Publications by authors named "Lakshmanan Jeyaseelan"

85 Publications

Impact of exclusive breast feeding until six months of age on common illnesses: A prospective observational study.

J Family Med Prim Care 2022 Apr 18;11(4):1482-1488. Epub 2022 Mar 18.

Department of Paediatrics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.

Objectives: The WHO recommends exclusive breast feeding (EBF) for all infants for the first six months of life. National Family Health Survey-4 (2015-16) shows EBF rates of only 54.9%. We conducted a prospective study to assess prevalence of EBF and incidences of illnesses in infants from birth till six months of age.

Methods: Healthy term infants born in our hospital between December 2017 and November 2018 were recruited at birth. Structured diary cards were given to mothers to record feeding patterns, occurrence and severity of illnesses. Mothers were interviewed at 6, 10, 14 and 26 weeks or contacted by telephone at 18 and 22 weeks. Data were analyzed using SPSS IBM Statistics 22.

Results: The prevalence of EBF among 450 infants (M:F = 1.3:1) who completed the study was 47% at 6 months. 185 (69 EBF + 116 non-EBF) of 450 infants reported a total of 242 illnesses, most commonly respiratory (82.6%) followed by gastrointestinal (11.6%). Number of illnesses per infant was 0.45 and 0.6 in EBF group and non-EBF group respectively (p = 0.015). Illness incidences in EBF infants were significantly lower during all successive time intervals after 10 weeks of age. Logistic regression analysis confirmed significantly lower illness incidences in EBF infants at 10-14 weeks [OR = 0.27 (CI 0.12-0.64)] and 18-22 weeks [OR = 0.50 (CI 0.27-0.90)].

Conclusions: The prevalence of EBF is suboptimal in our setting, with illness incidences significantly higher in non-EBF children. Appropriate intervention strategies need to be tailored to reinforce early initiation and continuation of EBF throughout the first six months of life.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_1423_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9067194PMC
April 2022

The clinical demand and supply of blood in India: A National level estimation study.

PLoS One 2022 6;17(4):e0265951. Epub 2022 Apr 6.

National AIDS Control Organization (NACO), Janpath, New Delhi, India.

Background: Estimating the clinical demand for blood and components arising in a health facility is crucial to ensure timely availability of blood. This study aims to estimate disease-specific clinical demand, supply and utilization of whole blood and components in India.

Methods: We conducted a national level cross-sectional study in five randomly selected states from five regions of the country. We included 251 public and private facilities representing primary, secondary and tertiary care facilities. We collected annual disease-specific demand, supply and utilization of blood and components using a structured tool. We estimated the national demand by extrapolating the study data (demand and beds) to the total number of estimated beds in the country.

Findings: According to the study, the total clinical demand of 251 health facilities with 51,562 beds was 474,627 whole blood units. Based on this, the clinical demand for India was estimated at 14·6 million whole blood units (95 CI: 14·59-14·62), an equivalent of 36·3 donations per 1,000 eligible populations, which will address whole blood and component requirement. The medicine specialty accounted for 6·0 million units (41·2%), followed by surgery 4·1 million (27·9%), obstetrics and gynecology 3·3 million (22·4%) and pediatrics 1·2 million (8·5%) units. The supply was 93% which is equivalent to 33·8 donations against the demand.

Conclusion: The study indicated a demand and supply gap of 2.5 donations per 1,000 eligible persons which is around one million units. The gap emphasises the need for sustained and concerted efforts from all stakeholders and for increasing the awareness about repeat voluntary non-remunerated blood donation (VNRBD); optimizing the availability of blood components through efficient blood component separation units; promoting modern principles of patient blood management and strengthening capacities of human resources in the blood transfusion system in India.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0265951PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8986005PMC
April 2022

Sleep Quality and Emotional State of Medical Students in Dubai.

Sleep Disord 2022 14;2022:8187547. Epub 2022 Feb 14.

College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE.

Poor sleep quality has been reported to be common amongst medical students and healthcare professionals worldwide. Sleep disturbance has been associated with increased rates of burnout and depression. As a result, this has been negatively impacting performance and functioning. Research on this topic is limited in the United Arab Emirates (UAE). This study is aimed at exploring sleep pattern and the emotional state of medical and dental students in Dubai, UAE. This cross-sectional study was based on an electronic survey sent to 181 medical and dental students. Of the 181 invitations, 96 individuals agreed to participate and complete the rating scales. The Pittsburgh Sleep Quality Index was utilized to explore sleep duration, quality, and daytime functioning. The Positive and Negative Affect Scale was used to assess the emotional states of the participants. Overall, the findings revealed diminished sleep duration. The average duration of sleep amongst the study participants was 5 hours and 24 minutes, which is significantly below the recommended duration as per sleep guidelines. Results also showed a significant positive correlation between total sleep duration and overall sleep quality with enthusiasm during the day. Future research designed to explore factors contributing to sleep efficiency, in more depth, as well as strategies to enhance sleep quality is highly warranted.
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http://dx.doi.org/10.1155/2022/8187547DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8860528PMC
February 2022

Breast milk contains red cell isohaemagglutinins: An observational study of 176 mothers.

Vox Sang 2022 Jun 26;117(6):847-852. Epub 2022 Jan 26.

Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, India.

Background And Objectives: Maternal antibodies are transferred to the child, predominantly IgG, via the transplacental route, and mostly IgA through breast milk. Cases reported by us and others have shown the transfer of red cell allo-antibodies through breast milk. This study was conducted to assess the presence of isohaemagglutinins in breast milk, the range of titres, and the correlation between breast milk and maternal plasma titres.

Materials And Methods: A total of 176 mothers were recruited in this study. Breast milk was collected after sufficient feeding was established and within 2-5 days of delivery in a sterile container without any anticoagulant. Antibody screen, identification and titres were performed on maternal plasma as well as breast milk.

