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   Table of Contents - Current issue
Coverpage
October 2020
Volume 152 | Issue 4
Page Nos. 325-438

Online since Monday, December 28, 2020

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EDITORIALS  

The COVID-19 pandemic: Challenges to prevent suicide in megacities Highly accessed article p. 325
Carolina Ziebold, Jair de Jesus Mari
DOI:10.4103/ijmr.IJMR_3992_20  PMID:33380695
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Psychiatry shifting to a new paradigm Highly accessed article p. 329
Tilman Steinert
DOI:10.4103/ijmr.IJMR_3913_20  PMID:33380696
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COMMENTARY Top

Predicting outcomes in patients with community-acquired pneumonia using weighted track & trigger early warning systems: Lessons learnt & insights for future use Highly accessed article p. 332
Alladi Mohan, KM Bhargav
DOI:10.4103/ijmr.IJMR_261_20  PMID:33380697
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PERSPECTIVE Top

Translational research in biomedical sciences in India: Challenges, observations & national perspectives Highly accessed article p. 335
Rahmat Bano, Sushma Gupta, Chander Shekhar
DOI:10.4103/ijmr.IJMR_1296_19  PMID:33380698
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REVIEW ARTICLES Top

A pragmatic approach to tackle the rising burden of breast cancer through prevention & early detection in countries 'in transition' p. 343
Partha Basu, Li Zhang, Roopa Hariprasad, Andre L Carvalho, Anton Barchuk
DOI:10.4103/ijmr.IJMR_1868_19  PMID:33380699
Among the emerging economies Brazil, Russia, India, China and South Africa (together known as the BRICS countries) share collectively approximately 40 per cent of the global population and contribute to 25 per cent of the world gross domestic products. All these countries are facing the formidable challenge of rising incidence of breast cancer and significant number of premature deaths from the disease. A multidimensional approach involving prevention, early detection and improved treatment is required to counteract the growing burden of breast cancer. A growing trend in the prevalence of major preventable risk factors of breast cancer such as obesity, western dietary habits, lack of physical activity, consumption of alcohol and smoking is contributing significantly to the rising burden of the disease in BRICS nations. Specific interventions are needed at the individual and population levels to mitigate these risk factors, preferably within the broader framework of non-communicable disease control programme. Population-based quality assured mammography-based screening of the 50-69 yr old women can reduce breast cancer mortality at least by 20 per cent. However, none of the BRICS countries have been able to implement population-based organized screening programme. Large scale opportunistic screening with mammography targeting predominantly the younger women is causing harms to the women and wasting precious healthcare resources. There are recent national recommendations to screen women with mammography in Brazil and Russia and with clinical breast examination in China (along with ultrasound) and India. Given the challenges of implementing systematic screening of the population, the BRICS countries should prioritize the early diagnosis approach and invest in educating the women about the breast cancer symptoms, training the frontline health providers to clinically detect breast cancers and appropriately refer for diagnostic confirmation, and creating improved access to good quality diagnostic and treatment facilities for breast cancer. The early diagnosis approach has been proved to achieve downstaging and improve survival at a fraction of the resources needed for population screening. The countries also need to focus on improving the services and capacity for multidisciplinary treatment of breast cancer, histopathology and immunohistochemistry, safe administration of chemotherapy and palliative care.
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Nutritional rickets & osteomalacia: A practical approach to management p. 356
Suma Uday, Wolfgang Högler
DOI:10.4103/ijmr.IJMR_1961_19  PMID:33380700
Defective mineralization of the growth plate and preformed osteoid result in rickets and osteomalacia, respectively. The leading cause of rickets worldwide is solar vitamin D deficiency and/or dietary calcium deficiency collectively termed as nutritional rickets. Vitamin D deficiency predominates in high-latitude countries in at-risk groups (dark skin, reduced sun exposure, infants and pregnant and lactating women) but is emerging in some tropical countries due to sun avoidance behaviour. Calcium deficiency predominates in tropical countries, especially in the malnourished population. Nutritional rickets can have devastating health consequences beyond bony deformities (swollen wrist and ankle joints, rachitic rosary, soft skull, stunting and bowing) and include life-threatening hypocalcaemic complications of seizures and, in infancy, heart failure due to dilated cardiomyopathy. In children, diagnosis of rickets (always associated with osteomalacia) is confirmed on radiographs (cupping and flaring of metaphyses) and should be suspected in high risk individuals with the above clinical manifestations in the presence of abnormal blood biochemistry (high alkaline phosphatase and parathyroid hormone, low 25-hydroxyvitamin D and calcium and/or low phosphate). In adults or adolescents with closed growth plates, osteomalacia presents with non-specific symptoms (fatigue, malaise and muscle weakness) and abnormal blood biochemistry, but only in extreme cases, it is associated with radiographic findings of Looser's zone fractures. Bone biopsies could confirm osteomalacia at earlier disease stages, for definitive diagnosis. Treatment includes high-dose cholecalciferol or ergocalciferol daily for a minimum of 12 wk or stoss therapy in exceptional circumstances, each followed by lifelong maintenance supplementation. In addition, adequate calcium intake through diet or supplementation should be ensured. Preventative approaches should be tailored to the population needs and incorporate multiple strategies including targeted vitamin D supplementation of at-risk groups and food fortification with vitamin D and/or calcium. Economically, food fortification is certainly the most cost-effective way forward.
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ORIGINAL ARTICLES Top

