Publications by authors named "M Manu"

78 Publications

Probiotics in Prevention and Treatment of COVID-19: Current Perspective and Future Prospects.

Arch Med Res 2021 Mar 19. Epub 2021 Mar 19.

Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India-576104.

Saving lives and flattening the curve are the foremost priorities during the ongoing pandemic spread of SARS-CoV-2. Developing cutting-edge technology and collating available evidence would support frontline health teams. Nutritional adequacy improves general health and immunity to prevent and assuage infections. This review aims to outline the potential role of probiotics in fighting the COVID-19 by covering recent evidence on the association between microbiota, probiotics, and COVID-19, the role of probiotics as an immune-modulator and antiviral agent. The high basic reproduction number (R0) of SARS-CoV-2, absence of conclusive remedies, and the pleiotropic effect of probiotics in fighting influenza and other coronaviruses together favour probiotics supplements. However, further support from preclinical and clinical studies and reviews outlining the role of probiotics in COVID-19 are critical. Results are awaited from many ongoing clinical trials investigating the benefits of probiotics in COVID-19.
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http://dx.doi.org/10.1016/j.arcmed.2021.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972717PMC
March 2021

Mortality due to TB-COVID-19 coinfection in India.

Int J Tuberc Lung Dis 2021 03;25(3):250-251

Regional Team Lead (South), WHO NTEP Technical Support Network, Cochin, India.

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http://dx.doi.org/10.5588/ijtld.20.0947DOI Listing
March 2021

Soil mite communities (Acari: Mesostigmata) as indicators of urban ecosystems in Bucharest, Romania.

Sci Rep 2021 Feb 15;11(1):3794. Epub 2021 Feb 15.

Department of Ecology, Taxonomy and Nature Conservation, Romanian Academy, Institute of Biology Bucharest, street Splaiul Independenţei, no. 296, PO-BOX 56-53, 0603100, Bucharest, Romania.

The aim of the present study was to establish the effect of management type and of environmental variables on the structure, abundance and species richness of soil mites (Acari: Mesostigmata) in twelve urban green areas in Bucharest-Romania. Three categories of ecosystem based upon management type were investigated: protected area, managed (metropolitan, municipal and district parks) and unmanaged urban areas. The environmental variables which were analysed were: soil and air temperature, soil moisture and atmospheric humidity, soil pH and soil penetration resistance. In June 2017, 480 soil samples were taken, using MacFadyen soil core. The same number of measures was made for quantification of environmental variables. Considering these, we observed that soil temperature, air temperature, air humidity and soil penetration resistance differed significantly between all three types of managed urban green area. All investigated environmental variables, especially soil pH, were significantly related to community assemblage. Analysing the entire Mesostigmata community, 68 species were identified, with 790 individuals and 49 immatures. In order to highlight the response of the soil mite communities to the urban conditions, Shannon, dominance, equitability and soil maturity indices were quantified. With one exception (numerical abundance), these indices recorded higher values in unmanaged green areas compared to managed ecosystems. The same trend was observed between different types of managed green areas, with metropolitan parks having a richer acarological fauna than the municipal or district parks.
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http://dx.doi.org/10.1038/s41598-021-83417-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884781PMC
February 2021

Population Attributable Risk of Tuberculosis Vulnerabilities in Kerala, India.

Indian J Community Med 2020 Jul-Sep;45(3):367-370. Epub 2020 Sep 1.

State TB Training and Demonstration Centre, Thiruvananthapuram, Kerala, India.

Background: A robust disaggregated understanding of the determinants of tuberculosis (TB) in each local setting is essential for effective health system and policy action to control TB.

Objectives: The objective of the study was to identify population attributable risk (PAR) for TB disease based on the locally available evidences for Kerala, India.

Methods: Systematic review was done for risk factors of TB in the state. The second set of searches was done to understand the prevalence of the identified risk factors in general population in Kerala. With all available studies and reports, an expert group consensus was made to finalize state-specific prevalence of risk factors. Population attributable fractions were calculated for identified risk factors.

Results: PAR for TB disease in Kerala obtained was 24% for undernutrition, 15% for diabetes, 15% for tobacco use, and 1% for HIV.

Conclusion: Kerala state's PAR for TB was comparatively lower for HIV but higher for diabetes mellitus. Similar exercises for summarizing population risk factors need to happen at all states for making plans to effectively combat TB.
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http://dx.doi.org/10.4103/ijcm.IJCM_336_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745824PMC
September 2020

Assessment of Risk Factors of African Swine Fever in India: Perspectives on Future Outbreaks and Control Strategies.

Pathogens 2020 Dec 12;9(12). Epub 2020 Dec 12.

Faculty of Veterinary and Animal Sciences, Banaras Hindu University, Mirzapur 231001, India.

African swine fever (ASF) is one of the most important transboundary diseases of pigs. ASF has been identified in India for the first time in domestic pigs from outbreaks reported in two of the northeastern states, Arunachal Pradesh and Assam in 2020. A total of 11 ASF outbreaks in different regions killed over 3700 pigs and devastated the economy of small-scale livestock owners of both the states. Considering the first outbreak of ASF in India, a generic risk assessment framework was determined to identify potential risk factors that might favor future emergence of the disease. Based on the Indian scenario, we considered population density of host, farming practice, availability of biological vectors and wildlife reservoirs, epidemiological cycles, and international trade to analyze the possibility of future outbreaks of ASF and chances of establishment of endemism. On critical analysis of the identified risk factors associated with ASFV transmission, we observed that the risk factors are well preserved in the Indian geography and might participate in future outbreaks, further disseminating the disease to nearby countries. Since no vaccine is currently available against ASF, the domestic and the wild pigs (wild boars and the endangered pygmy hogs native to India) of this region are under constant threat of infection. For the near future, this region will have to continue to rely on the implementation of preventive measures to avoid the devastating losses that outbreaks can cause. The various adaptive control strategies to minimize the risks associated with the transmission of ASF, keeping our views to Indian settings, have been described. The risk-analysis framework presented in the study will give a further understanding of the dynamics of disease transmission and will help to design control strategies and corresponding measures to minimize the catastrophic consequences of ASF disease.
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http://dx.doi.org/10.3390/pathogens9121044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763524PMC
December 2020

The first state-level public health program for obstructive airway disease in India: An early field-level evaluation.