Results: Anti-A and anti-B in breast milk corresponding to their respective maternal blood groups were found in all the samples. This study has shown titres in the breast milk of anti-A and anti-B ranging from 2 to 1024 in both saline and Coombs phases. There was no association between plasma and breast milk titres, thus making it impossible to predict which mother may potentially transfer a larger amount of these haemagglutinins. Isotypes of anti-A and anti-B were evaluated in both plasma and breast milk of 11 samples, which showed predominantly IgG in 7 (63.63%) and predominantly IgA in 4 (36.36%) samples.

Conclusion: Our study demonstrates the presence of a wide range of titres for IgG antibodies of the ABO blood group system in breast milk. The clinical impact of this finding needs to be studied further, as it assumes great relevance in developing countries where anaemia continues to challenge young infants.
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http://dx.doi.org/10.1111/vox.13253DOI Listing
June 2022

Knee meniscal retears after repair: A systematic review comparing diagnostic imaging modalities.

Libyan J Med 2022 Dec;17(1):2030024

College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates.

The meniscus is a relatively avascular fibrocartilaginous structure that provides a key role in shock absorption and load transmission. However, accurate diagnosis of meniscal retear can present a clinical challenge. The purpose of this study was to conduct a systematic review on the available literature, which compare the sensitivities, specificities, and accuracies of different diagnostic modalities of diagnosing knee meniscal retears in patients who have undergone surgical meniscal repair, such as Magnetic Resonance Imaging (MRI), Magnetic Resonance Arthrography with intraarticular contrast (direct MRA), and a combination of MRI and direct MRA. Two authors independently searched two databases (PubMed and Scopus) for literature related to knee meniscus retear according to the PRISMA guidelines. Four studies were found, which resulted in 291 patients with 293 menisci. All studies were published in 2008 and 2014. In our analysis, we calculated sensitivity to be 78.79% (95% CI, 64.07-93.51), specificity to be 56.58% (95% CI, 20.21-92.94), and overall accuracy to be 66.25% (95% CI, 54.29-78.22) for MRI and sensitivity to be 87.84% (95% CI, 83.93-91.74), specificity to be 88.68% (95% CI, 81.93-95.43), and overall accuracy to be 87.22% (95% CI, 82.22-91.62) for direct MRA. We recommend the use of direct MRA for the diagnosis of meniscal retears due to its higher sensitivity, specificity, and accuracy as compared to MRI and its reduced cost and invasive nature as compared to second-look arthroscopy. However, our review is limited by the number of studies available on this topic. More studies using study designs such as randomized controlled trials, involving MRI, direct MRA, and combinations of such techniques, should be performed to accurately assess the different techniques and aid in designing guidelines to guide the diagnosis of meniscal retears following meniscal repair.
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http://dx.doi.org/10.1080/19932820.2022.2030024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8786236PMC
December 2022

Noninvasive Ventilation in the Management of Respiratory Failure Due to COVID-19 Infection: Experience From a Resource-Limited Setting.

Mayo Clin Proc 2022 01 13;97(1):31-45. Epub 2021 Oct 13.

Medical Intensive Care Unit, Christian Medical College, Vellore, India.

Objective: To study the role of noninvasive ventilation (NIV) in Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV2) related acute respiratory failure (C-ARF).

Patients And Methods: Patients with C-ARF managed on NIV were categorized as NIV success or failure (death or intubation). Factors associated with failure were explored using regression analysis and expressed as odds ratio (OR) with 95% CI.

Results: Between April 1, 2020, and September 15, 2020, a total of 286 patients with a mean ± SD age of 53.1±11.6 years and Acute Physiology and Chronic Health Evaluation II score of 11.1±5.5 were initiated on NIV. Of the 182 patients (63.6%) successfully managed on NIV alone, 118 had moderate or severe acute respiratory distress syndrome. When compared with NIV success, NIV failure was associated with lower admission PaO to fraction of inspired oxygen ratio (P<.001) and higher respiratory rate (P<.001). On penalized logistic regression analysis, NIV failure was associated with higher Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.01 to 1.24), severe acute respiratory distress syndrome (OR, 3.99; 95% CI, 1.24 to 12.9), D-dimer level of 1000 ng/mL DDU (to convert to mg/L, divide by 1000) or greater (OR, 2.60; 95% CI, 1.16 to 5.87), need for inotropes or dialysis (OR, 12.7; 95% CI, 4.3 to 37.7), and nosocomial infections (OR, 13.6; 95% CI, 4.06 to 45.9). Overall mortality was 30.1% (86/286). In patients requiring intubation, time to intubation was longer in nonsurvivors than survivors (median, 5; interquartile range, 3-8 vs 3; interquartile range, 2-3 days; P<.001).

Conclusion: Noninvasive ventilation can be used successfully in C-ARF. Illness severity and need for non-respiratory organ support predict NIV failure.
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http://dx.doi.org/10.1016/j.mayocp.2021.10.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511655PMC
January 2022

Prolonged corrected QT interval in hospitalized patients with coronavirus disease 2019 in Dubai, United Arab Emirates: a single-center, retrospective study.

J Int Med Res 2021 Nov;49(11):3000605211056834

Rashid Hospital, Dubai, U.A.E.

Objective: To evaluate the association of a prolonged corrected QT (QTc) interval in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its association with in-patient mortality.

Methods: A cohort of 745 patients were recruited from a single center between 1 March 2020 and 31 May 2020. We analyzed the factors associated with a prolonged QTc and mortality.

Results: A prolonged QTc interval >450 ms was found in 27% of patients admitted with SARS-CoV-2 infection. These patients were predominantly older, on a ventilator, and had hypertension, diabetes mellitus, or ischemic heart disease. They also had high troponin and D-dimer concentrations. A prolonged QTc interval had a significant association with the requirement of ventilator support and was associated with an increased odds of mortality. Patients who died were older than 55 years, and had high troponin, D-dimer, creatinine, procalcitonin, and ferritin concentrations, a high white blood cell count, and abnormal potassium concentrations (hypo- or hyperkalemia).

Conclusions: A prolonged QTc interval is common in patients with SARS-CoV-2 infection and it is associated with worse outcomes. Older individuals and those with comorbidities should have an electrocardiogram performed, which is noninvasive and easily available, on admission to hospital to identify high-risk patients.
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http://dx.doi.org/10.1177/03000605211056834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8647239PMC
November 2021

Utility of oral glucose tolerance test in predicting type 2 diabetes following gestational diabetes: Towards personalized care.

