Differential risk factor profile of diabetes and atherosclerosis in rural, sub-urban and urban regions of South India: The KMCH-Non-communicable disease studies.

AIMS: South Asia has emerged rapidly as an epicentre of non-communicable diseases (NCDs) specifically diabetes and cardiovascular diseases. The prevalence rate, risk factors and aetiology of NCDs in different socio-demographic settings are not clearly understood. This study was performed to assess the prevalence of diabetes and atherosclerosis and their risk factors in urban, sub-urban and rural communities of South India. METHODS: Three communities [Nallampatti (rural), Thadagam (sub-urban) and Kalapatti (urban)] in South India were selected for participation in the KMCH-NCD Studies. Study volunteers were administered a detailed questionnaire, underwent anthropometric measurements, clinical measurements including blood pressure, glycated haemoglobin (HbA1c ), non-fasting lipid profile and serum creatinine. Carotid intima-media thickness was measured using B-mode ultrasound. Multiple logistic regression analyses were performed to understand the association of risk factors with diabetes and atherosclerosis. RESULTS: A total of 2976 native participants, ≥20 years of age were screened. The prevalence of diabetes was 16%, 26% and 23% respectively in the rural, sub-urban and urban study populations. Association of obesity with diabetes was observed in only urban population while hypertension and dyslipidaemia showed association in both urban and semi-urban populations. Association of diabetes with atherosclerosis was observed in urban and semi-urban populations. Hypertension in semi-urban and obesity and dyslipidaemia in urban population showed association with atherosclerosis. CONCLUSIONS: Diabetes and atherosclerosis burden reported in the three different communities were higher than previous reports, especially in rural and sub-urban regions. No traditional risk factor is identified to be associated with prevalence of diabetes and atherosclerosis in rural population. These findings suggest an urgent need for investigation into the role of non-traditional risk factors like environmental or occupational exposures may help to better understand the aetiology of diseases in non-urbanized communities.

Correction to: Association of co-accumulation of arsenic and organophosphate insecticides with diabetes and atherosclerosis in a rural agricultural community: KMCH-NNCD-I study.

Authors would like to correct the error in the online publication, which is mentioned below.

Association of co-accumulation of arsenic and organophosphate insecticides with diabetes and atherosclerosis in a rural agricultural community: KMCH-NNCD-I study.

AIMS: In last few decades, the prevalence of diabetes and vascular diseases has intensified concurrently with increased use of synthetic chemicals in agriculture. This study is aimed to evaluate the association of co-accumulation of arsenic and organophosphate (OP) insecticides with diabetes and atherosclerosis prevalence in a rural Indian population. METHODS: This study included observations from KMCH-NNCD-I (2015) cross-sectional study (n = 865) from an Indian farming village. The participants had assessment of clinical parameters including HbA1c and carotid intima-media thickness and urinary heavy metals. Serum OP residues were extracted and quantified by GC-MS. Statistical analyses were performed to unravel the co-association of arsenic and OPs on prevalence of diabetes and atherosclerosis. RESULTS: On multivariate regression analyses, total organophosphate level and arsenic accumulation showed association with diabetes and atherosclerosis. Higher odds ratio with significant trends were observed for the sub-quartiles formed by the combination of higher quartiles of arsenic and total organophosphates in association with diabetes and atherosclerosis. CONCLUSIONS: We observed evidence of possible synergism between arsenic and OPs in association with prevalence of diabetes, pre-diabetes and atherosclerosis in the study population. Our findings highlight the importance of understanding health effects of mixed exposures and raises vital questions on the role of these agrochemicals in the etiology of diabetes and vascular diseases.

Metals in urine in relation to the prevalence of pre-diabetes, diabetes and atherosclerosis in rural India.