J Family Med Prim Care 2020 Sep 30;9(9):4998-5003. Epub 2020 Sep 30.

Health Action by People, Thiruvananthapuram, Kerala, India.

Background: Chronic obstructive pulmonary disease (COPD) is the second leading cause of mortality in India; however, there are no programs for COPD in India at primary care level. Kerala became the first state in India to implement a program at primary care for COPD, called the Step Wise Approach to Airway Syndrome program.

Objective: The objective of the study was to evaluate and document the implementation status of a program for obstructive airway disease (OAD) in Trivandrum district of Kerala state in India and compare the treatment characteristics of patients with OAD seeking care from the centers implementing and not implementing this program for OADs.

Methods: A cross-sectional study was done as early evaluation of a program for OAD implemented in Kerala state, India, from October 2018 to February 2019.

Results: A reflection of the health-seeking behavior due to better facilities at the FHCs. There was no difference in the hospital visits or emergency department visits between the two groups. However, there was a statistically significant difference in the average number of visits per patient to health center for taking injectable drugs and visits for nebulization. Forty-nine (94%) of the COPD and 36 (100%) of the asthma patients underwent spirometry from implementing center itself. A higher proportion of patients receiving care from implementing centers (30.9%) never had to buy inhalers from outside.

Conclusion: This is the first time that a public health programme for chronic respiratory disease management at primary care level was evaluated in India. The study has provided valuable insights on the need for strengthening the training for health care providers as well as patient education in bringing about a change in patient attitudes.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_216_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652171PMC
September 2020

ETNA-VTE Europe: Benefits and risks of venous thromboembolism treatment using edoxaban in the first 3 months.

Thromb Res 2020 12 12;196:297-304. Epub 2020 Sep 12.

Guy's and St Thomas' NHS Foundation Trust, King's College London, United Kingdom. Electronic address:

Introduction: Edoxaban had a positive risk-benefit ratio for the treatment of venous thromboembolism (VTE) compared to conventional therapy with warfarin. The objective of this analysis of the ongoing ETNA-VTE Europe study was to assess the real-world benefits and risks of edoxaban during the first 3 months of treatment, the highest risk period for further VTE events.

Methods: ETNA-VTE Europe is a prospective, non-interventional, post-authorization study, conducted in eight European countries. Participants had initial or recurrent acute VTE (deep vein thrombosis [DVT] and/or pulmonary embolism [PE]) that occurred ≤2 weeks prior to enrolment and received edoxaban therapy.

Results: The analysis set included 2672 patients (PE ± DVT, n = 1117; DVT only, n = 1555); mean age 62.9 ± 16.0 years, bodyweight 81.9 ± 17.4 kg, estimated glomerular filtration rate 95.4 ± 42.8 mL/min; 46.4% were female. Overall, 66.4% of patients (PE ± DVT, 68.5%; DVT-only, 64.8%) received heparin lead-in treatment for at least 5 days. Most patients (87.7%) received edoxaban at a dose of 60 mg once daily. Event rates at 3 months were: recurrent VTE 0.34% (n = 9), major bleeding 0.97% (n = 26), all-cause mortality 0.79% (n = 21). Rates were numerically higher in the PE ± DVT group compared with the DVT-only group (recurrent VTE, 0.45% (n = 5) versus 0.26% (n = 4); major bleeding, 1.34% (n = 15) versus 0.71% (n = 11); and all-cause mortality 1.16% (n = 13) versus 0.51% (n = 8)).

Conclusions: The results support the safety and effectiveness of edoxaban in a general VTE population during the most critical time period, the first 3 months. The outcomes of this study extend the principal efficacy and safety data on edoxaban into the routine clinical practice setting.
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http://dx.doi.org/10.1016/j.thromres.2020.09.001DOI Listing
December 2020

Structure and regulation of SWEET transporters in plants: An update.

Plant Physiol Biochem 2020 Nov 29;156:1-6. Epub 2020 Aug 29.

National Institute of Plant Genome Research, Aruna Asaf Ali Marg, New Delhi, 110067, India. Electronic address:

Sugar will eventually be exported transporters (SWEETs), a novel family of sugar transporters found in both eukaryotes and prokaryotes, facilitate sugar flux across the cell membrane. Although these transporters were first discovered in plants, their homologs have been reported in different organisms. SWEETs have critical roles in various developmental processes, including phloem loading, nectar secretion, and pathogen nutrition. The structure of bacterial homologs, called SemiSWEETs, has been well studied thus far. Here, we provide an overview of SWEET protein structure and dynamic function by analyzing the solved crystal structures and predicted models that are available for a few SWEETs in a monocot plant (rice) and dicot plant (Arabidopsis thaliana). Despite the advancement in structure-related studies, the regulation of SWEETs remains unknown. In light of reported regulatory mechanisms of a few other sugar transporters, we propose the regulation of SWEETs at the post-translational level. We then enumerate the potential post-translational modification sites in SWEETs using computational tools. Overall, in this review, we critically analyze SWEET protein structure in plants to predict the post-translational regulation of SWEETs. Such findings have a direct bearing on plant nutrition and defense and targeting the regulation at these levels will be important in crop improvement.
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http://dx.doi.org/10.1016/j.plaphy.2020.08.043DOI Listing
November 2020

Stability of live attenuated classical swine fever cell culture vaccine virus in liquid form for developing an oral vaccine.

Biologicals 2020 Nov 1;68:108-111. Epub 2020 Sep 1.