World J Diabetes 2021 Oct;12(10):1778-1788

Department of Endocrinology, Dubai Health Authority, Dubai 123, United Arab Emirates.

Background: Women with gestational diabetes mellitus (GDM) are at a seven-fold higher risk of developing type 2 diabetes (T2D) within 7-10 years after childbirth, compared with those with normoglycemic pregnancy. Although raised fasting blood glucose (FBG) levels has been said to be the main significant predictor of postpartum progression to T2D, it is difficult to predict who among the women with GDM would develop T2D. Therefore, we conducted a cross-sectional retrospective study to examine the glycemic indices that can predict postnatal T2D in Emirati Arab women with a history of GDM.

Aim: To assess how oral glucose tolerance test (OGTT) can identify the distinct GDM pathophysiology and predict possible distinct postnatal T2D subtypes.

Methods: The glycemic status of a cohort of 4603 pregnant Emirati Arab women, who delivered in 2007 at both Latifa Women and Children Hospital and at Dubai Hospital, United Arab Emirates, was assessed retrospectively, using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. Of the total, 1231 women were followed up and assessed in 2016. The FBG and/or the 2-h blood glucose (2hrBG) levels after a 75-g glucose load were measured to assess the prevalence of GDM and T2D, according to the IADPSG and American Diabetes Association (ADA) criteria, respectively. The receiver operating characteristic curve for the OGTT was plotted and sensitivity, specificity, and predictive values of FBG and 2hrBG for T2D were determined.

Results: Considering both FBG and 2hrBG levels, according to the IADPSG criteria, the prevalence of GDM in pregnant Emirati women in 2007 was 1057/4603 (23%), while the prevalence of pre-pregnancy T2D among them, based on ADA criteria, was 230/4603 (5%). In the subset of women ( = 1231) followed up in 2016, the prevalence of GDM in 2007 was 362/1231 (29.6%), while the prevalence of pre-pregnancy T2D was 36/1231 (2.9%). Of the 362 pregnant women with GDM in 2007, 96/362 (26.5%) developed T2D; 142/362 (39.2%) developed impaired fasting glucose; 29/362 (8.0%) developed impaired glucose tolerance, and the remaining 95/362 (26.2%) had normal glycemia in 2016. The prevalence of T2D, based on ADA criteria, stemmed from the prevalence of 36/1231 (2.9%) in 2007 to 141/1231 (11.5%), in 2016. The positive predictive value (PPV) for FBG suggests that if a woman tested positive for GDM in 2007, the probability of developing T2D in 2016 was approximately 24%. The opposite was observed when 2hrBG was used for diagnosis. The PPV value for 2hrBG suggests that if a woman was positive for GDM in 2007 then the probability of developing T2D in 2016 was only 3%.

Conclusion: FBG and 2hrBG could predict postpartum T2D, following antenatal GDM. However, each test reflects different pathophysiology and possible T2D subtype and could be matched with a relevant T2D prevention program.
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http://dx.doi.org/10.4239/wjd.v12.i10.1778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8554365PMC
October 2021

Rezum Therapy for Benign Prostatic Hyperplasia: Dubai's Initial Experience.

Cureus 2021 Sep 18;13(9):e18083. Epub 2021 Sep 18.

Urology, Mohammed Bin Rashid University of Health and Medical Sciences, Dubai, ARE.

Introduction Symptomatic benign prostatic hyperplasia (BPH) is a condition that affects middle-aged men, leading to a decreased quality of life secondary to symptoms of difficult urination, urinary frequency, urgency and nocturia. The treatment modalities of this pathology include pharmacologic and invasive interventions, both of which vary in effectiveness and they come with a myriad of side effects. Recent advancements have allowed for the development of Rezum, a minimally invasive and effective approach to treating BPH while maintaining a good safety profile with comparable outcomes to other treatment modalities. Methods We retrospectively identified 49 patients with symptomatic BPH who underwent Rezum therapy in one center in Dubai, the United Arab Emirates between January and December 2020. We assessed several parameters related to their condition including prostate volume, pre-operative and post-operative post-void residual (PVR) and peak urinary flow (Qmax) number of treatments given, trial without catheter and mean date of follow-up. Safety and side effects were also assessed. Result Our sample included symptomatic men with a mean age of 64 (10) who had a mean follow-up time of three months (IQR 2-5.2), median prostatic volume of 58 cc (IQR 44-82) and a mean of (SD 33.9). The initial Qmax and PVR were 7.3 ml/s (IQR 5.5-10.3) and 80.4 cm(IQR 43.4-120.0) respectively, and post-operative Qmax and PVR were 16.3 ml/s (SD 5.7) and 20.7 cm (IQR 16.2-28.2). Post-operatively, we observed a significant increase in Qmax of 8.11 ml/s (p=0.001) post-operatively, a mean decrease of 94.32 cm (p=0.001) in PVR. The favorable outcome parameters in Qmax and PVR demonstrate the efficacy of this procedure. We have also noted that the change in Qmax and PVR does not vary by initial prostate volume. Conclusion In this report, we aimed to highlight the benefit, efficacy and safety of offering Rezum to patients with symptomatic BPH in a single center in Dubai, reporting on the first United Arab Emirates experience with this novel procedure. This procedure confers the benefit of being minimally invasive, safe and effective, and with lower rates of sexual dysfunction compared to medical therapy or trans-urethral resection of the prostate (TURP). It is associated with similar outcomes to TURP, and an improvement in quality of life, while carrying a low-risk profile. Our experience corresponds with the available literature regarding the efficacy and satisfaction rates of Rezum for BPH patients. We hope that results from this study encourage further investigation into the long-term implications of Rezum, up to five years post-operatively.
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http://dx.doi.org/10.7759/cureus.18083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8523475PMC
September 2021

Factors associated with mortality among moderate and severe patients with COVID-19 in India: a secondary analysis of a randomised controlled trial.

