Pre-pregnancy weight, the rate of gestational weight gain, and the risk of early gestational diabetes mellitus among women registered in a tertiary care hospital in India.

BACKGROUND: The impact of pre-pregnancy weight and the rate of gestational weight gain (GWG) together on the risk of early GDM (< 24 weeks gestation; eGDM) has not been studied in the Indian context. We aimed to study the influence of (1) pre-pregnancy weight on the risk of eGDM diagnosed in two time intervals; and (2) in addition, the rate of GWG by 12 weeks on the risk of eGDM diagnosed in 19-24 weeks. METHOD: Our study utilized real-world clinical data on pregnant women routinely collected at an antenatal care clinic at a private tertiary hospital, in Pune, India. Women registering before 12 weeks of gestation (v1), with a singleton pregnancy, and having a follow-up visit between 19-24 weeks (v2) were included (n = 600). The oral glucose tolerance test was conducted universally as per Indian guidelines (DIPSI) at v1 and v2 for diagnosing eGDM. The data on the onset time of eGDM were interval censored; hence, we modeled the risk of eGDM using binomial regression to assess the influence of pre-pregnancy weight on the risk of eGDM in the two intervals. The rate of GWG by 12 weeks was added to assess its impact on the risk of eGDM diagnosed in v2. RESULT: Overall, 89 (14.8%) women (age 32 ± 4 years) were diagnosed with eGDM by 24 weeks, of which 59 (9.8%) were diagnosed before 12 weeks and 30 of 541 (5.5%) women were diagnosed between 19-24 weeks. Two-thirds (66%) of eGDM were diagnosed before 12 weeks of gestation. Women's pre-pregnancy weight was positively associated with the risk of GDM in both time intervals though the lower confidence limit was below zero in v1. The rate of GWG by 12 weeks was not observed to be associated with the risk of eGDM diagnosed between 19-24 weeks of gestation. These associations were independent of age, height, and parity. CONCLUSION: Health workers may focus on pre-pregnancy weight, a modifiable risk factor for eGDM. A larger community-based study measuring weight and GDM status more frequently may be warranted to deepen the understanding of the role of GWG as a risk factor for GDM.

Complementary and Integrative Approaches to Sleep Disorders in Children.

Sleep problems are very common in children and adolescents. Chronic insomnia is the leading cause of sleep disorders in children and adolescents. Adjunctive interventions that address low ferritin levels and vitamin D3 deficiency are helpful in children and adolescents. The addition of l-5-hydroxytryptophan, gabadone, l-theanine, Ashwagandha, omega 3 fatty acids, probiotics in bipolar disorder, and children with colic, meditation, and changing from a high-fat diet to a Mediterranean diet are also helpful adjunctive interventions. Actigraphy data should be collected in future sleep studies because subjective data may not indicate the true effect of the intervention.

Complementary and Integrative Approaches to Prevention and Treatment of Child and Adolescent Obesity.

Childhood obesity is a significant global challenge with increasing prevalence. It is associated with long-term health risks. Interventions especially early on can be effective in the prevention and reducing the impact on health in children. In children, dysbiosis and inflammation are associated with obesity. Studies demonstrate that intensive lifestyle interventions in form of parent education, motivational interviewing to improve diet and exercise as well as mindfulness, and sleep improvement can help alleviate the risk. The article outlines the current research describing complementary and integrative approaches to the prevention and treatment of obesity in children.

Maternal early pregnancy body mass index, gestational weight gain and pregnancy outcomes among urban slum dwellers in Pune, India-A retrospective analysis.