Division of Biological Standardization, ICAR-Indian Veterinary Research Institute, Bareilly, 243122, India. Electronic address:

Classical swine fever (CSF) is an important viral disease of pigs and controlled by vaccination. Unorganised backyard and wild pigs are difficult to vaccinate by needle vaccination. Here we formulated liquid vaccines using an Indian CSF cell culture vaccine virus and four stabilisers and evaluated their stability at 4 °C, 25 °C and 37 °C up to 24 h for use as oral vaccine. The stabilisers were Lactalbumin hydrolysate-Trehalose, Lactalbumin hydrolysate-Trehalose-Gelatin, Lactalbumin hydrolysate-Lactose-Sucrose and Lactalbumin hydrolysate-Sucrose. The liquid vaccines, with or without stabilisers, were stable at 4 °C up to 24 h, whereas, a drop of one log titre was observed at 25 °C during the same period. At 37 °C, the virus titre diminished by only one log with the Lactalbumin hydrolysate-Trehalose (LT) stabiliser up to 24 h compared to two log losses in virus titre with other stabilisers and virus control. We therefore conclude that for developing a CSF oral vaccine, the vaccine virus in liquid form can be used directly during the winter, whereas for developing the oral vaccine for summer, the LT stabiliser would provide maximum stability to the virus to withstand the warm temperature while maintaining adequate therapeutic titre for inducing a protective immune response.
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http://dx.doi.org/10.1016/j.biologicals.2020.07.004DOI Listing
November 2020

Comparison of fractional exhaled nitric oxide, spirometry, and Asthma Control Test, in predicting asthma exacerbations: A prospective cohort study.

Lung India 2020 Sep-Oct;37(5):394-399

Department of Data Science, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India.

Context: Fractional exhaled nitric oxide (FeNO) is a noninvasive test for airway inflammation in asthma. The usefulness of FeNO in predicting exacerbations is uncertain.

Aims: The study aims to assess and compare the ability of FeNO, spirometry, and asthma control test (ACT) in predicting future exacerbations of asthma and their correlation with each other.

Settings And Design: This prospective, cohort study was conducted at the Department of Respiratory Medicine, Kasturba Medical College, Manipal.

Materials And Methods: Adult asthma patients of age 18-65 years were included. Patients with a smoking history of >10 pack-years and those in whom spirometry was contraindicated were excluded. Patients who consented underwent FeNO and spirometry. The control of asthma was assessed using the ACT questionnaire. We captured the number of exacerbations in the follow-up period of 4 months.

Statistical Analysis Used: Mann-Whitney test was used to compare the utility of FeNO, spirometry, ACT in predicting exacerbations and Spearman's correlation coefficient was used to ascertain the correlation among them.

Results: Of 154 study patients, 28% had exacerbations. We found that there was no significant difference in FeNO in patients with and without exacerbations. The median (interquartile range [IQR]) FEV1% in the patients with and without exacerbations were 68 (55-79) and 75 (65-88), respectively (P = 0.013). The median (IQR) ACT score in patients with exacerbations was 12 (10-16) which was significantly lower than in those without exacerbation in whom it was 16 (14-18) (P = 0.003). There was a negative correlation of ACT with FeNO (Correlation coefficient: -0.167, P = 0.038). The median (IQR) FeNO level (ppb) was lower in patients who were on inhaled corticosteroid (ICS) than in the other group values being 22 (14-38) and 30 (17-58), respectively (P = 0.05).

Conclusions: In our study, FEV1% and ACT score could predict exacerbations of asthma whereas FeNO could not. FeNO level correlated inversely with ACT score. FeNO level decreased with inhaled corticosteroid usage.
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http://dx.doi.org/10.4103/lungindia.lungindia_546_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857384PMC
September 2020

Vitamin D in Prevention and Treatment of COVID-19: Current Perspective and Future Prospects.

J Am Coll Nutr 2020 Sep 1:1-14. Epub 2020 Sep 1.

Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India.

Vitamin D deficiency (VDD) partly explains geographical differences in COVID-19 susceptibility, severity, and mortality. VDD among African-Americans, diabetics, hypertensive, and aged populations possibly explain the higher death rate, aggravated by cocooning. Vitamin D is pleiotropic, mediating bone metabolism, calcium homeostasis, and immune functions, whereas VDD is associated with inflammatory reactions and immune dysfunction, predisposing individuals to severe infections. Vitamin D modulates innate and adaptive immunity via the expression of genes that code antimicrobial peptides (AMPs). And the expression of cluster of differentiation (CD)14, the co-receptor for epidermal toll-like receptor (TLR)4. AMPs stimulate TLR2 in macrophages, increasing the conversion of vitamin D into its active form by cytochrome P450 27B1. Antiviral properties of vitamin D-induced AMPs can shift the polarization of the adaptive immune response from helper T cells (Th)1 to the more regulatory Th2 responses that suppress immune over-reactivity by preventing cytokine storm, which is already demonstrated during the Spanish flu episode. Vitamin D induces antiviral effects by both direct and indirect mechanisms via AMPs, immunomodulation, the interplay between major cellular and viral elements, induction of autophagy and apoptosis, variation of genetic and epigenetic factors. The crosstalk between vitamin D and intracellular signaling pathways may operate as a primary regulatory action on viral gene transcription. VDD may increase the likelihood of infection with enveloped viruses, including retrovirus, hepatitis, and dengue. Global data correlates severe VDD with COVID-19 associated coagulopathy, disrupted immune response and mortality, reduced platelet count, and prolonged prothrombin time, suggesting benefits from supplementation. Key teaching points Vitamin D induces antiviral effects by direct and indirect mechanisms via AMPs, immunomodulation, induction of autophagy, etc. Epidemiology of VDD partly explains geographical differences in COVID-19 susceptibility, severity, and mortality. Global data correlates severe VDD with COVID-19 associated coagulopathy, disrupted immune response and mortality, reduced platelet count, and prolonged prothrombin time, together suggesting benefits from supplementation. Many clinical trials are underway globally to delineate the role of vitamin D in both prevention and treatment of COVID-19.
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http://dx.doi.org/10.1080/07315724.2020.1806758DOI Listing
September 2020

ETNA VTE Europe: A contemporary snapshot of patients treated with edoxaban in clinical practice across eight European countries.

Eur J Intern Med 2020 12 18;82:48-55. Epub 2020 Aug 18.

Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy. Electronic address:

Introduction: Edoxaban has proven its efficacy and safety in the ENGAGE AF-TIMI 48 and HOKUSAI-VTE clinical trials. Clinical practice patients, however, may differ from those enolled in clinical trials. We aimed to compare patients from the HOKUSAI-VTE clinical trial with those treated in clinical practice.