BMJ Open 2021 10 4;11(10):e050571. Epub 2021 Oct 4.

Infectious Diseases, Kasturba Hospital for Infectious Diseases, Mumbai, Maharashtra, India.

Objective: Large data on the clinical characteristics and outcome of COVID-19 in the Indian population are scarce. We analysed the factors associated with mortality in a cohort of moderately and severely ill patients with COVID-19 enrolled in a randomised trial on convalescent plasma.

Design: Secondary analysis of data from a Phase II, Open Label, Randomized Controlled Trial to Assess the Safety and Efficacy of Convalescent Plasma to Limit COVID-19 Associated Complications in Moderate Disease.

Setting: 39 public and private hospitals across India during the study period from 22 April to 14 July 2020.

Participants: Of the 464 patients recruited, two were lost to follow-up, nine withdrew consent and two patients did not receive the intervention after randomisation. The cohort of 451 participants with known outcome at 28 days was analysed.

Primary Outcome Measure: Factors associated with all-cause mortality at 28 days after enrolment.

Results: The mean (SD) age was 51±12.4 years; 76.7% were males. Admission Sequential Organ Failure Assessment score was 2.4±1.1. Non-invasive ventilation, invasive ventilation and vasopressor therapy were required in 98.9%, 8.4% and 4.0%, respectively. The 28-day mortality was 14.4%. Median time from symptom onset to hospital admission was similar in survivors (4 days; IQR 3-7) and non-survivors (4 days; IQR 3-6). Patients with two or more comorbidities had 2.25 (95% CI 1.18 to 4.29, p=0.014) times risk of death. When compared with survivors, admission interleukin-6 levels were higher (p<0.001) in non-survivors and increased further on day 3. On multivariable Fine and Gray model, severity of illness (subdistribution HR 1.22, 95% CI 1.11 to 1.35, p<0.001), PaO/FiO ratio <100 (3.47, 1.64-7.37, p=0.001), neutrophil lymphocyte ratio >10 (9.97, 3.65-27.13, p<0.001), D-dimer >1.0 mg/L (2.50, 1.14-5.48, p=0.022), ferritin ≥500 ng/mL (2.67, 1.44-4.96, p=0.002) and lactate dehydrogenase ≥450 IU/L (2.96, 1.60-5.45, p=0.001) were significantly associated with death.

Conclusion: In this cohort of moderately and severely ill patients with COVID-19, severity of illness, underlying comorbidities and elevated levels of inflammatory markers were significantly associated with death.

Trial Registration Number: CTRI/2020/04/024775.
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http://dx.doi.org/10.1136/bmjopen-2021-050571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8491003PMC
October 2021

Predicting antitubercular drug-induced liver injury and its outcome and introducing a novel scoring system.

Int J Mycobacteriol 2021 Apr-Jun;10(2):116-121

Department of Internal Medicine, Christian Medical College, Vellore, Tamil Nadu, India.

Background: Tuberculosis (TB) is a major global health problem, mainly in developing countries. Despite the availability of highly effective first-line antitubercular (ATT) drugs, ATT drug-induced liver injury (ATT DILI) leads to treatment interruption and consequently loss of therapeutic efficacy.

Methods: In this prospective cohort study from India, all consecutive patients who met inclusion criteria and started on ATT were included. The incidence, risk factors, and outcome of ATT DILI were determined. A clinical prediction score for ATT DILI was derived.

Results: A total of 393 patients were included. The incidence of ATT DILI was 9.7% (95% confidence interval 7%-13.2%). HIV infection, daily regimen, disseminated disease, and chronic liver disease were identified as significant risk factors (P < 0.05) for developing DILI. A prediction score derived from the risk factors showed that a score of >5 could predict DILI with a sensitivity of 74% and a specificity of 67%. All-cause mortality in DILI was 4.7%.

Conclusion: The incidence of ATT DILI was 9.7% in our cohort with higher incidence among the patients on daily regimen. The study suggests that the combination of risk factors of extensive TB disease, HIV infection, chronic liver disease, and under nutrition increases the vulnerability to DILI, particularly with daily treatment regimen, emphasizing the role of acquired risk factors in the development of DILI.
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http://dx.doi.org/10.4103/ijmy.ijmy_15_21DOI Listing
October 2021

Rodenticide ingestion is an important cause of acute hepatotoxicity in Tamil Nadu, southern India.

Indian J Gastroenterol 2021 Aug 30;40(4):373-379. Epub 2021 Jun 30.

Department of Hepatology and Transplant Hepatology, Gleneagles Global Health City Hospital, Chennai, 600 100, India.

Background And Aim: Though rodenticidal hepatotoxicity is reported from India, there is no systematic study to assess its magnitude. This study aimed to assess exposure to rodenticide as a risk factor for acute hepatotoxicity in Tamil Nadu, India.

Methods: We retrospectively analyzed acute hepatotoxicity caused by ingestion of hepatotoxin or potentially hepatotoxic drug overdose across 15 hospitals in 6 districts of Tamil Nadu from 1 January 2019 to 30 June 2019. Study exclusion criteria were idiosyncratic drug-induced liver injury and chronic liver diseases.

Results: Of the 702 patients, 685 gave history of consuming rodenticide; hepatotoxicity in the other patients resulted from paracetamol overdose (n=10) and due to other drugs (n=7); 97% patients had a suicidal intent. Of 671 patients with complete data, ratio of number of patients with hepatotoxicity due to rodenticide to paracetamol overdose was 450:6 (i.e. 75:1). The 451 rodenticidal hepatotoxicity patients (255 males, 75% were 15-34 years old) underwent conservative management (n=396), plasma exchange (n=54) and plasma exchange followed by liver transplant (n=1); 159 patients (35%) had poor outcome (131 died, 28 discharged in moribund state). Based on our observations, we estimate a case burden of 1584 rodenticidal hepatotoxicity patients (95% CI: 265-6119) with poor outcome in 554 patients in Tamil Nadu from January 2019 to June 2019. Population attributable risk for rodenticide as cause of hepatotoxicity was 22.7%.