Context: Studies on prepregnancy body mass index (BMI), gestational weight gain (GWG), and pregnancy outcomes among urban Indian slums are sparse. Aims: To study BMI during early pregnancy, GWG, and maternal and neonatal outcomes among slum-dwelling women in Pune, India. Design: A retrospective study among pregnant women attending antenatal care (ANC) facility. Methods and Material: Anthropometric and clinical data throughout pregnancy and pregnancy outcomes postdelivery were collected during hospitalization for delivery using ANC cards. Asian BMI cut-offs were used to define underweight (UW), normal weight (NW), overweight (OW), and obesity (OB). GWG was classified into insufficient, adequate, and excessive categories (2009 Institute of Medicine). Statistical analysis was performed using R (v 4.0). Results: Slum-dwelling pregnant women (n = 509, mean age 24 (3.6) years) were studied. Seventy-five percent of the women visited ANC clinics at least thrice during pregnancy. Only 17.5% (n = 89) of the women registered before 12 weeks of gestation, and higher education and being primiparous were the correlates. A total of 28% of the women were UW, whereas 25% of the women were OW/OB as per early pregnancy BMI. The highest percentage of preterm deliveries and cesarean/instrumental deliveries were observed in OW/OB categories. A total of 27% gained appropriate gestational weight. This cohort had 508 live births (mean BW- 2.8 kgs) and one stillbirth. One baby had macrosomia (BW >4 Kg), whereas 19% were low birth weight (LBW) (BW <2.5 Kg). Conclusions: Double burden of malnutrition (UW and OW) was observed among young slum-dwelling women. The proportion of slum-dwelling women attending ANC clinics during early pregnancy is still low. Increased uptake of government programs is required to enhance maternal and child health.

Birth cohort differences in height, weight and BMI among Indian women aged 15-30 years: analyses based on three cross-sectional surveys.

OBJECTIVE: To explore long-term trends in height, weight and BMI across birth cohorts among Indian women aged 15-30 years. DESIGN: Nationally representative cross-sectional surveys. SETTING: Data from three National Family Health Surveys were conducted in 1998-1999, 2005-2006 and 2015-2016. Height and weight were modelled jointly, employing a multivariate regression model with age and birth cohorts as explanatory variables. The largest birth cohort (born 1988-1992) was the reference cohort. Stratified analyses by place of residence and by marital status and dichotomised parity were also performed. PARTICIPANTS: 437 753 non-pregnant women aged 15-30 years. RESULTS: The rate of increase in height, weight and BMI differed across birth cohorts. The rate of increase was much lower for height than weight, which was reflected in an increasing trend in BMI across all birth cohorts. In the stratified analyses, increase in height was found to be similar across urban and rural areas. Rural women born in the latest birth cohort (1998-2001) were lighter, whereas urban women were heavier compared to the reference cohort. A relatively larger increase in regression coefficients was observed among women born between 1978 and 1982 compared to women born between 1973 and 1977 when considering unmarried and nulliparous ever-married women and, one cohort later (1983-1987 v. 1978-1982), among parous ever-married women. CONCLUSION: As the rate of increase was much larger for weight than for height, increasing trends in BMI were observed across the birth cohorts. Thus, cohort effects show an important contributory role in explaining increasing trends in BMI among young Indian women.

Legal and Ethical Challenges, Part 1: General Population.

Several federal and state laws and regulations, as well as ethical medical principles, govern the emergency clinician's practice of care. Although some common legal-medical and ethical principles are shared with other medical specialties, emergency medicine and emergency psychiatry have unique legal and ethical challenges. This article presents and discusses these challenges, including the physician-patient relationship, malpractice, confidentiality and privilege, duty to report, decision-making capacity and vicarious decision-making, the Emergency Medical Treatment and Labor Act, right to treatment, hospital admissions, involuntary commitment, forced medication administration, and child and elder abuse.

Corrigendum to "Management Challenges in a Child with Chronic Hyponatremia: Use of V2 Receptor Antagonist".

[This corrects the article DOI: 10.1155/2017/3757423.].

Management Challenges in a Child with Chronic Hyponatremia: Use of V2 Receptor Antagonist.

