FASE-family and social engagement model for prevention and management of self harm behavior-a study protocol for cluster randomized control trial in India.

Background: Suicide is a substantial public health concern for countries worldwide. Effective preventive and curative interventions for self-harm behavior (SHB) are imperative for nations with an alarmingly high rate of suicide and self-harm behaviors. The intervention protocol named FASE (Family and Social Engagement) consists of comprehensive assessment, Attachment-Based Family Therapy (ABFT), and community linkages for people presenting with suicide or self-harm in emergency departments of tertiary hospitals. Methods: This article reports the design and protocol for a cluster randomized control trial for suicide prevention and management. After the developed intervention is pilot tested in a tertiary hospital in Kerala, the intervention will be scaled up to be implemented in various tertiary hospitals in Kerala. Each hospital emergency department will be considered a cluster, and these clusters will be randomized to the intervention group and control group in a 1:1 ratio. The eligible people from the intervention clusters will undergo a baseline assessment, a structured moderate intense intervention with twelve sessions spread across 6 months by the trained social workers supervised by the Mental health team, and a follow-up assessment at the end. Participants will be recruited after obtaining consent and explaining the study. The primary outcome includes suicidality measured by the Depressive Symptom Inventory-Suicidality Subscale (DSI-SS), Depression, Anxiety and Stress Scale (DASS), MOS Social Support Survey, and Brief resilience scale (BRS). Discussion: Knowledge generated from this trial can significantly affect new programmatic policy and clinical guidelines that will improve the reduction of suicide rates in the country. Trial registration: Prospectively registered in Clinical Trial Registry India (ICMR-NIMS) on 18/10/2021 (ref number- REF/2021/10/048264).

Vulnerabilities and life stressors of people presented to emergency departments with deliberate self-harm; consolidating the experiences to develop a continuum of care using a mixed-method framework.

Objective: Suicide is a crucial public health concern. However, the interactions between bio psychosocial vulnerabilities and stressors leading to deliberate self-harm behavior remain unexplored, especially in the Indian context. This study examined the experiences leading to self-harm behavior among people who presented to emergency departments with suicidal attempts. Methods: In this mixed-methods study, we enrolled 44 patients who presented with self-harm behavior at three tertiary health care facilities between October and December 2019. To collect quantitative data, we employed standardized tools: General Health Questionnaire (GHQ-28), General Help-Seeking Questionnaire, Mini International Neuropsychiatric Interview, and the Brief Resilience Scale. Further, we conducted semi-structured interviews to qualitatively explore participants' life experiences and other risk factors. Qualitative analyses were performed using thematic analysis and quantitative descriptive and inferential statistics were performed using STATA software. Results: The mean age of subjects were 29.8 years. The mean suicidality score for the patients was 26 (±8.7). In univariate analysis, depression and anxiety were positively associated with suicidality. While help-seeking behavior and resilience were negatively associated with suicidality. Qualitative results were centered on three major themes; life stressors, family related stressors, and social support-related vulnerabilities. The subjects' lived experiences were introduced in the backdrop of the interplay of vulnerabilities and stressors. Conclusion: The biopsychosocial vulnerabilities remain dormant until it is activated by life stressors resulting in severe self-harm behaviors. Mental health team-driven assertive engagement, positive coping, and social support interventions would help prevent reattempts in people with self-harm behaviors.

A profile of metabolic acidosis in patients with sepsis in an Intensive Care Unit setting.