Comparison of pneumonia severity scores for patients diagnosed with pneumonia in emergency department p. 368
Aynur Ecevit Kaya, Seda Ozkan, Eren Usul, Engin Deniz Arslan
DOI:10.4103/ijmr.IJMR_595_18  PMID:33380701
Background & objectives: Sepsis due to pneumonia or pneumonia itself is one of the main causes of deaths in patients despite the advanced treatment methods. The optimal prognostic tool in pneumonia is still not clear. This study was aimed to compare the pneumonia severity scores and the possibility of using the new scores in patients who were diagnosed with pneumonia in the emergency department. Methods: Demographic data, laboratory and imaging results, confusion, elevated blood urea nitrogen, respiratory rate and blood pressure plus age ≥65 yr (CURB-65), pneumonia severity index (PSI), national early warning score (NEWS), NEWS-lactate (NEWS-L) scores, hospitalization, referral, discharge and 30-day mortality of patients who were diagnosed with pneumonia in emergency department were recorded. Results: A total of 250 patients were included in the study. The most successful score in predicted mortality was found to be NEWS-L. This was followed by NEWS, CURB-65 and PSI, respectively. Most successful scores in anticipation of admission to the intensive care unit were NEWS-L followed by NEWS. This was followed by CURB-65 and PSI scores, respectively. The most successful score in anticipation of hospital admission was NEWS-L, followed by NEWS, CURB-65 and PSI, respectively. There was a significant difference between all pneumonia severity scores of the patients who died and survived within 30 days. There was a significant difference between the scores of patients in intensive care unit (ICU) and service, compared to non-ICU patients. Interpretation & conclusions: NEWS-L score was found to be the most successful score in predicting mortality, ICU admission and hospitalization requirement. Both NEWS-L and NEWS scores can be used in determining the mortality, need for hospitalization and intensive care of the patients with pneumonia in the emergency department.
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Multicentric validation of indigenous molecular test Truenat™ MTB for detection of Mycobacterium tuberculosis in sputum samples from presumptive pulmonary tuberculosis patients in comparison with reference standards p. 378
NS Gomathi, Manjula Singh, Urvashi B Singh, VP Myneedu, DS Chauhan, Rohit Sarin, Anant Mohan, Anuj Bhatnagar, Jiten Singh Khangembam, T Kannan, M V.V Rao, Jyoti Logani, Bindu Dey, Raman R Gangakhedkar, Soumya Swaminathan, Srikanth Tripathy
DOI:10.4103/ijmr.IJMR_2539_19  PMID:33380702
Background & objectives: Early case detection is essential to interrupt transmission and to prevent further spread of tuberculosis (TB) in high endemic settings. Nucleic acid amplification tests (NAATs) with visual read-outs are ideal as point-of-care tests. Truenat™ MTB is an indigenous chip-based NAAT for detection of Mycobacterium tuberculosis, which involves extraction of DNA and real-time polymerase chain reaction (PCR) using portable, automated, battery-operated instruments. The current multicentric study was aimed to evaluate Truenat for detection of MTB in sputum samples obtained from patients with presumptive pulmonary TB with reference to culture as gold standard and Xpert as a comparator. Methods: The study was conducted at four sites, namely ICMR-National Institute for Research in Tuberculosis, Chennai; All India Institute of Medical Sciences, New Delhi; ICMR-National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Agra; and National Institute of TB and Respiratory Diseases, New Delhi. Patients suspected to have TB were screened for eligibility. Two sputum samples were collected from each patient. Tests included smear, Xpert and Truenat directly from the sputum sample and culture by Lowenstein-Jensen (L-J) medium and MGIT960 from decontaminated pellets. Sample used for Truenat assay was coded. Resolution of Truenat false positives was done using an in-house PCR with TRC4 primers. Results: The study enrolled 2419 presumptive TB patients after screening 2465 patients, and 3541 sputum samples were collected from the enrolled patients. Results of 2623 samples were available for analysis. Truenat showed a positivity rate of 48.5 per cent as compared to 37.0 per cent by Xpert. The sensitivities of Truenat and Xpert were was 88.3 and 79.7 per cent, respectively in comparison with culture. Interpretation & conclusions: Truenat MTB identified more positives among culture-confirmed samples than Xpert and had higher sensitivity. In addition, other advantageous operational features of Truenat MTB were identified which would be useful in field settings.
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Acute kidney injury is an independent predictor of in-hospital mortality in a general medical ward: A retrospective study from a tertiary care centre in south India p. 386
Vignesh Kumar Chandiraseharan, Murugabharathy Kalimuthu, Turaka Vijay Prakash, Tina George, Ashwin Rajenesh, Visalakshi Jayaseelan, Thambu David Sudarsanam
DOI:10.4103/ijmr.IJMR_1685_18  PMID:33380703