Chronic hyponatremia is very rare in children and is often seen in the setting of congestive heart failure or liver failure in adults. Here, we report an 8-year-old child with hypothalamic glioma who presented with severe hyponatremia. Initial management consisted of fluid restriction. This was very difficult for the child to follow and the child developed bizarre drinking habits requiring intervention from child psychiatry. So therapy was initiated with low dose V2 receptor antagonist under close inpatient monitoring. While initial response was reassuring, her sodium levels tended to drift down with longer duration of treatment requiring us to increase the dose frequently. Her response to therapy and her stable clinical situation off therapy suggest that she may have reset osmostat.

Failure to Use and Sustain Male Condom Usage: Lessons Learned from a Prospective Study among Men Attending STI Clinic in Pune, India.

BACKGROUND: Sustained or consistent use of condoms by men remains a challenge. A study was carried out to identify factors associated with failure to use condoms consistently by men attending STD clinics in Pune, India. METHOD: Among 14137 STI clinic attendees, 8360 HIV sero-negative men were enrolled in a cohort study. The changes in condom usage behavior were studied among 1284 men who returned for first scheduled quarterly follow up, 309 reported consistent condom use at the time of enrollment in the cohort. Data pertaining to heterosexual men practicing high risk behavior were analyzed to identify factors associated with change in condom use behavior using logistic regression model. Demographic, behavioral and biological factors observed to be associated with condom use were fitted in five Cox proportional hazards models to calculate hazard ratios and their 95% confidence intervals to identify independent predictors of failure to sustain condom use behavior. RESULTS: The univariate analysis showed that men who were 30 years or older in age (p = 0.002) and those who did not have contact female sex worker (FSW) were more likely to fail to sustain consistent condom use. However both these factors did not show significant association in multivariable analysis. Marital status and contact with Hijra (eunuch) in lifetime were associated with failure to change in their condom use behavior [AOR 0.33 (CI 0.13-0.82; p = 0.017)]. During the follow up of 2 years, 61 events (15.5 per 100 person years, 95% CI 12.3-19.5 years) of 'failure of condom use' were recorded despite counseling. Older age, contact with non CSW partner and presence of genital ulcer disease / discharge syndrome were significant predictors of failure to sustain condom use. DISCUSSION: Married monogamous older men, who report contact with sex worker and present with genital ulcer disease are at risk of failure to use condom after first exposure to voluntary HIV counseling and testing. This is a scenario of primary prevention program. Condom promotion and counseling needs to be reinforced through follow up counseling among this population.

Meta-analysis to Compare the Safety and Efficacy of Manual Small Incision Cataract Surgery and Phacoemulsification.

PURPOSE: A systematic review and meta-analysis comparing the safety, efficacy, and expenses related to phacoemulsification versus manual small incision cataract surgery (SICS). METHODS: PubMed, Cochrane, and Scopus databases were searched with key words manual SICS 6/18 and 6/60; astigmatism and endothelial cell loss postoperatively, intra- and post-operative complications, phacoemulsification, and comparison of SICS and phacoemulsification. Non-English language manuscripts and manuscripts not indexed in the three databases were also search for comparison of SICS with phacoemulsification. Data were compared between techniques for postoperative uncorrected and corrected distance visual acuity (UCVA and best corrected visual acuity [BCVA], respectively) better than 6/9, surgical cost and duration of surgery. The Oxford cataract treatment and evaluation team scores were used for grading intraoperative and postoperative complications, uncorrected near vision. RESULT: This review analyzed, 11 comparative studies documenting 76,838 eyes that had undergone cataract surgery considered for analysis. UCVA of 6/18 UCVA and 6/18 BCVA were comparable between techniques (P = 0.373 and P = 0.567, respectively). BCVA of 6/9 was comparable between techniques (P = 0.685). UCVA of 6/60 and 6/60 BCVA aided and unaided vision were comparable (P = 0.126 and P = 0.317, respectively). There was no statistical difference in: Endothelial cell loss during surgery (P = 0.298), intraoperative (P = 0.964) complications, and postoperative complications (P = 0.362). The phacoemulsification group had statistically significantly less astigmatism (P = 0.005) and more eyes with UCVA of 6/9 (P = 0.040). UCVA at near was statistically significantly better with SICS due to astigmatism and safer during the learning phase (P = 0.003). The average time for SICS was lower than phacoemulsification and cost <½ of phacoemulsification. CONCLUSION: The outcome of this meta-analysis indicated there is no difference between phacoemulsification and SICS for BCVA and UCVA of 6/18 and 6/60. Endothelial cell loss and intraoperative and postoperative complications were similar between procedures. SICS resulted in statistically greater astigmatism and UCVA of 6/9 or worse, however, near UCVA was better.