CONTEXT: Metabolic acidosis is frequently found in patients with severe sepsis. An understanding of types of acidosis in sepsis and their evolution over the course of treatment may give us insight into the behavior of acid-base balance in these patients. AIMS: To describe at Intensive Care Unit (ICU) admission and over the first 5 days the composition of metabolic acidosis in patients with sepsis and to evaluate and compare acidosis patterns in survivors and nonsurvivors. SETTINGS AND DESIGN: A prospective study conducted at Amrita Institute of Medical Sciences, Kochi, Kerala, in the Department of Internal Medicine. SUBJECTS AND METHODS: Seventy-five consecutive patients admitted in the medical ICU with sepsis and metabolic acidosis were assessed. Arterial blood gas and serum electrolytes were measured during the first five days of admission or until death, renal replacement or discharge supervened. STATISTICAL ANALYSIS: To test the statistical significance of the difference in mean values of different study variables at day 1 and last day between survivors and non survivors, Mann-Whitney U-test was applied. To test the statistical significance of the difference in mean changes in different study parameters from day 1 to last day, paired t-test was done in the survivor group and Mann-Whitney U-test in the non survivor group. RESULTS: Regardless of survival status, on day 1 of admission, 37 had High Anion Gap metabolic acidosis (HAGMA), 21 had predominant lactic acidosis (LA), 8 had Normal anion gap metabolic acidosis (NAGMA), and 9 had both HAGMA and LA [Figure 1]. When we compared this to the last day, 25 had HAGMA, 3 had LA, 3 had both HAGMA and LA, and 22 patients had resolution of acidosis. Sixty-four patients survived for up to 5 days of admission. Fifteen of these patients underwent hemodialysis on the day of admission itself in view of HAGMA. The remaining 49 comprised of HAGMA (31), Lactic acidosis (12), and a combination (6) on day 1. On the last day in this group, 25 had HAGMA, 2 had LA, and 22 patients had resolution of acidosis. In survivors, over the observation period, changes seen were: mean pH: 7.25-7.34 (P < 0.001), mean serum bicarbonate: 13.9 mEq to 17.2 mEq (P < 0.001), and mean serum lactate: 3.18-1.9 (P = 0.002). The changes in serum albumin and pCO2 were not significant. Eleven patients in the study population succumbed. Seven patients underwent hemodialysis on day 1 and the remaining four were followed up for more than 1 day. On day 1, 7 had lactic acidosis and 5 had HAGMA. Over the observation period, changes seen were mean pH: 7.15-7.14, mean serum lactate: 6.3-7.3 mEq. CONCLUSIONS: In patients with sepsis and septic shock, high anion gap metabolic acidosis is the dominant blood gas anomaly. Fall in lactate levels over the first 5 days of admission is a good prognostic marker of survival. Evolution of the blood gas profile over time suggests that a fall in lactate levels and a rise in bicarbonate levels correlate with a better outcome. The role of the anion gap as a prognostic marker holds promise and further studies are needed in this regard.

A fatal case of pulmonary nocardiosis.

Pulmonary nocardiosis is a serious, most often considered an opportunistic infection affecting the respiratory tract. Even though it is more common in immunocompromised hosts, it is not infrequently seen in immunocompetent patients as well. The aerosol route is the main portal of entry in to the body. Molecular techniques have revolutionised the identification of Nocardia species. However such tests are limited to referral laboratories. The radiographic appearances of Nocardia infection vary from a small nodule to bilateral infiltrates with cavitation. Traditionally sulphonamides have been considered the treatment of choice. However, resistance to sulphonamides is increasingly recognised. Carbapenems and linezolid have been found to be uniformly active against all the pathogenic species of Nocardia that affect human beings. The authors report a case of pulmonary nocardiosis in an immunocompetent patient, in whom the infection relentlessly progressed to florid sepsis despite prompt institution of right antibiotics. Florid sepsis relating to pulmonary nocardiosis is rare.

Acute community acquired Aspergillus pneumonia in a presumed immunocompetent host.

Infection from Aspergillus results in a wide range of diseases from simple Aspergillus pneumonia to fatal invasive Aspergillosis. Though the fungus is known to predominantly affect the immunocompromised host, it has also been known to cause acute pneumonia in immunocompetent hosts which is invariably fatal. It presents as an acute pneumonia with bilateral chest infiltrates on radiograph. Early clinical suspicion and microbiological identification by measures such as broncho alveolar lavage and initiation of therapy with voricanozole significantly increase the chances of survival. In this article the authors discuss a case of acute community acquired Aspergillus pneumonia in an immunocompetent host who survived due to early identification and prompt treatment with appropriate antifungal medication.