OBJECTIVE: Diabetes and cardiovascular diseases are growing burdens in rural communities worldwide. We have observed a high prevalence of diabetes among rural farming communities in India and sought to evaluate the association of non-traditional risk factors, such as metals, with diabetes and other cardiometabolic risk factors in this community. METHODS: Anthropometric measurements, chemistries and carotid intima-media thickness were determined in 865 participants of the Kovai Medical Center and Hospital-Nallampatti Non-Communicable Disease Study-I (KMCH-NNCD-I, 2015), a cross-sectional study conducted in a farming village in South India. Urinary metal levels were determined by inductively couped plasma-mass spectrometry analysis and corrected to urinary creatinine level. Statistical analyses were performed to study the association between urinary metal levels and clinical parameters. RESULTS: 82.5% of the study population were involved in farming and high levels of toxic metals were detected in the synthetic fertilisers used in the study village. The prevalence of pre-diabetes, diabetes and atherosclerosis was 43.4%, 16.2% and 10.3%, respectively. On logistic regression analysis, no association of traditional risk factors such as body mass index, blood pressure and total cholesterol with disease conditions was observed, but urinary levels of metals such as arsenic, chromium, aluminium and zinc showed an association with diabetes, while arsenic and zinc showed an association with pre-diabetes and atherosclerosis. CONCLUSIONS: Our data suggest a probable role of metals in the aetiology of diabetes and cardiovascular diseases in rural communities. Identifying and eliminating the causes of increased levels of these environmental chemicals could have a beneficial impact on the burden of non-communicable diseases in rural population.

The impact of systems-of-care on pharmacoinvasive management with streptokinase: The subgroup analysis of the TN-STEMI programme.

OBJECTIVES: We evaluated the impact of implementation of the TN-STEMI programme on various characteristics of the pharmacoinvasive group by comparing clinical as well as angiographic outcomes between the pre- and post-implementation groups. METHODS: The TN-STEMI programme involved 2420 patients of which 423 patients had undergone a pharmacoinvasive strategy of reperfusion. Of these, 407 patients had a comprehensive blinded core-lab evaluation of their angiograms post-lysis and clinical evaluation of various parameters including time-delays and adverse cardio- and cerebro-vascular events at 1year. Streptokinase was used as the thrombolytic agent in 94.6% of the patients. RESULTS: In the post-implementation phase, there was a significant improvement in 'First medical contact (FMC)-to-ECG' (11 vs. 5min, p<0.001) and 'Lysis-to-angiogram' (98.3 vs. 18.2h, p<0.001) times. There was also a significant improvement in the number of coronary angiograms performed within 24h (20.7% vs. 69.3%, p<0.001). The 'Time-to-FMC' (160 vs. 135min, p=0.07) and 'Total ischemic time' (210 vs. 176min, p=0.22) also showed a decreasing trend. IRA patency rate (70.2% vs. 86%, p<0.001) and thrombus burden (TIMI grade 0: 49.1% vs. 73.4%, p<0.001) were superior in this group. The MACCE rates were similar except for fewer readmissions (29.8% vs. 12.6%, p=0.0002) and target revascularizations at 1year (4.8% vs. none, p=0.002) in the post-implementation group. CONCLUSION: The implementation of a system-of-care (hub-and-spoke model) in the pharmacoinvasive group of the TN-STEMI programme demonstrated shorter lysis-to-angiogram times, better TIMI flow patterns and lower thrombus burden in the post-implementation phase.

A System of Care for Patients With ST-Segment Elevation Myocardial Infarction in India: The Tamil Nadu-ST-Segment Elevation Myocardial Infarction Program.

Importance: Challenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors. Objective: To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model. Design, Setting, and Participants: This multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period. Exposures: Creation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology. Main Outcomes and Measures: Primary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality. Results: A total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04). Conclusions and Relevance: A hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.

Noncommunicable disease in rural India: Are we seriously underestimating the risk? The Nallampatti noncommunicable disease study.

AIM: To assess the prevalence of noncommunicable diseases in a true rural farming population in South India and compare the data with the landmark contemporary Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study. METHODS: Local Ethics Committee approval and informed consent was obtained from all participants. Inclusion criteria were participants, aged ≥20 and ≤85 years, from Nallampatti, a classical farming village from Tamil Nadu state, India. All participants were administered a detailed questionnaire, had anthropometric measurements including height, weight, and waist circumference. Bloods were drawn for random blood glucose, glycated hemoglobin (HbA1c), nonfasting lipid profile, Cystatin C, uric acid, and hemoglobin. All participants had carotid intima-media thickness (CIMT) done by high-resolution B-mode carotid ultrasound. RESULTS: More than 50% of the population had either diabetes or prediabetes based on HbA1c. Nearly, 40% of the population had hypertension with suboptimal control in those with known hypertension. Nearly, a third of the population had dyslipidemia, elevated cystatin C levels, and abnormal CIMT. The burden was higher than the comparable ICMR-INDIAB study in rural Tamil Nadu. CONCLUSION: One-third to one-half of this rural farming population is at risk of cardiovascular disease, with poor control of preexisting cardiovascular risk factors. Current Indian data may underestimate the risk in different ethnic populations and regions of India. Long-term follow-up of this cohort for the incident cardiovascular disease will shed light on the true cardiovascular risk in a typical South Indian rural farming population.