Children's emotional and behavioral reactions to disasters: role of the primary care physician.

BACKGROUND: Children are especially vulnerable to the effects of disasters. The coming tornado season raises concerns about enduring problems and anniversary reactions related to the May 2013 tornadoes as well as anxiety about the possibility of new events. METHODS: This article describes common emotional and behavioral disaster reactions in children and also identifies reactions unique to a particular age. Reactions are clustered into depressive, anxious, and behavioral symptoms and physiological responses. PRIMARY RESULTS: This article outlines the key elements in assessing children's disaster reactions and provides specific recommendations for situations that would indicate the need for a mental health evaluation such as for directly-exposed children, children who experience disaster-related losses, those with pre-existing vulnerabilities, and those with significant symptoms. PRINCIPAL CONCLUSIONS: Primary care physicians can help identify the emotional and behavioral effects of disasters in children, educate parents to recognize children's reactions, and refer children in need of specialized care.

Correlates of lower comprehension of informed consent among participants enrolled in a cohort study in Pune, India.

BACKGROUND: Optimum comprehension of informed consent by research participants is essential yet challenging. This study explored correlates of lower comprehension of informed consent among 1334 participants of a cohort study aimed at estimating HIV incidence in Pune, India. METHODS: As part of the informed consent process, a structured comprehension tool was administered to study participants. Participants scoring ≥90% were categorised into the 'optimal comprehension group', whilst those scoring 80-89% were categorised into the 'lower comprehension group'. Data were analysed to identify sociodemographic and behavioural correlates of lower consent comprehension. RESULTS: The mean ± SD comprehension score was 94.4 ± 5.00%. Information pertaining to study-related risks was not comprehended by 61.7% of participants. HIV-negative men (adjusted OR [AOR] = 4.36, 95% CI 1.71-11.05) or HIV-negative women (AOR = 13.54, 95% CI 6.42-28.55), illiteracy (AOR= 1.65, 95% CI 1.19-2.30), those with a history of multiple partners (AOR = 1.73, 95% CI 1.12-2.66) and those never using condoms (AOR = 1.35, 95% CI 1.01-1.82) were more likely to have lower consent comprehension. CONCLUSIONS: We recommend exploration of domains of lower consent comprehension using a validated consent comprehension tool. Improved education in these specific domains would optimise consent comprehension among research participants.

Conventional and novel cardiovascular risk factors and markers of vascular damage in rural and urban Indian men.

BACKGROUND: India is undergoing rapid epidemiological and nutritional transition largely as a consequence of rapid urbanisation. We investigated conventional and novel cardiovascular risk factors in rural and urban Indian men and studied their association with markers of vascular damage. METHODS: We randomly selected and studied 149 rural, 142 urban slum residents and 150 urban middle class middle aged Indian men. We measured conventional (obesity, blood pressure, lipids, smoking habits) and novel (proinflammatory and prothrombotic factors) cardiovascular risk factors and markers of vascular damage (carotid intima media thickness (IMT), von Willebrand Factor (vWF), e-selectin). RESULTS: There was a progressive increase in most of the conventional cardiovascular (CV) risk factors from rural to slum to urban middle class men. Plasminogen activator inhibitor-1 (PAI-1), platelet count, total homocysteine and C-reactive protein showed similar patterns. Carotid IMT was similar in the three groups; vWF was highest in rural and e-selectin in slum men. Adjusting for location, age explained 17%, obesity 3% and conventional risk factors 1% of the variance in carotid IMT, whilst novel cardiovascular risk factors were without any significant impact. CONCLUSIONS: Urbanisation increases obesity related as well as prothrombotic and proinflammatory CV risk factors in Indian men, but appears not to impact on IMT.