Conclusion: Rodenticide ingestion was an important cause of acute hepatotoxicity in Tamil Nadu. Most patients were young and one-third had poor outcome. Public health interventions are needed to address this.
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http://dx.doi.org/10.1007/s12664-021-01178-4DOI Listing
August 2021

The prevalence, severity, and risk factors for dry eye disease in Dubai - a cross sectional study.

BMC Ophthalmol 2021 May 17;21(1):219. Epub 2021 May 17.

College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE.

Background: The prevalence of dry eye disease is increasing globally and requires the attention of healthcare professionals as it worsens patients' quality of life. No published studies on the epidemiology of dry eyes have been found in Dubai.

Purpose: To describe the epidemiology, prevalence, severity, and associated factors of dry eyes in Dubai, United Arab Emirates, in 2019.

Methods: This was an analytical, cross-sectional, survey-based study. An online survey was distributed by email to Mohammed Bin Rashid University students, staff, and faculty and to the staff at Mediclinic City and Parkview Hospitals in Dubai, United Arab Emirates, from April-June 2019. The survey included demographic questions and the Ocular Surface Disease Index (OSDI).

Results: The survey was completed by 452 participants; the majority were females (288/452; 63.7 %). The prevalence of dry eyes in Dubai was estimated to be 62.6 % (283/452), with severely dry eyes being the most prevalent (119/283; 42 %). Females, high daily screen time (> 6 h), and the use of contact lenses were found to be associated with dry eyes (P-value < 0.05, 95 % confidence interval). Age was found to be negatively correlated with prevalence of dry eyes. Exposure to smoking/shisha, history of eye injury/surgery, and nationality were not associated with dry eyes.

Conclusions: This is the first cross-sectional study to investigate the prevalence of dry eyes in Dubai (62.6 %). The majority of participants had severe dry eyes symptoms. Severely dry eyes were more common among females and users of contact lenses.
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http://dx.doi.org/10.1186/s12886-021-01978-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8127306PMC
May 2021

A national level estimation of population need for blood in India.

Transfusion 2021 06 15;61(6):1809-1821. Epub 2021 May 15.

National AIDS Control Organization (NACO), New Delhi, India.

Background: The population need for blood is the total volume required to transfuse all the individuals who need transfusion in a defined population over a defined period. The clinical demand will arise when people with a disease or condition who require transfusion, access healthcare services, and subsequently the clinicians request blood. Essentially, the conversion of need to demand must be maximum to avoid preventable mortality and morbidity. The study estimated the population need for blood in India.

Methods: The methodology included a comprehensive literature review to determine the diseases and conditions requiring transfusion, the population at risk, and prevalence or incidence; and Delphi method to estimate the percentage of people requiring transfusion, and the quantum.

Results: The estimated annual population need was 26.2 million units (95% CI; 17.9-38.0) of whole blood to address the need for red cells and other components after the separation process. The need for medical conditions was 11.0 million units (95% CI:8.7-14.7), followed by surgery 6.6 million (95% CI:3.8-10.0), pediatrics 5.0 million (95% CI:3.5-7.0), and obstetrics and gynecology 3.6 million units (95% CI:1.9-6.2). The gap between need and demand which depends upon the access and efficiency of healthcare service provision was estimated at 13 million units.

Conclusion: The study brings evidence to highlight the gap between need and demand and the importance of addressing it. It cannot be just the responsibility of blood transfusion or health systems, it requires a multi-sectoral approach to address the barriers affecting the conversion of need to clinical demand for blood.
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http://dx.doi.org/10.1111/trf.16369DOI Listing
June 2021

Diagnostic accuracy of urinary aquaporin-1 as a biomarker for renal cell carcinoma.

Indian J Urol 2021 Jan-Mar;37(1):59-64. Epub 2021 Jan 1.

Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.

Introduction: Optimal patient selection plays a vital role in management of renal tumors with the introduction of nephron-sparing approaches and active surveillance. A reliable and accurate diagnostic biomarker will be a useful adjunct to decision-making. We studied the diagnostic accuracy of urinary aquaporin-1 (uAQP-1), an upcoming urinary biomarker, for renal cell carcinoma.

Materials And Methods: In this prospective biomarker study, urine samples were obtained preoperatively from 36 patients with an imaged renal mass suggestive of RCC and 24 healthy age-matched controls, chosen from among voluntary kidney donors. uAQP-1 concentrations were estimated with a sensitive and specific enzyme-linked immunosorbent assay (ELISA) and normalized by estimation of urinary creatinine. The Mann-Whitney U-test was used to compare differences between any two groups. A receiver operator characteristic (ROC) curve was plotted to analyze the diagnostic accuracy of uAQP-1 for RCC.

Results: The median uAQP-1 concentration among the cases and controls was 8.78 ng/mg creatinine (interquartile range [IQR]: 5.56-12.67) and 9.52 ng/mg creatinine (IQR: 5.55-12.45), respectively. There was no significant difference in uAQP-1 concentrations between the two groups. ROC analysis showed that, for a cutoff value of 8 ng/mg creatinine, the sensitivity and specificity of uAQP-1 as a diagnostic test were 47.2% and 66.7%, respectively, and area under the curve was 0.52 (95% confidence interval: 0.42-0.62).

Conclusions: uAQP-1 concentrations did not discriminate between healthy individuals and patients with RCC. The results of this study suggest that uAQP-1 may not be a suitable diagnostic biomarker for RCC in the study population.
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http://dx.doi.org/10.4103/iju.IJU_330_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8033244PMC
January 2021

The Role of Frozen Section in the Rapid Diagnosis of Severe Cutaneous Adverse Drug Reactions.

Indian Dermatol Online J 2021 Jan-Feb;12(1):78-83. Epub 2021 Jan 16.

Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India.

Context: Early diagnosis is the mainstay in the management of severe cutaneous adverse reactions (SCARs) to drugs.

Aims: To study the role of frozen section in the rapid diagnosis of SCARs and the impact on outcome of the affected patients.

Settings And Design: A single-blind, hospital-based study was conducted from December 2014-July 2016.