Materials And Methods: ETNA-VTE-Europe is a prospective, non-interventional post-authorisation safety study conducted in eight European countries.

Results: A total of 2,879 patients presenting with acute symptomatic venous thromboembolism (VTE) were enrolled at 339 sites. Of the 2,680 patients with complete data, 23.6% reported prior VTE and 2.8% had a history of bleeding. Patients in ETNA-VTE were older (65vs.57 years), more likely to be female (46.5vs.39.8%) and had a higher prevalence of chronic venous insufficiency (11.1vs.1.6%) than those in the European cohort of the HOKUSAI-VTE trial (n=1,512). Bodyweight and creatinine clearance were substantially lower in clinical practice. Edoxaban dosing was adherent to label in 90% of patients, with higher (60 mg) and lower than recommended doses (30 mg) used in 6.6% and 3.3% of the patients, respectively. Heparin lead-in was used in 84.7% of the patients overall, and was more frequently used in patients with PE than patients with DVT only (91.3% vs. 80.1%; p<0.0001).

Conclusions: These data reinforce the largely appropriate use of edoxaban in routine clinical practice, where the study population differs from those in prior randomised controlled trials. CLINICALTRIALS.

Gov Identifier: NCT02943993.
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http://dx.doi.org/10.1016/j.ejim.2020.08.014DOI Listing
December 2020

Edoxaban for stroke prevention in atrial fibrillation in routine clinical care: 1-year follow-up of the prospective observational ETNA-AF-Europe study.

Eur Heart J Cardiovasc Pharmacother 2021 Apr;7(FI1):f30-f39

Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, IBR 136, Wolfson Drive, Birmingham B15 2TT, UK.

Aims: Non-vitamin K oral anticoagulants are safe and effective for stroke prevention in patients with atrial fibrillation (AF). Data on the safety and efficacy of edoxaban in routine care are limited in Europe. We report 1-year outcomes in patients with AF treated with edoxaban in routine care.

Methods And Results: ETNA-AF-Europe is a prospective, multicentre, post-authorization, observational study enrolling patients treated with edoxaban in 10 European countries, the design of which was agreed with the European Medicines Agency as part of edoxaban's post-approval safety plan. Altogether 13 092 patients in 852 sites completed the 1-year follow-up [mean age: 73.6 ± 9.5 years; 57% male, mean follow-up: 352 ± 49 days (median: 366 days)]. Most patients had associated comorbidities (mean CHA2DS2-VASc score: 3.1 ± 1.4). Stroke or systemic embolism was reported in 103 patients (annualized event rate: 0.82%/year), and major bleeding events were reported in 132 patients (1.05%/year). Rates of intracranial haemorrhage were low [30 patients (0.24%/year)]. Death occurred in 442 patients (3.50%/year); cardiovascular (CV) death occurred in 206 patients (1.63%/year). The approved dosing of edoxaban was chosen in 83%. All-cause and CV mortality were higher in patients receiving edoxaban 30 mg vs. 60 mg, in line with the higher age and more frequent comorbidities of the 30 mg group. Major bleeding was also numerically more common in patients receiving edoxaban 30 mg vs. 60 mg.

Conclusion: The rates of stroke, systemic embolism, and major bleeding are low in this large unselected cohort of high-risk AF patients routinely treated with edoxaban.
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http://dx.doi.org/10.1093/ehjcvp/pvaa079DOI Listing
April 2021

Thromboembolic and bleeding risk in obese patients with atrial fibrillation according to different anticoagulation strategies.

Int J Cardiol 2020 Nov 21;318:67-73. Epub 2020 Jun 21.

Chair of Cardiology, University of Pisa, Italy. Electronic address:

Background: Data on the relationship between body mass index (BMI), thromboembolic events (TEE) and bleeding in patients with atrial fibrillation (AF) are controversial, and further evidence on the risk of such events in obese patients with AF receiving different anticoagulant therapies (OAC) is needed.

Methods And Results: We divided a total of 9330 participants from the prospective PREFER in AF and PREFER in AF PROLONGATION registries into BMI quartiles at baseline. Outcome measures were TEE and major bleeding complications at the 1-year follow-up. Without OAC, there was a ≥6-fold increase of TEE in the 4th vs other BMI quartiles (P = .019). OAC equalized the rates of TEE across different BMI strata. The occurrence of major bleeding was highest in patients with BMI in the 1st as well as in the 4th BMI quartile [OR 1.69, 95% CI 1.03-2.78, P = .039 and OR 1.86, 95% CI 1.13-3.04, P = .014 vs those in the 3rd quartile, respectively]. At propensity score-adjusted analysis, the incidence of TEE and major bleeding in obese patients receiving non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K-antagonist anticoagulants (VKAs) was similar (P ≥ .34).

Conclusions: Our real-world data suggest no obesity paradox for TEE in patients with AF. Obese patients are at higher risk of TEE, and here OAC dramatically reduces the risk of events. We here found a comparable clinical outcome with NOACs and VKAs in obese patients. Low body weight and obesity were also associated with bleeding, and therefore OAC with the best safety profile should be considered in this setting.
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http://dx.doi.org/10.1016/j.ijcard.2020.06.010DOI Listing
November 2020

Ocular adverse events in drug sensitive TB patients on daily fixed dose combination anti-TB drugs: A record review study from Kerala, India.

Indian J Tuberc 2020 Apr 28;67(2):216-221. Epub 2020 Feb 28.

Center for Operational Research, The Union South-East Asia Regional Office, New Delhi, India.

Background: Government of India's Revised National TB Control Programme (RNTCP) has begun implementing daily fixed dose combination (FDC) anti-TB treatment regimen for drug sensitive TB patients in which ethambutol is given for six months. Prolonged ethambutol use is known to cause ocular adverse drug events (ADE).

Objectives: To assess the magnitude of ocular ADEs in adult drug sensitive TB patients initiated on daily FDCs and to describe the demographic and clinical profile of patients with ocular ADEs.