Attitudes of married men to the use of vaginal microbicides by their female partners in Pune, India.

The availability of female-initiated HIV prevention options does not necessarily lead to their uptake. We investigated if married men were willing to support open or covert use of microbicides by their spouses in Pune, India. Data was collected using an interview-administered questionnaire from 151 consenting married men with a mean age of 34 years. Logistic regression analysis was used to examine the relationships between sociodemographic and behavioural factors. One hundred and thirty-seven men (71.5%) were educated and 146 men (96.7%) were employed. Men aged <34 years were eight times (p=0.024) and those in a harmonious relationship were seven times (p=0.008) more willing to use microbicides compared with men aged ≥34 years and men in less harmonious relationships, respectively. Men practicing high-risk sexual behaviour were twice (p=0.049) and men with a history of using contraceptives were three times (p=0.05) more likely to support the covert use of microbicides compared with those reporting no or low-risk sexual behaviour and those who had never used contraceptives, respectively. This suggests that sociodemographic and behavioural factors relating to men as well as women should be considered when developing and marketing microbicides.

Acceptability of coitally-associated versus daily use of 1% tenofovir vaginal gel among women in Pune, India.

This study reports on the acceptability of 1% tenofovir microbicide gel among participants randomised to the coitally-associated use (n = 50) or daily use (n = 50) arms of a Phase II clinical trial in Pune, India. In a 6-month follow-up study, information on behavioural domains was collected on a 6-point Likert scale and gel acceptability was measured on a 5-point Likert scale. Random intercept logistic modelling was performed to examine the simultaneous effects of study arm, follow-up time, sociodemographic factors and behavioural domains on gel acceptability. The mean age of female participants was 32.7 years. Women in both study arms had similar sociodemographic profiles. Women liked features such as easy use of the gel and its protective effect against HIV. Messiness was the most disliked feature. Gel acceptability increased during subsequent follow-up visits in both arms, especially in the coitally-associated use arm. Non-acceptability of the gel was almost two and a half times higher in daily users (adjusted odds ratio 2.55, 95% CI 1.18-5.51; p = 0.017). Acceptability differed significantly between the two study arms at 2 months (68% vs 40%; p = 0.006) and 6 months (64% vs 46%; p = 0.07). Acceptability was significantly lower in those participants who reported 'messiness' as the most disliked feature (odds ratio 2.42, 95% CI 1.02-5.72; p = 0.045). In conclusion, microbicides were more acceptable in coitally-associated users than in daily users. Leakage was a problem that requires attention. Positioning of the product in a setting such as India where the majority of decision-making is done by men would need extensive and systematic education of men.

Mortality in HIV infected individuals in Pune, India.

BACKGROUND & OBJECTIVES: With the presence of HIV epidemic for more than two decades in India, rise in the number of HIV related deaths is expected. Data on mortality in HIV infected individuals from prospective studies are scanty in India. We report here data on mortality in a systematically followed cohort of HIV infected individuals at Pune, Maharashtra, India. METHODS: A total of 457 HIV infected individuals were enrolled in a prospective study in Pune between September 2002 and November 2004. They were evaluated clinically and monitored for CD4 counts at every quarterly visit. Mortality data were collected from the records of hospital facilities provided by the study. If the death occurred outside such hospitals; relatives of the participants were requested to inform about the death. RESULTS: Median CD4 count in study participants was 218 cells/µl (95% CI: 107-373) at baseline. The median duration of follow up was 15 months (IQR: 12, 22). Mortality was higher in antiretroviral therapy (ART) naive patients compared to those who received treatment (16.59 vs. 7.25 per 100 person years). Participants above 35 yr of age, CD4 count less than or equal to 100 cells/µl at baseline, tuberculosis at any study time point and ART status were independently associated with high mortality [(RR=1.97; 95% CI: (1.23, 3.14), P=0.005, (RR=33.20, 95%CI (7.59, 145.29), P<0.001, (RR=2.38, 95% CI (1.38, 4.09), P= 0.002 and RR=5.60, 95% CI (3.18, 9.86), P<0.001, respectively]. Interpretation & conclusions : High mortality at advanced immunosuppression highlights the importance of early detection of HIV infection. Emphasis needs to be given at timely diagnosis and management of tuberculosis and ART initiation. It is important to create awareness about availability of free antiretroviral drugs in the government ART roll out programme.

