve in upper limb and common peroneal nerve in lower limb was performed. Result: The MNCV of median and ulnar nerves in upper limb showed no significant bilateral decreased in diabetic non-smokers and subgroup of diabetic smokers when compared with control. However, there was a significant bilateral decrease in MNCV of common peroneal nerves in the lower limb of diabetic heavy smokers when compared with control. A negative, but statistically non-significant correlation was found between MNCV and smoking index. The decrease in MNCV was dependent on smoking index by 3%, 1%, 1%, 1%, 3% and 1% in median nerve (right), median nerve (left), ulnar nerve (right), ulnar nerve (left), common peroneal nerve (right) and common peroneal nerve (left) respectively. Conclusion: The present study indicates that MNCV is more resistant to hyperglycemia induced local metabolic and microvascular changes. However, the coalition of diabetes and smoking can augment their effects many folds and can lead to motor neuropathy, reiterating the fact that smoking itself is an independent risk factor for diabetic neuropathy.

Prevalence of tuberculosis in Faridabad district, Haryana State, India.

Background & objectives: Epidemiological information on tuberculosis (TB) has always been vital for planning control strategies. It has now gained further importance for monitoring the impact of interventions to control the disease. The present study was done to estimate the prevalence of bacillary tuberculosis in the district of Faridabad in Haryana State of India among persons aged older than 15 years. Methods: In this cross-sectional study, residents of Faridabad district were assessed for the prevalence of tuberculosis. Twelve rural and 24 urban clusters with estimated populations of 41,106 and 64,827 individuals were selected for the study. Two sputum samples were collected from individuals found eligible for inclusion. The samples were also cultured by modified Petroff’s method and were examined for growth of Mycobacterium tuberculosis once a week for eight weeks. A person found positive by smear and/or culture was identified as sputum-positive pulmonary TB positive. Results: A total of 105,202 subjects were enumerated in various clusters of the Faridabad district. There were 50,057 (47.58%) females and 55,145 (52.42%) males. Of these 98,599 (93.7%) were examined by the study group (47,976 females; 50,623 males). The overall prevalence of sputum smear or culture positive pulmonary tuberculosis in our study was found to be 101.4 per 100,000 population. Interpretation & conclusions: The present results showed that the prevalence of sputum positive pulmonary tuberculosis was higher in Faridabad district than the notification rates recorded by the World Health Organization for the contemporary period, a disparity that could be explained by a difference in case detection strategy employed for the study.

Doctors do cry.

Physicians have tried to understand whether crying for a patient is a raw emotion that demonstrates their lack of control over themselves and the situation, or whether it is a sign of humanity and concern for one’s fellow beings. Studies on medical students and doctors’narrations of times when they have shed tears over a patient’s suffering or death have established beyond doubt that medical students and physicians are not immune to their patients’suffering and may cry when overwhelmed by stress and emotions. Even though humanity is the cornerstone of medicine, depersonalisation has somehow crept into the physician–patient relationship and crying is considered incompatible with the image of a good physician, who is supposed to be strong, confident and fully in charge. Thus, crying has been equated to weakness and at times, incompetence. This could be attributed to the fact that our medical curriculum has ingrained in us the belief that emotion clouds rationality and prevents us from being objective while making decisions regarding a patient’s clinical progress. Our curriculum fails to teach us how to handle emotional situations, witness the dying process, communicate bad news, interact with the bereaved during the period of grief immediately following death, and reduce the professional stress involved in working with newly bereaved persons. Our training focuses on cure, amelioration of disease and the restoration of good health, with little emphasis on death, which is an absolute reality. It is crucial that medical educators take note of these lacunae in the curriculum. Physicians and teachers must recognise and accept the emotions that medical students experience in these situations, and teach them to offer their patients a sound blend of rationality and compassion with an attitude of humility.

A study of aetiology of portal hypertension in adults (including the elderly) at a tertiary centre in southern India.

Background & objectives: There are only a few studies on aetiology of portal hypertension among adults presenting to tertiary care centres in India; hence we conducted this study to assess the aetiological reasons for portal hypertension in adult patients attending a tertiary care centre in southern India. Methods: Causes of portal hypertension were studied in consecutive new adult patients with portal hypertension attending department of Hepatatology at a tertiary care centre in south India during July 2009 to July 2010. Results: A total of 583 adult patients (>18 yr old) were enrolled in the study. After non-invasive testing, commonest causes of portal hypertension were cryptogenic chronic liver disease (35%), chronic liver disease due to alcohol (29%), hepatitis B (17%) or hepatitis C (9%). Of the 203 patients with cryptogenic chronic liver disease, 39 had liver biopsy - amongst the latter, idiopathic non cirrhotic intrahepatic portal hypertension (NCIPH) was seen in 16 patients (41%), while five patients had cirrhosis due to non alcoholic fatty liver disease. Fifty six (10%) adult patients with portal hypertension had vascular liver disorders. Predominant causes of portal hypertension in elderly (>60 yrs; n=83) were cryptogenic chronic liver disease (54%) and alcohol related chronic liver disease (16%). Interpretation & conclusions: Cryptogenic chronic liver disease was the commonest cause of portal hypertension in adults, followed by alcohol or hepatitis B related chronic liver disease. Of patients with cryptogenic chronic liver disease who had liver biopsy, NCIPH was the commonest cause identified. Vascular liver disorders caused portal hypertension in 10 per cent of adult patients. Cryptogenic chronic liver disease was also the commonest cause in elderly patients.