Methods And Material: We biopsied 32 adults with SCARs diagnosed by clinical features and standard criteria. The histopathological features seen on frozen sections were compared to that of paraffin blocks. The impact of rapid diagnosis on the clinical outcome was studied in toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), drug rash with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP).

Statistical Analysis: Z test was used to compare two proportions. Kappa statistic, sensitivity, specificity, positive predictive value, and negative predictive value of the frozen section diagnosis were calculated in TEN/SJS and DRESS using MedCalc software.

Results: Frozen and paraffin sections were done in TEN/SJS spectrum (13), DRESS (17), and AGEP (2). The sensitivity, specificity and kappa values for frozen section diagnosis in SJS/TEN and DRESS were 91.7%, 95%, 0.867 and 94.4%, 100%, 0.937 respectively. The concordance between frozen and paraffin section diagnosis was 100% in TEN, SJS, DRESS and AGEP. All the 6 patients with TEN and 2 with AGEP survived. Taking the worst-case scenario, the mortality in SJS was 28.6%. The mortality among patients with DRESS was 11.8%.

Conclusions: Frozen section helps in the rapid diagnosis and early treatment of SCARs and differentiates it from diseases that mimic it.
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http://dx.doi.org/10.4103/idoj.IDOJ_397_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982049PMC
January 2021

Combination of obesity and co-morbidities leads to unfavorable outcomes in COVID-19 patients.

Saudi J Biol Sci 2021 Feb 3;28(2):1445-1450. Epub 2020 Dec 3.

Ministry of Health and Prevention (MOHAP), Dubai, United Arab Emirates.

Objective: Obesity has been described as a significant independent risk factors of COVID-19. We aimed to study the association between obesity, co-morbidities and clinical outcomes of COVID-19.

Methods: Clinical data from 417 patients were collected retrospectively from the Al Kuwait Hospital, Ministry of Health and Prevention (MOHAP), Dubai, United Arab Emirates, who were admitted between March and June 2020. Patients were divided according to their body mass index (BMI). Various clinical outcomes were examined: presenting symptoms, severity, major co-morbidities, ICU admission, death, ventilation, ARDS, septic shock and laboratory parameters.

Results: The average BMI was 29 ± 6.2 kg/m. BMI alone was not associated with the outcomes examined. However, class II obese patients had more co-morbidities compared to other groups. Hypertension was the most significant co-morbidity associated with obesity. Patients with BMI above the average BMI (29 kg/m) and presence of underlying co-morbidities showed significant increase in admission to ICU compared to patients below 29 kg/m and underlying co-morbidities (21.7% Vs. 9.2%), ARDS development (21.7% Vs. 10.53%), need for ventilation (8.3% Vs. 1.3%), and mortality (10% Vs. 1.3%).

Conclusions: Our data suggests that presence of underlying co-morbidities and high BMI work synergistically to affect the clinical outcomes of COVID-19.
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http://dx.doi.org/10.1016/j.sjbs.2020.11.081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713568PMC
February 2021

Cerebral Venous Thrombosis, Seasonal Trends, and Climatic Influence: A Region-SpecificStudy.

Ann Indian Acad Neurol 2020 Jul-Aug;23(4):522-527. Epub 2019 Jul 11.

Department of Neurology, Christian Medical College Hospital, Vellore, Tamil Nadu, India.

Background And Purpose: Studies looking at seasonal variation on cerebral venous thrombosis (CVT) are few with conflicting conclusions. In this region-specific study, we looked for climatic influence and seasonal trends on the incidence of CVT.

Methods: Imaging proven adult CVT cases treated over a period of 18 years from a specific geographical location with similar seasons and climatic conditions were studied. Metrological parameters prepared using 30 years of data was used. Quantum geographical information system (QGIS software) and SPSS v 22 were used for patient plotting and analysis.

Results: Total of 970 cases were studied. The incidence was significantly higher in summer 411 (42.3%) compared with autumn 317 (32.7%) and winter 242 (25.05); = 0.038. This trend was consistent across all the 18 years in time series analysis. Mean age was 33.5 years (range 18-88 years). A significant majority 673 (69.4%) were below 40 years of age; = 0.012. Females constituted 394 (40.6%) of cases. Postpartum CVT cases constituted 237 (30%). Interaction analysis showed younger age (<40 years) were more vulnerable for CVT in summer; = 0.009. There was no seasonal influence on postpartum CVT. Apart for a weak positive correlation between rain fall ( = 0.18, < 0.01); humidity and cloud cover was not influencing the incidence.

Conclusions: Higher ambient temperatures were consistently associated with higher incidence of CVT. This is the largest region-specific study on CVT in the world. These results may be applicable to other regions with similar climatic conditions.
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http://dx.doi.org/10.4103/aian.AIAN_409_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657288PMC
July 2019

Management of relapse in acute promyelocytic leukaemia treated with up-front arsenic trioxide-based regimens.

Br J Haematol 2021 01 20;192(2):292-299. Epub 2020 Nov 20.

Department of Haematology, Christian Medical College, Vellore, India.

The standard of care for patients with acute promyelocytic leukaemia (APL) relapsing after front-line treatment with arsenic trioxide (ATO)-based regimens remains to be defined. A total of 67 patients who relapsed after receiving ATO-based up-front therapy and were also salvaged using an ATO-based regimen were evaluated. The median (range) age of patients was 28 (4-54) years. While 63/67 (94%) achieved a second molecular remission (MR) after salvage therapy, three (4·5%) died during salvage therapy. An autologous stem cell transplant (auto-SCT) was offered to all patients who achieved MR, 35/63 (55·6%) opted for auto-SCT the rest were administered an ATO + all-trans retinoic acid maintenance regimen. The mean (SD) 5-year Kaplan-Meier estimate of overall survival and event-free survival of those who received auto-SCT versus those who did not was 90·3 (5·3)% versus 58·6 (10·4)% (P = 0·004), and 87·1 (6·0)% versus 47·7 (10·3)% (P = 0·001) respectively. On multivariate analysis, failure to consolidate MR with an auto-SCT was associated with a significantly increased risk of relapse [hazard ratio (HR) 4·91, 95% confidence interval (CI) 1·56-15·41; P = 0·006]. MR induction with ATO-based regimens followed by an auto-SCT in children and young adults with relapsed APL who were treated with front-line ATO-based regimens was associated with excellent long-term survival.
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http://dx.doi.org/10.1111/bjh.17221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7894296PMC
January 2021

Demystifying the varying case fatality rates (CFR) of COVID-19 in India: Lessons learned and future directions.