Methods: We conducted a retrospective cohort study involving review of RNTCP records of all adult (age >14 years) drug sensitive TB patients initiated on daily FDCs between1 January 2018 and 31st July 2018 in Thiruvananthapuram district, Kerala State, India.

Results: 714 patients were initiated on daily FDCs during the study period. It was unknown whether all patients had undergone assessment for ocular ADEs. However, of these 714 patients, 8 patients (1.1%) were documented to have had ocular ADEs. Seven of these 8 patients had received ethambutol more than 15 mg/kg body weight and had developed ocular symptoms (decreased/blurring of vision) 3 months after TB treatment initiation. Ethambutol was stopped in all these 8 patients. In 5 patients it was recorded that ocular ADEs had resolved following stoppage of ethambutol and in the remaining it was unknown.

Conclusion: The study confirms the occurrence of ocular ADEs among drug sensitive TB patients on daily FDCs and recommends strengthening of systems for assessing, documenting and managing ocular ADE.
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http://dx.doi.org/10.1016/j.ijtb.2020.02.008DOI Listing
April 2020

Lung Health Care pilot project trims patient pill load and antibiotic prescription in primary health care settings in Kerala, India.

Indian J Tuberc 2020 Apr 17;67(2):202-207. Epub 2020 Feb 17.

WHO Country Office for India, New Delhi, India.

Introduction: Kerala, the southern Indian state piloted Lung Health Care Project (LHCP) which is a locally adopted version of WHO recommended Practical Approach to Lung health (PAL). The current study assessed the impact of the project on the prescribing practices of doctors and consumption of antibiotics and other drugs.

Methods: This study compared performance of primary health care institutions with regard to drug prescriptions and consumptions before and after the implementation of the project. Chronic respiratory disease (CRD) patients in institutions implemented the project were interviewed in the OPD at exit and their prescriptions were documented at baseline and after six months. Focus group discussions were conducted with doctors to explore the reasons behind changes in drug consumption pattern.

Results: In the project implementing institutions, mean number of drugs prescribed for CRDs was 3.88 (SD 1.50) and 2.73 (SD 1.18) at baseline and after six months respectively (p < 0.001). Adjusted odds ratio for prescribing an antibiotic and injection to a CRD patient during impact assessment at institutions implementing project was 0.34 (95% CI 0.15-0.75 p 0.008) and 0.39 (95% CI 0.20-0.74 p 0.004) respectively, as compared to baseline. The factors which helped in reducing antibiotic and injection use as felt by the doctors were presence of a protocol, good quality trainings, supportive supervision and monitoring, availability of alternate drugs and good participation of staff nurses especially in-patient education.

Conclusion: Strict adherence to diagnostic and management algorithms of Lung health care project in a primary health care setting in India helped in reducing pill burden to patients and prescription of antibiotics and injections.
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http://dx.doi.org/10.1016/j.ijtb.2020.02.001DOI Listing
April 2020

Comparing Surgeon Adherence with World Health Organization Antiseptic Guidelines for Surgical Site Preparation in the United Kingdom and India.

Surg Infect (Larchmt) 2020 Sep 17;21(7):634-638. Epub 2020 Jun 17.

Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom.

Skin preparation with an antiseptic solution aims to reduce surgical site infection rates. Surgical site infections (SSIs) create a high burden on healthcare systems with impacts on morbidity, mortality, and cost. In 2016, The World Health Organization (WHO) conducted an extensive systematic review and meta-analysis of the existing evidence. From this, they recommended the use of "alcohol based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures." This study aimed to assess surgeon compliance with this guidance in the United Kingdom and India. A multiple-choice questionnaire was developed to assess surgeon preferences for antiseptic use in their surgical site preparation. The end point of data collection was defined after 50 responses in each region. The majority of respondents in each center was general surgeons (n = 24, 48% United Kingdom; n = 21, 45% India), and registrars (n = 22, 44% United Kingdom; n = 23, 49% India). No surgeon preferred the use of any aqueous preparation. Chlorhexidine gluconate (CHG) was the preparation used most commonly in both centers (n = 30, 64% India; n = 24, 48% United Kingdom). In India, this represented a statistically significant difference (p = 0.0008), however, this was not observed in the United Kingdom (p = 0.22). There were no statistically significant differences between surgeon's reasons between the United Kingdom and India, other than "easier to see" (p = 0.016). This data show a reduced compliance of U.K. surgeons with WHO guidance for antiseptic use compared with Indian surgeons. Although the WHO has attempted to summarize the existing data to minimize the previous uncertainty surrounding antiseptic choices, the use of CHG continues to not be adopted widely. To draw robust conclusions to provide the foundations of further guidelines, future research should focus on prospective randomized controlled trials with large numbers across multiple surgical specialties.
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http://dx.doi.org/10.1089/sur.2020.084DOI Listing
September 2020

Impact of a catastrophic flood on the heavy metal pollution status and the concurrent responses of the bentho-pelagic community in a tropical monsoonal estuary.

Mar Pollut Bull 2020 Jun 25;155:111191. Epub 2020 Apr 25.

ICAR-National Bureau of Fish Genetic Resources, Kerala 682018, India.

Consequences of a catastrophic flood on the habitat quality and the concurrent responses of the bentho-pelagic community were studied in Cochin estuary, a eutrophic estuary along the southwest coast of India. The episodic flood in 2018 led to a marked decline in the dissolved nutrients and heavy metal concentrations in water and sediments of the estuary. The pre-flood phytoplankton abundance dominated by a bloom-forming species Cerataulina bicornis experienced a significant drop after the flood. Contrarily, zooplankton and macrobenthos responded favorably towards the flood-imposed habitat alterations. Higher susceptibility to heavy metal pollution and increased grazing pressure from gelatinous carnivores restricted the abundance of Copepoda, the dominant zooplankton taxon during pre-flood. The lower heavy metal concentration in the sediment after the flood favored higher macrobenthic abundance and diversity with a conspicuous change in the community structure from opportunistic polychaetes, indicators of pollution to molluscans and crustaceans, indicators of the healthy benthic zones.
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http://dx.doi.org/10.1016/j.marpolbul.2020.111191DOI Listing
June 2020

Effects of vineyard inter-row management on the diversity and abundance of plants and surface-dwelling invertebrates in Central Romania.