Is glaucoma blindness a disease of deprivation and ignorance? A case-control study for late presentation of glaucoma in India.

AIM: The aim was to identify the presenting symptoms and social risk factors for late presentation of primary glaucoma in newly diagnosed cases. MATERIALS AND METHODS: It was a case-control study in a tertiary eye care center in Maharashtra, India. Newly diagnosed patients with primary glaucoma were classified as cases (late presenters) where there was no perception of light in one eye or severe visual field loss affecting an area within 20° of fixation or a cup-disc (C:D) ratio ≥0.8 and controls (early presenters), presenting relative scotoma within 20° of fixation or a C:D ratio <0.8, but >0.5. All patients underwent a comprehensive ocular examination including gonioscopy, perimetry, and detailed family and social history. Occupation, education, and socioeconomic status were graded. SPSS version 12.0 was used, and univariate and multivariate logistic regression analysis was performed. RESULTS: Gradual progressive painless loss of vision was the commonest symptom (175, 87.5%). Primary angle closure glaucoma was more common in females (P = 0.001) and lower socioeconomic groups (P = 0.05). Patients who were less educated were more likely to have late presentation of glaucoma (P < 0.001, odds ratio = 0.07; 95% CI, 0.02-0.25). Knowledge of family history of glaucoma (P = 0.80, odds ratio = 1.16; 95% CI, 0.36-3.71) and eye clinic attendance in past 2 years still resulted in late presentation (P = 0.45, odds ratio = 1.34, 95% CI, 0.63-2.82). CONCLUSION: Lack of education and awareness of glaucoma were major risk factors for late presentation.

Incidence of common opportunistic infections in HIV-infected individuals in Pune, India: analysis by stages of immunosuppression represented by CD4 counts.

BACKGROUND: Opportunistic infections (OIs) influence the morbidity and mortality due to HIV infections. Data from India on the incidence of OIs among HIV-infected individuals by stages of immunodeficiency are scarce. METHODS: Between September 2002 and November 2004, HIV-infected individuals were enrolled in a prospective study in Pune. They were clinically and immunologically evaluated quarterly. Incidence rates of specific OIs were calculated. RESULTS: Median CD4 counts in HIV-infected male and female patients at baseline were 197/mm(3) and 413/mm(3), respectively. Tuberculosis was the most common OI with an incidence of 15.4 (95% CI 12.2-19.2) per 100 person-years, followed by oral candidiasis 11.3 (95% CI 8.6-14.5), herpes zoster 10.1 (95% CI 7.6-13.1), and cryptococcal meningitis 1.7 (95% CI 0.8-3.1) per 100 person-years. Patients with baseline CD4 counts of <200/mm(3) were six times more likely to develop OIs compared to those with CD4 counts of >350/mm(3) (p<0.001). CONCLUSIONS: The high incidence of commonly reported OIs in Indian HIV-infected individuals highlights the need for early screening and also the need to increase awareness in healthcare providers, in order to improve decisions regarding prophylaxis for prevention and appropriate therapeutic intervention. Emphasis needs to be given to the early diagnosis and management of tuberculosis in HIV-infected individuals.