J Infect Dev Ctries 2020 Oct 31;14(10):1128-1135. Epub 2020 Oct 31.

Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India.

Introduction: At the end of the second week of June 2020, the SARS-CoV-2 responsible for COVID-19 infected above 7.5 million people and killed over 400,000 worldwide. Estimation of case fatality rate (CFR) and determining the associated factors are critical for developing targeted interventions.

Methodology: The state-level adjusted case fatality rate (aCFR) was estimated by dividing the cumulative number of deaths on a given day by the cumulative number confirmed cases 8 days before, which is the average time-lag between diagnosis and death. We conducted fractional regression analysis to determine the predictors of aCFR.

Results: As of 13 June 2020, India reported 225 COVID-19 cases per million population (95% CI:224-226); 6.48 deaths per million population (95% CI:6.34-6.61) and an aCFR of 3.88% (95% CI:3.81-3.97) with wide variation between states. High proportion of urban population and population above 60 years were significantly associated with increased aCFR (p=0.08, p=0.05), whereas, high literacy rate and high proportion of women were associated with reduced aCFR (p<0.001, p=0.03). The higher number of cases per million population (p=0.001), prevalence of diabetes and hypertension (p=0.012), cardiovascular diseases (p=0.05), and any cancer (p<0.001) were significantly associated with increased aCFR. The performance of state health systems and proportion of public health expenditure were not associated with aCFR.

Conclusions: Socio-demographic factors and burden of non-communicable diseases (NCDs) were found to be the predictors of aCFR. Focused strategies that would ensure early identification, testing and effective targeting of non-literate, elderly, urban population and people with comorbidities are critical to control the pandemic and fatalities.
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http://dx.doi.org/10.3855/jidc.13340DOI Listing
October 2020

Defining IL-6 levels in healthy individuals: A meta-analysis.

J Med Virol 2021 06 22;93(6):3915-3924. Epub 2020 Nov 22.

Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India.

Background: Interleukin-6 (IL-6) is produced by and impacts different cell types in human. IL-6 is associated with different diseases and viral infections, including COVID-19. To our knowledge, no normal values were reported for IL-6 in the blood of healthy individuals. We have reviewed and performed a meta-analysis on a total of 140 studies, including 12,421 values for IL-6 in the blood of healthy adult donors. Among these studies, 83 did not report a mean value and the standard deviation. Therefore, for the statistical analysis, we used the values reported in 57 studies, which included 3166 values for IL-6.

Results: The reported values for IL-6 in the blood of healthy donors varied between 0 and 43.5 pg/ml. The pooled estimate of IL-6 was 5.186 pg/ml (95% confidence interval [CI]: 4.631, 5.740). As the age increased by 1 year, IL-6 values increased by 0.05 pg/ml (95% CI: 0.02, 0.09; p < .01). Though the heterogenicity, as determined by I statistics, was high in our study, the differences in IL-6 values are still at the level of a few pg/ml, which might be related to the differences in the conditions that influence IL-6 production in the healthy population.

Conclusions: This is the first meta-analysis reporting the levels of IL-6 in the blood of healthy donors based on a large number of studies and donors. Therefore the 95% CI values determined in our study could well serve as a reference range for quick decision-making in clinical interventions, particularly those aiming to inhibit IL-6, especially urgent interventions, for example, COVID-19.
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http://dx.doi.org/10.1002/jmv.26654DOI Listing
June 2021

Who is dying from COVID-19 and when? An Analysis of fatalities in Tamil Nadu, India.

Clin Epidemiol Glob Health 2021 Jan-Mar;9:275-279. Epub 2020 Oct 3.

Professor, Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, 632 002, India.

Background: As the number of COVID-19 cases continues to rise, public health efforts must focus on preventing avoidable fatalities. Understanding the demographic and clinical characteristics of deceased COVID-19 patients; and estimation of time-interval between symptom onset, hospital admission and death could inform public health interventions focusing on preventing mortality due to COVID-19.

Methods: We obtained COVID-19 death summaries from the official dashboard of the Government of Tamil Nadu, between 10th May and July 10, 2020. Of the 1783 deaths, we included 1761 cases for analysis.

Results: The mean age of the deceased was 62.5 years (SD: 13.7). The crude death rate was 2.44 per 100,000 population; the age-specific death rate was 22.72 among above 75 years and 0.02 among less than 14 years, and it was higher among men (3.5 vs 1.4 per 100,000 population). Around 85% reported having any one or more comorbidities; Diabetes (62%), hypertension (49.2%) and CAD (17.5%) were the commonly reported comorbidities. The median time interval between symptom onset and hospital admission was 4 days (IQR: 2, 7); admission and death was 4 days (IQR: 2, 7) with a significant difference between the type of admitting hospital. One-fourth of (24.2%) deaths occurred within a day of hospital admission.

Conclusion: Elderly, male, people living in densely populated areas and people with underlying comorbidities die disproportionately due to COVID-19. While shorter time-interval between symptom onset and admission is essential, the relatively short time interval between admission and death is a concern and the possible reasons must be evaluated and addressed to reduce avoidable mortality.
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http://dx.doi.org/10.1016/j.cegh.2020.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532809PMC
October 2020

The impact of demonetisation on the utilisation of hospital services, patient outcomes and finances: a multicentre observational study from India.

BMJ Glob Health 2020 09;5(9)

Division of Critical Care, George Institute for Global Health, Sydney, New South Wales, Australia.

Background: This study assessed trends in healthcare utilisation in relation to the implementation of an economic policy in India wherein 500 and 1000 rupee notes were demonetised.