J Insect Conserv 2020 14;24(1):175-185. Epub 2020 Jan 14.

11Institute of Zoology, University of Natural Resources and Life Sciences, Vienna (BOKU), Gregor Mendel Straße 33, 1180 Vienna, Austria.

Vineyard inter-rows are important biodiversity hotspots within agricultural landscapes, especially when they are covered with vegetation. However, little is known on the effects to management intensity on a broad range of surface-dwelling invertebrates and their interaction with vegetation. We assessed the diversity and activity density of ants, beetles, millipedes, mites, spiders, springtails and woodlice using pitfall traps in vineyards with either high management intensity (HI) consisting of frequently tilled inter-rows or low management intensity (LO) with alternating tillage in every second inter-row. The study was performed in the Târnave wine region in Central Romania. We wanted to know whether, (i) vineyard management intensity affects the diversity of plants and invertebrates, and (ii) local habitat characteristics affect species richness of different functional guilds and taxa. Species richness of some invertebrate taxa (Coleoptera, Araneae, Formicidae) did significantly differ between HI and LO vineyards. Only phytophages (some Coleoptera) increased in species richness and activity density with vegetation cover. Vineyard soil properties (organic matter content, pH, P, and K) did not significantly differ between HI and LO vineyards. We conclude that vineyard inter-row management can affect both the conservation of biodiversity and the provision of biodiversity-driven ecosystem services.
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http://dx.doi.org/10.1007/s10841-019-00215-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7002328PMC
January 2020

Soil mite communities (Acari: Mesostigmata, Oribatida) as bioindicators for environmental conditions from polluted soils.

Sci Rep 2019 12 27;9(1):20250. Epub 2019 Dec 27.

Romanian Academy, Institute of Biology Bucharest, Department of Ecology, Taxonomy and Nature Conservation, street Splaiul Independenţei, no. 296, Bucharest, Romania.

An anthropic ecosystem from Romania was investigated from acarological, vegetation and chemical point of view. The community structures of two groups of mites were studied (Acari: Mesostigmata, Oribatida) from a tailing pond, using transect method, in correlation with concentrations of heavy metals (As, Cu, Pb, Ni, Mn and Zn), with abiotic factors (altitude, aspect, soil temperature, soil humidity, soil pH) and biotic factor (vegetation coverage). Taking into account the mite communities, in total, 30 mite species were identified, with 1009 individuals and 18 immatures (10 species with 59 individuals, 5 immatures of Mesostigmata and 20 species with 950 individuals, 13 immatures of Oribatida). The investigated habitats from the tailing pond were grouped in five transects, with different degree of pollution, based on total metal loads. Taking into account of the connection between mites communities, abiotic factors and heavy metals, each transect were characterized through specific relationship. Using multivariate statistical analysis, we revealed that the occurrence of some Oribatida species was strongly correlated with vegetation coverage, soil pH and soil humidity, though concentrations of Cu, As, Mn, Ni and Zn also had an influence. Pb and Zn concentrations were shown to influence the occurrence of Mesostigmata mites. The heterogeneity of mites species richness at 2 m scale was correlated with a metric related to the heterogeneity of heavy metals at the same scale.
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http://dx.doi.org/10.1038/s41598-019-56700-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6934548PMC
December 2019

Phase I Trial of a Modified Vaccinia Ankara Priming Vaccine Followed by a Fowlpox Virus Boosting Vaccine Modified to Express Brachyury and Costimulatory Molecules in Advanced Solid Tumors.

Oncologist 2020 07 26;25(7):560-e1006. Epub 2019 Dec 26.

Genitourinary Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA.

Lessons Learned: Modified vaccinia Ankara-Bavarian Nordic (MVA-BN)-Brachyury followed by fowlpox virus-BN-Brachyury was well tolerated upon administration to patients with advanced cancer. Sixty-three percent of patients developed CD4+ and/or CD8+ T-cell responses to brachyury after vaccination. BN-Brachyury vaccine also induced T-cell responses against CEA and MUC1, which are cascade antigens, that is, antigens not encoded in the vaccines.

Background: Brachyury, a transcription factor, plays an integral role in the epithelial-mesenchymal transition, metastasis, and tumor resistance to chemotherapy. It is expressed in many tumor types, and rarely in normal tissues, making it an ideal immunologic target. Bavarian Nordic (BN)-Brachyury consists of vaccination with modified vaccinia Ankara (MVA) priming followed by fowlpox virus (FPV) boosting, each encoding transgenes for brachyury and costimulatory molecules.

Methods: Patients with metastatic solid tumors were treated with two monthly doses of MVA-brachyury s.c., 8 × 10 infectious units (IU), followed by FPV-brachyury s.c., 1 × 10 IU, for six monthly doses and then every 3 months for up to 2 years. The primary objective was to determine safety and tolerability.

Results: Eleven patients were enrolled from March 2018 to July 2018 (one patient was nonevaluable). No dose-limiting toxicities were observed. The most common treatment-related adverse event was grade 1/2 injection-site reaction observed in all patients. Best overall response was stable disease in six patients, and the 6-month progression-free survival rate was 50%. T cells against brachyury and cascade antigens CEA and MUC1 were detected in the majority of patients.

Conclusion: BN-Brachyury vaccine is well tolerated and induces immune responses to brachyury and cascade antigens and demonstrates some evidence of clinical benefit.
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http://dx.doi.org/10.1634/theoncologist.2019-0932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356719PMC
July 2020

Comparison of reaction time and functional balance in chronic obstructive pulmonary disease and healthy participants.

Heart Lung 2019 Nov - Dec;48(6):570-573. Epub 2019 Oct 10.

Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India. Electronic address:

Background: Reaction time is one of the components of functional balance and could contribute to balance impairment. Information regarding this relationship is scant among Chronic Obstructive Pulmonary Disease (COPD) participants.

Objectives: To compare stepping reaction time between participants with COPD and age; gender-matched healthy individuals to find out whether reaction time in COPD population is affected.