Dengue Outbreak 2012: Geo Mapping and Snapshot of Clinical Course from a Tertiary Referral Center in South India.

BACKGROUND: Using technology to track endemic areas of communicable diseases is possible nowadays. Effectual use of such facilities, especially in developing countries, will increase earlier detection of cases as well as aid in the formulation of effective prevention strategies. METHODS: A retrospective data analysis was carried out by collecting the details of patients presented with positive dengue serology, during the outbreak season in the second half of 2012, at Kovai Medical Center and Hospital, Coimbatore, India. Clinical variables were analysed statistically using SPSS 20 and geographical mapping of the cases was carried out using EPI INFO 7 software. RESULTS: 1004 dengue positive cases were identified during the study period. Geographical mapping of the case clusters showed specific areas in the city as well as neighbouring districts, which were an indirect evidence of the causative mosquito's endemic breeding places. Overall mortality noted in this group was 1.3% and mortality in cases with severe thrombocytopenia was 4 in 1000 cases. Severe thrombocytopenia (Plat≤ 10,000) on admission increased odds ratio for mortality i.e. around 10 times higher than the rest of the cohorts. CONCLUSIONS: Identification of endemic mosquito breeding places and implementation of proper preventive measures is always a crucial step in the prevention of further outbreaks. Effective registry using softwares by tertiary care hospitals will be obligatory to track the location of the cases as these hospitals are the nodal point of care for most of the cases in developing countries.

Impact of clinical pharmacist in an Indian Intensive Care Unit.

BACKGROUND AND OBJECTIVES: A critically ill patient is treated and reviewed by physicians from different specialties; hence, polypharmacy is a very common. This study was conducted to assess the impact and effectiveness of having a clinical pharmacist in an Indian Intensive Care Unit (ICU). It also evaluates the clinical pharmacist interventions with a focus on optimizing the quality of pharmacotherapy and patient safety. MATERIALS AND METHODS: The prospective, observational study was carried out in medical and surgical/trauma ICU over a period of 1 year. All detected drug-related problems and interventions were categorized based on the Pharmaceutical Care Network Europe system. RESULTS: During the study period, average monthly census of 1032 patients got treated in the ICUs. A total of 986 pharmaceutical interventions due to drug-related problems were documented, whereof medication errors accounted for 42.6% (n = 420), drug of choice problem 15.4% (n = 152), drug-drug interactions were 15.1% (n = 149), Y-site drug incompatibility was 13.7% (n = 135), drug dosing problems were 4.8% (n = 47), drug duplications reported were 4.6% (n = 45), and adverse drug reactions documented were 3.8% (n = 38). Drug dosing adjustment done by the clinical pharmacist included 140 (11.9%) renal dose, 62 (5.2%) hepatic dose, 17 (1.4%) pediatric dose, and 104 (8.8%) insulin dosing modifications. A total of 577 drug and poison information queries were answered by the clinical pharmacist. CONCLUSION: Clinical pharmacist as a part of multidisciplinary team in our study was associated with a substantially lower rate of adverse drug event caused by medication errors, drug interactions, and drug incompatibilities.

Framework for a National STEMI Program: consensus document developed by STEMI INDIA, Cardiological Society of India and Association Physicians of India.

The health care burden of ST elevation myocardial infarction (STEMI) in India is enormous. Yet, many patients with STEMI can seldom avail timely and evidence based reperfusion treatments. This gap in care is a result of financial barriers, limited healthcare infrastructure, poor knowledge and accessibility of acute medical services for a majority of the population. Addressing some of these issues, STEMI India, a not-for-profit organization, Cardiological Society of India (CSI) and Association Physicians of India (API) have developed a protocol of "systems of care" for efficient management of STEMI, with integrated networks of facilities. Leveraging newly-developed ambulance and emergency medical services, incorporating recent state insurance schemes for vulnerable populations to broaden access, and combining innovative, "state-of-the-art" information technology platforms with existing hospital infrastructure, are the crucial aspects of this system. A pilot program was successfully employed in the state of Tamilnadu. The purpose of this article is to describe the framework and methods associated with this programme with an aim to improve delivery of reperfusion therapy for STEMI in India. This programme can serve as model STEMI systems of care for other low-and-middle income countries.