Methods: In this ambidirectional observational study of private not-for-profit hospitals, data on hospital outpatient and inpatient numbers, surgeries, emergency department (ED) visits, obstetric admissions and mortality were obtained for pre-demonetisation (September/October 2016), early (November/December 2016) and late demonetisation (January/February 2017), and post-demonetisation periods (March/April 2017) and compared with the control period (2015-2016) from 11 centres (three tertiary hospitals; eight secondary). A Bayesian regression analysis was performed to adjust for seasonal (winter) effect. Monthly financial data, including the proportion of cash versus non-cash transactions, were collected.

Findings: Overall, at the pooled all-hospital level, Bayesian analysis showed non-significant increase in outpatients (535.4, 95% CI -7097 to 8116) and decrease in deaths (-6.3 per 1000 inpatients, 95% CI -15.45 to 2.75) and a significant decrease in inpatients (-145.6, 95% CI -286.4 to -10.63) during demonetisation. Analysis at the level of secondary and tertiary hospitals showed a variable effect. For individual hospitals, after adjusting for the seasonal effect, some hospitals observed a significant reduction in outpatient (n=2) and inpatient (n=3) numbers, ED visits (n=4) and mortality (n=2) during demonetisation, while others reported significantly increased outpatient numbers (n=3) and ED visits (n=2). Deliveries remained unchanged during demonetisation in the hospitals that provided the service. There was no significant reduction in hospital incomes during demonetisation. In tertiary hospitals, there was a significant increase in non-cash component of transactions from 35% to 60% (p=0.02) that persisted beyond the demonetisation period.

Conclusions: The effect of demonetisation on healthcare utilisation was variable. Some hospitals witnessed a significant reduction in utilisation in some areas, while others reported increased utilisation. There was an increase in non-cash transactions that persisted beyond the period of demonetisation.
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http://dx.doi.org/10.1136/bmjgh-2020-002509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493109PMC
September 2020

Measurement of non-invasive blood pressure in lateral decubitus position under general anaesthesia - Which arm gives more accurate BP in relation to invasive BP - dependent or non-dependent arm?

Indian J Anaesth 2020 Jul 1;64(7):631-636. Epub 2020 Jul 1.

Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu, India.

Background And Aims: Non-invasive blood pressure (NiBP) varies with the arm and body position. In the lateral decubitus position (LDP), the non-dependent arm reads lower, and the dependent arm reads higher pressure. We aimed to study the correlation between the NiBP and invasive arterial blood pressure (ABP) as anaesthesia progressed and its correlation in different BP ranges.

Methods: American Society of Anesthesiologists (ASA I-III) patients, between 18-70 years undergoing neurosurgical procedures in the LDP were studied. All were anaesthetised using a standard protocol, positioned in the LDP. NiBP was measured every 15 min in both dependent and non-dependent arms and correlated with the ABP.

Results: Intra-class correlation (ICC) done between the dependent arm NiBP and ABP showed good correlation for mean and systolic BP and moderate correlation for diastolic BP. ICC was 0.800, 0.846 and 0.818 for mean and 0.771, 0.782, 0.792 for systolic BP at 15 min, 1 h, and 2 h, respectively. The ICC between the non-dependent arm NiBP and the invasive ABP showed poor correlation for all BP (systolic, diastolic and mean). As anaesthesia progressed, the mean difference between the NiBP and the ABP decreased in the dependent arm and increased in the non-dependent arm. The strength of agreement between the NiBP and the ABP in various BP ranges showed moderate correlation for the dependent arm NiBP (0.45-0.54) and poor correlation (0.21-0.38) for the non-dependent arm.

Conclusion: The NiBP of the dependent arm correlated well with ABP in LDP under general anaesthesia (GA). It is better to defer measuring NiBP in the non-dependent arm as the correlation with ABP is poor.
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http://dx.doi.org/10.4103/ija.IJA_125_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413357PMC
July 2020

Feasibility of computer-generated telephonic message-based follow-up system among healthcare workers with diabetes: a randomized controlled trial.

BMJ Open Diabetes Res Care 2020 07;8(1)

Internal Medicine, Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India.

Introduction: To assess the feasibility of computer-generated educational messaging system in healthcare workers of a tertiary care hospital. The secondary objectives were glycemic control, patient satisfaction and adherence to lifestyle modifications.

Research Design And Methods: Single-center parallel-group open-labeled randomized controlled trial with computer generated block randomization.

Setting: Healthcare workers with diabetes working in Christian Medical College Vellore, Tamil Nadu.

Participants: 431 assessed, 341 met the selection criteria, 320 participants were randomized and 161 were taken into intervention arm and 159 in the control arm.

Intervention: Computer-generated short message service (SMS) based on transtheoretical model of behavioral change, 2 messages per week for 3 months, along with standard of care diabetic care. Messages had educational material regarding healthy eating habits and exercise and these messages were sent twice weekly. The messages were scheduled via an automatic calendar in a way that each subject in the intervention arm received 15 educational messages per month.Control group received only standard of care diabetic care which included dietary advice, exercise regimen and diabetic medications under supervision of their physician every 3 months.

Follow-up: 6 months.

Results: 95.65% of people in the intervention arm (n=154) received regular messages, out of which 93.17% read the messages regularly. 80.12% acted on the messages. 93.17% felt more satisfied with their healthcare.While both groups showed improvement in body mass index (BMI) and hemoglobin A1c (HbA1c), the difference was greater in the intervention with regard to both decrease in BMI (-0.6, p<0.001) and HBA1c (-0.48, p<0.001).

Conclusions: SMS-based education system is feasible in improving healthcare among healthcare workers with diabetes. It improves patient satisfaction, adherence and improves healthcare among individuals with diabetes by decreasing their BMI and decreasing HbA1c.
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http://dx.doi.org/10.1136/bmjdrc-2020-001237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359061PMC
July 2020

The role of thymus and activation-regulated chemokine as a marker of severity of atopic dermatitis.

J Am Acad Dermatol 2021 Feb 19;84(2):545-547. Epub 2020 May 19.

Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India.

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http://dx.doi.org/10.1016/j.jaad.2020.05.052DOI Listing
February 2021
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