Methods: This cross-sectional study included 41 COPD participants and 41 age and gender-matched healthy individuals. All the participants underwent measurements of stepping reaction time (SRT) and timed up and go test (TUG).

Results: SRT was significantly higher in COPD participants compared to healthy individuals [median of difference- 350 milliseconds (110, 830), p < 0.001]. TUG was significantly higher in COPD participants compared to healthy individuals [median of difference = 2.82 seconds (0.34 and 4.5), p < 0.001].

Conclusions: Participants with COPD exhibit marked increase in SRT and demonstrate a deficiency in functional balance compared to the healthy participants.
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http://dx.doi.org/10.1016/j.hrtlng.2019.09.006DOI Listing
March 2020

Characterization of defective interfering (DI) particles of Pestedes petitsruminants vaccine virus Sungri/96 strain-implications in vaccine upscaling.

Biologicals 2019 Nov 3;62:57-64. Epub 2019 Oct 3.

Division of Biological Products, ICAR-Indian Veterinary Research Institute, Uttar Pradesh, India. Electronic address:

The present investigation deals with the characterization of defective interfering (DI) particles of Peste-des-petits ruminants (PPR) vaccine Sungri/96 strain generated as a result of high MOI in Vero cells. During the serial 10 passages, infectivity titres drastically reduced from 6.5 to 2.25 logTCID/ml at high MOI. Further, attenuation of CPE with high MOI indicated generation of DI particles that resulted in no/slow progression of CPE during the late passages. Monoclonal antibody based cell ELISA indicated normal protein (N & H) packaging in samples with DI activity. At genomic level, inconsistency in amplicon intensity of H gene was observed in RT-PCR, indicating a possible defect of H gene. Further analysis of copy number of PPRV by RT-qPCR indicated intermittent fluctuations of viral genomic RNA copies. The significant decline of viral RNA copies with MOI 3 (314 copies) compared to low MOI (512804 copies), proved that higher DI multiplicities cause more interference with the replication process of the standard virus. Therefore, MOI is critical for manufacturing of vaccines. These investigations will help in upscaling of PPR vaccines in view of ongoing National and Global PPR control and eradication programme.
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http://dx.doi.org/10.1016/j.biologicals.2019.09.008DOI Listing
November 2019

Hampton's hump, Westermark's sign and Palla's sign in acute pulmonary thromboembolism: a rare concurrence.

BMJ Case Rep 2019 Sep 5;12(9). Epub 2019 Sep 5.

Respiratory Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.

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http://dx.doi.org/10.1136/bcr-2019-231693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731904PMC
September 2019

Impact of a Clinical Pharmacist Intervention on Medicine Costs in Patients with Chronic Obstructive Pulmonary Disease in India.

Pharmacoecon Open 2020 Jun;4(2):331-342

Unaizah College of Pharmacy, Qassim University, Qassim, Saudi Arabia.

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality, especially in low- and middle-income countries (LMICs) such as India. Medicine costs are a key issue in LMICs, with typically high patient co-payments. In addition, pharmacists are underutilised in LMICs, including India. However, pharmacist-led educational interventions may improve the care of patients with COPD, as well as reduce medicine costs. Consequently, the objective of this study was to assess the effectiveness of a pharmacist-led intervention in reducing medicine costs.

Methodology: We assessed the impact of a pharmacist intervention on direct medicine costs in COPD patients (medicine costs and pharmacist time) in a randomised controlled study involving an intervention and control group, conducted at a tertiary care teaching hospital in India.

Results: The 6-monthly cost of medicines at baseline increased with disease severity, from a maximum of US$29.46 for those with mild COPD to US$63.28 for those with very severe COPD. Substantial savings in medical costs were achieved with the pharmacist-led programme, to a maximum of US$20.49 over 6 months for very severe patients. This equates to a reduction of 30.6% in medicine costs (p < 0.001), reduced to 26.1% when pharmacists' time (US$3.00/patient) was included.

Conclusion: There could be a key role for pharmacists as educators for COPD patients in LMICs, to improve care and reduce costs, including patient co-payments.
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http://dx.doi.org/10.1007/s41669-019-0172-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7248138PMC
June 2020

Power of BODE Index in Predicting Future Exacerbations of COPD: A Prospective Observational Study in Indian Population.

J Assoc Physicians India 2019 Apr;67(4):14-16

Associate Professor, Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal; Manipal Academy of Higher Education, Manipal, Udupi, Karnataka.

Background: BODE index is a multidimensional measure of survival in chronic obstructive pulmonary disease (COPD). It is composed of body mass index (B), the degree of airflow obstruction (O), dyspnoea (D), and exercise capacity (E). Studies have shown that BODE index can predict future exacerbations, but similar data in Indian population is unavailable. This study was aimed at evaluating the power of BODE index to predict the frequency of exacerbations of COPD in Indian cohort.

Methods: We conducted a prospective observational cohort study that included stable COPD subjects aged above 40 years. We assessed the BODE index at baseline and recorded the number of exacerbations at the end of 12 months. Spearman's Rho and Poisson regression model were used to correlate the BODE index with the frequency of exacerbations.

Results: We analysed 78 COPD patients. A significant correlation was seen between BODE index at baseline and number of exacerbations at 12 months (Spearman's Rho 0.738). A unit change in BODE index at baseline would have 1.25 times higher number of exacerbations at 12 months (95% CI: 1.17-1.33).

Conclusions: BODE index has significant power to predict the frequency of future exacerbations in Indian COPD patients.
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April 2019

A rationale for cone beam CT with extended longitudinal field-of-view in image guided adaptive radiotherapy.

Phys Med 2019 Jun 21;62:129-139. Epub 2019 May 21.

Department of Radiation Oncology, Christian Medical College, Vellore 632004, Tamil Nadu, India. Electronic address:

Purpose: To investigate the efficacy of using cone beam CT with extended longitudinal field-of-view (CBCT) for image guided adaptive radiotherapy (IGART).