Why does an undergraduate student choose medicine as a career.

Background. There are more than 44 000 seats in over 350 medical colleges in India for pursuing the MBBS course. This is not enough as we have only 1 doctor for as many as 1953 persons in India. Yet, medicine is not among the top vocations in most career advisories and the best school students do not aspire to be doctors. Methods. This cross-sectional study was done at a tertiary care, teaching hospital in March 2010. Medical students in their second semester were asked to fill an indigenously designed, structured questionnaire, looking at their reasons for joining the course, interpersonal relationships, satisfaction with the curriculum and future prospects following graduation. Results. The mean (SD) age of the students was 19.2 (0.85) years. Of the 100 students of second semester, 41 had been influenced by a family member in choosing their career. Twelve felt that medicine would give them a chance to serve the society. Forty-six students felt that the expectations they had from the course before joining were not being fulfilled. Nearly one-third of the students (31) stated that they would not choose medicine as a career if given another chance. Further, 19 said that they would still choose a different profession after completing their graduation. Non-fulfilment of expectations from the course was associated with the belief that they would not opt for this course if given a second chance (likelihood ratio 7.12, p=0.008). Students felt that teaching should lay stress on problem-based learning including workshops on stress and time management. Conclusion. We find that several students do not have a defined career plan and opt for a career in medicine because they are influenced by family members. Some students were dissatisfied with the curriculum and expressed that they would not like to pursue the course if given a second chance.

Leprosy and psoriasis co-existence.

Psoriasis and leprosy are almost mutually exclusive, with the prevalence of psoriasis in leprosy patients being as low as 0.014%. We present a case of a patient of psoriasis who was treated and developed Leprosy. We also did a review on the hypothesis which states that psoriasis protects from clinical progression of leprosy, and that leprosy was contained because of increase in prevalence of psoriasis. This inverse phenomenon is supported from our review but needs genetic and paleoepidemiological confirmation.

Structured internship orientation programme for undergraduate students: Easy transition to clinical work.

Background. Internship is a phase of training when a new graduate is expected to acquire skills under supervision, so that he/she may become capable of functioning independently. Often, new graduates go through this period without a clear aim. We conducted an orientation programme before fresh graduates started their 1-year internship to familiarize them with their clinical tasks and their role in the community. Methods. Interns were invited to participate in a one-anda- half day programme conducted by faculty members and administrators that included interactive lectures, structured panel discussions, group discussions and role plays. The participants provided feedback using a structured questionnaire and during informal group discussions. They were also evaluated by a pre-test and post-test questionnaire. Results. Of the 41 interns who attended the programme on day 1 and the 28 who completed it on day 2, 19 completed the post-test questionnaire. The post-test score (median 14.5; range 10–18) represented a significant improvement over the pre-test score (median 13, range 3–16). All participants felt that the workshop was successful in achieving its objectives. Conclusion. A brief and structured orientation programme before internship offers a practical means of making the transition of new graduates from students to practising doctors smoother.

Parameatal urethral cyst.

Cyst formation in the parameatal area of the urethra is an uncommon entity. It was first reported in two male cases as recently as 1956 by Thompson and Lantin. Further reports have been rare. Herein, we report a case of a 21 year-old male having a spherical, cystic swelling 1 cm in size at the external urethral meatus. The diagnosis of parameatal urethral cyst was made and the cyst was excised. Histopathological examination revealed a monolocular cyst lined with transitional cells. The postoperative period was uneventful.

Pesticide poisoning.

Acute poisoning with pesticides is a global public health problem and accounts for as many as 300,000 deaths worldwide every year. The majority of deaths occur due to exposure to organophosphates, organochlorines and aluminium phosphide. Organophosphate compounds inhibit acetylcholinesterase resulting in acute toxicity. Intermediate syndrome can develop in a number of patients and may lead to respiratory paralysis and death. Management consists of proper oxygenation, atropine in escalating doses and pralidoxime in high doses. It is Important to decontaminate the skin while taking precautions to avoid secondary contamination of health personnel. Organochlorine pesticides are toxic to the central nervous system and sensitize the myocardium to catecholamines. Treatment involves supportive care and avoiding exogenous sympathomimetic agents. Ingestion of paraquat causes severe inflammation of the throat, corrosive injury to the gastrointestinal tract, renal tubular necrosis, hepatic necrosis and pulmonary fibrosis. Administration of oxygen should be avoided as it produces more fibrosis. Use of immunosuppressive agents have improved outcome in patients with paraquat poisoning. Rodenticides include thallium, superwarfarins, barium carbonate and phosphides (aluminium and zinc phosphide). Alopecia is an atypical feature of thallium toxicity. Most exposures to superwarfarins are harmless but prolonged bleeding may occur. Barium carbonate Ingestion can cause severe hypokalaemia and respiratory muscle paralysis. Aluminium phosphide is a highly toxic agent with mortality ranging from 37% to 100%. It inhibits mitochondrial cytochrome c oxidase and leads to pulmonary and cardiac toxicity. Treatment is supportive with some studies suggesting a beneficial effect of magnesium sulphate. Pyrethroids and insect repellants (e.g. diethyltoluamide) are relatively harmless but can cause toxic effects to pulmonary and central nervous systems. Ethylene dibromide-a highly toxic, fumigant pesticide-produces oral ulcerations, followed by liver and renal toxicity, and is almost uniformly fatal. Physicians working in remote and rural areas need to be educated about early diagnosis and proper management using supportive care and antidotes, wherever available.