Cranioplasty using presurgically fabricated presterilised polymethyl methacrylate plate by a simple, cost-effective technique on patients with and without original bone flap: study on 29 patients.

OBJECTIVES: The purpose of the study was to assess the clinical effectiveness of presurgically fabricated pre-sterilized polymethyl methacrylate (PMMA) plate as a cranioplasty material. MATERIALS AND METHODS: The study group consisted of 29 patients with skull defect following decompressive craniectomy. Some patients had their original bone flap preserved and some were without it. In either group pre-sterilized prefabricated PMMA plate was used. On each visit, patients were clinically assessed; CT scans were taken in immediate follow up period but if needed more films were taken in subsequent follow ups. Post-op complications that include infection, post-op hematoma, chronic pain, aesthetic, biocompatibility, post-op dimensional changes of prosthesis were evaluated. RESULTS: Mean follow up was 7 1/2 months. Five patients developed swelling and pain in the subsequent follow ups. One patient was treated conservatively with antibiotics. Tapping was performed in couple of patients. Surgical evacuation of hematoma was performed in one patient. Of the five infected plates, one demanded removal from the patient. One complained of chronic pain. Post-op follow up assessed clinically and by CT scan confirmed good aesthetic result, biocompatibility and dimensional stability of prosthesis. CONCLUSION: The result of this study support the view that the use of prefabricated pre-sterilized PMMA plate as cranioplasty material is a simple, reliable, convenient way that brings acceptable function and aesthetics to patients who underwent decompressive craniectomy, in an inexpensive way.

Protocol for a prospective, controlled study of assertive and timely reperfusion for patients with ST-segment elevation myocardial infarction in Tamil Nadu: the TN-STEMI programme.

INTRODUCTION: Over the past two decades, India has witnessed a staggering increase in the incidence and mortality of ST-elevation myocardial infarction (STEMI). Indians have higher rates of STEMI and younger populations that suffer from it when compared with developed countries. Yet, the recommended reperfusion therapy with fibrinolysis and percutaneous coronary intervention is available only to a minority of patients. This gap in care is a result of financial barriers, limited healthcare infrastructure and poor knowledge and accessibility of acute medical services for a majority of its population. METHODS AND ANALYSIS: This is a prospective, multicentre, 'pretest/post-test' quasi-experimental, community-based study. This programme will use a 'hub-and-spoke' model of an integrated healthcare network based on clusters of primary-care health clinics, small hospitals and large tertiary-care facilities. It is an 'all-comers' study which will enrol consecutive patients presenting with STEMI to the participating hospitals. The primary objectives of the study is to improve the use of reperfusion therapy and reduce the time from first medical contact to device or drug in STEMI patients; and to increase the rates of early invasive risk stratification with coronary angiography within 3-24 h of fibrinolytic therapy in eligible patients through changes in process of care. Outcomes will be measured with statistical comparison made before and after implementing the TN-STEMI programme. The estimated sample size is based on the Kovai Erode Pilot study, which provided an initial work on establishing this type of programme in South India. It will be adequately powered at 80% with a superiority margin of 10% if 36 patients are enrolled per cluster or 108 patients in three clusters. Thus, the enrolment period of 9 months will result in a sample size of 1500 patients. ETHICS: This study will be conducted in accordance with the ethical principles that have their origin in the current Declaration of Helsinki and 'ethical guidelines for biomedical research on human participants' as laid down by the Indian Council for Medical Research. All participating hospitals will still obtain local ethics committee approval of the study protocol and written informed consent will be obtained from all participants. DISSEMINATION AND RESULTS: Our findings will be reported through scientific publications, research conferences and public policy venues aimed at state and local governments in India. If successful, this model can be extended to other areas of India as well as serve as a model of STEMI systems of care for low-income and middle-income countries across the world. REGISTRATION: Trial is registered with Clinical trial registry of India, No: CTRI/2012/09/003002.