Methods: The protocol acquires two CBCT scans with a linear translation of treatment couch in the patient plane, allowing a 1 cm penumbral overlap (i.e. cone beam abutment) and fused as a single DICOM set (CBCT) using a custom-developed software script (coded in MatLab®) for extended localization. Systemic validation was performed to evaluate the geometric and Hounsfield Units accuracy at the overlapping regions of the CBCT using a Catphan®-504 phantom. Two case studies were used to illustrate the CBCT-based IGART workflow in terms of dosimetric and clinical perspectives. Segmentation accuracy/association between repeat CT (re-CT) and CBCT was evaluated. Moreover, the efficacy of the CBCT image data in deformable registration was also described.

Results: Slice geometry, spatial resolution, line profiles and HU accuracy in the overlapping regions of the CBCT yielded identical results when compared with reference CBCT. In patient studies, the dice-similarity-coefficient evaluation showed a good association (>0.9) between re-CT and CBCT. Dosimetric analysis of the CBCT-based adaptive re-plans showed excellent agreement with re-CT based re-plans. Moreover, a similar and consistent pattern of results was also observed using deformed image data (initial planning CT deformed to CBCT) with extended longitudinal projection and the same frame-of-reference as that of the CBCT.

Conclusion: Utilization of CBCT proves to be clinically appropriate and enables accurate prediction of geometric and dosimetric consequences within the planned course of treatment. The ability to compute CBCT-based treatment plans equivalent to re-CT promises a potential improvement in IGART practice.
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http://dx.doi.org/10.1016/j.ejmp.2019.03.007DOI Listing
June 2019

Correlation between circulating level of tumor necrosis factor-alpha and insulin resistance in Nigerian women with gestational diabetes mellitus.

Ann Afr Med 2018 Oct-Dec;17(4):168-171

Department of Chemical Pathology, Ahmadu Bello University, Zaria, Nigeria.

Background: Gestational diabetes mellitus (GDM) results from an imbalance between insulin resistance and insulin secretion capacity during pregnancy. Tumor necrosis factor-alpha (TNF-α) is an inflammatory cytokine that is proposed to be involved in the pathogenesis of the insulin resistance, but the findings from studies across different ethnic groups are inconsistent or even conflicting.

Aim: The aim of this study is to determine the relationship between maternal circulating level of TNF-α and insulin resistance in pregnant Nigerian women with GDM.

Methodology: This was a cross-sectional analytical study involving 100 women with GDM and another 100 pregnant women with normal gestation. They were evaluated between 24 and 28 weeks' gestation. Diagnosis of GDM was based on the WHO diagnostic criteria. Fasting serum insulin and TNF-α levels were measured. Insulin resistance index was calculated as homeostasis model assessment of insulin resistance. Multivariate correlation analysis was used to determine the relationship between the maternal serum level of TNF-α and the insulin resistance.

Results: Pregnant women with GDM had greater insulin resistance than observed in the normal controls (3.14 ± 0.19 vs. 2.89 ± 0.20, P < 0.05). There was a positive correlation between serum TNF-α level and insulin resistance among the pregnant women with GDM (r = 0.49, P < 0.05). Multiple linear regression analysis indicated that TNF-α is a predictor of insulin resistance in pregnancies complicated by GDM.

Conclusion: It is concluded that among pregnant Nigerian women with GDM in this study, increased serum TNF-α level is associated with greater insulin resistance independent of age and body mass index.
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http://dx.doi.org/10.4103/aam.aam_53_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330778PMC
August 2019

Diffuse gingival enlargement: an unusual diagnostic clue for pulmonary tuberculosis.

Lancet Infect Dis 2018 11 24;18(11):1288. Epub 2018 Oct 24.

Department of Pathology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India.

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http://dx.doi.org/10.1016/S1473-3099(18)30229-9DOI Listing
November 2018

An mHealth Intervention to Improve Young Gay and Bisexual Men's Sexual, Behavioral, and Mental Health in a Structurally Stigmatizing National Context.

JMIR Mhealth Uhealth 2018 Nov 14;6(11):e183. Epub 2018 Nov 14.

Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States.

Background: Young gay and bisexual men (YGBM) in some Eastern European countries, such as Romania, face high stigma and discrimination, including in health care. Increasing HIV transmission is a concern given inadequate prevention, travel to high-prevalence countries, and popularity of sexual networking technologies.

Objective: This study aimed to adapt and pilot test, in Romania, a preliminarily efficacious mobile health (mHealth) HIV-prevention intervention, created in the United States, to reduce HIV risk among YGBM.

Methods: After an intervention formative phase, we enrolled 43 YGBM, mean age 23.2 (SD 3.6) years, who reported condomless sex with a male partner and at least 5 days of heavy drinking in the past 3 months. These YGBM completed up to eight 60-minute text-based counseling sessions grounded in motivational interviewing and cognitive behavioral skills training with trained counselors on a private study mobile platform. We conducted one-group pre-post intervention assessments of sexual (eg, HIV-risk behavior), behavioral (eg, alcohol use), and mental health (eg, depression) outcomes to evaluate the intervention impact.

Results: From baseline to follow-up, participants reported significant (1) increases in HIV-related knowledge (mean 4.6 vs mean 4.8; P=.001) and recent HIV testing (mean 2.8 vs mean 3.3; P=.05); (2) reductions in the number of days of heavy alcohol consumption (mean 12.8 vs mean 6.9; P=.005), and (3) increases in the self-efficacy of condom use (mean 3.3 vs mean 4.0; P=.01). Participants reported significant reductions in anxiety (mean 1.4 vs mean 1.0; P=.02) and depression (mean 1.5 vs mean 1.0; P=.003). The intervention yielded high acceptability and feasibility: 86% (38/44) of participants who began the intervention completed the minimum dose of 5 sessions, with an average of 7.1 sessions completed; evaluation interviews indicated that participation was rewarding and an "eye-opener" about HIV risk reduction, healthy identity development, and partner communication.

Conclusions: This first mHealth HIV risk-reduction pilot intervention for YGBM in Eastern Europe indicates preliminary efficacy and strong acceptability and feasibility. This mobile prevention tool lends itself to broad dissemination across various similar settings pending future efficacy testing in a large trial, especially in contexts where stigma keeps YGBM out of reach of affirmative health interventions.
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http://dx.doi.org/10.2196/mhealth.9283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6262207PMC
November 2018