Background & objectives: Acute kidney injury (AKI) has been identified as an independent risk factor for mortality in intensive care units. This retrospective study was conducted to determine the effect of AKI on in-hospital mortality in a general medical ward of a tertiary care hospital and risk factors for mortality in patients with AKI. Methods: Demographic and clinical details, and outcome data were collected from case records of patients. In all hospitalized patients, factors associated with increased in-hospital mortality, such as AKI, inotrope requirement, mechanical ventilation and primary disease were compared between patients who died during their hospital stay and those who were discharged alive. Among the hospitalized patients, who had AKI, likely predictors of in-hospital mortality were compared between dead and alive patients at discharge. Factors that were significant in univariate analysis were tested by multivariate regression analysis to identify those that independently predicted poor outcomes. Results: Of the 1150 patients admitted in a general medical ward in a year, 220 patients were identified to have AKI. In-hospital mortality rate among patients with AKI was 19.09 per cent as compared to 1.8 per cent without AKI [adjusted odds ratio (OR) 5.7 (95% CI: 1.56-20.74)]. The presence of AKI was an independent risk factor for death, with an adjusted OR of 6.0 [95% CI: 1.67-21.6]. Among patients with AKI, the presence of haematological malignancy, adjusted OR 25.86 (95% CI: 1.81-369.58), requirement of inotrope, adjusted OR 126.5 (95% CI: 19.39-825.93) and serum creatinine at admission (P<0.001) were found to be independent predictors of death. The presence of underlying chronic kidney disease and hospital-acquired AKI were not found to have an association with mortality. Interpretation & conclusions: The study showed the in-hospital mortality rate among patients with AKI in a general medical ward was 19.09 per cent. The occurrence of AKI was an independent risk factor for death, with haematological malignancy, use of vasopressors and higher serum creatinine at admission, significantly associated with death among patients with AKI. Large prospective studies need to be done to better understand the outcomes in AKI and the ways to present and manage AKI.
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A comparative study on the anti-inflammatory effect of angiotensin-receptor blockers & statins on rheumatoid arthritis disease activity p. 393
Tarek Mohamed Mostafa, Sahar Kamal Hegazy, Emad M Elshebini, Dalia S Saif, Ahmed H Elabd
DOI:10.4103/ijmr.IJMR_640_19  PMID:33380704
Background & objectives: Rheumatoid artherits (RA) is a refractory disease and the imbalance between pro- and anti-inflammatory cytokines in favor of pro-inflammatory cytokines has been implicated in pathogenesis of RA. In this context, the aim of the present study was to compare the anti-inflammatory and antioxidant effects of candesartan, an angiotensin-receptor blocker, and atorvastatin in RA patients. Methods: In this single-blinded parallel randomized placebo controlled study, the patients recruited between December 2017 and May 2018 were categorized into three groups: group 1 included 15 RA patients who served as control group and received traditional therapy (+ placebo); group 2 included 15 RA patients who received traditional therapy + candesartan (8 mg/day); and group 3 included 15 patients who received traditional therapy + atorvastatin (20 mg/day) for three months. Clinical status in RA patients was evaluated by Disease Activity Score 28 (DAS28), Health Assessment Questionnaire-Disability Index (HAQ-DI) and morning stiffness before and three months after treatment. All groups were subjected to biochemical analysis of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), tumour necrosis factor-alpha (TNF-α), interleukin-1beta (IL-1β) and malondialdehyde (MDA) before and three months after treatment. Results: Both candesartan and atorvastatin treated groups showed significant decrease in serum levels IL-1β and TNF-α, acute-phase reactants (CRP and ESR), number of swollen joint and patient global assessment. This was also associated with improvement in disease activity and quality of life regarding DAS28 and HAQ-DI as compared to baseline data and the control group. Atorvastatin group showed significant decrease in the serum level of oxidative stress marker (MDA). Interpretation & conclusions: Both candesartan and atorvastatin showed anti-inflammatory effect and immunomodulatory effects leading to improvement in clinical status and disease activity in RA patients. However, atorvastatin was superior to candesartan through its anti-oxidant effect.
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Assessment of quality of minor millets available in the south Indian market & glycaemic index of cooked unpolished little & foxtail millet p. 401
Muthukaruppan Malavika, Shanmugam Shobana, Parthasarathy Vijayalakshmi, Raman Ganeshjeevan, Rajagopal Gayathri, Vasudevan Kavitha, Nagamuthu Gayathri, Ravichandran Savitha, Ranjit Unnikrishnan, Ranjit Mohan Anjana, Nagappa Gurusiddappa Malleshi, Kamala Krishnaswamy, Christiani Jayakumar Henry, Viswanathan Mohan, Vasudevan Sudha
DOI:10.4103/ijmr.IJMR_2309_18  PMID:33380705
Background & objectives: Millets are widely marketed as healthier alternatives to white rice (WR). This study was conducted with two aims: firstly, to look at the nature and quality of minor millets available in the Chennai market and secondly, to estimate the glycaemic index (GI) of unpolished forms of the two most widely available minor millets, i.e. little (LM) and foxtail millet (FXM). Methods: A market survey was conducted of 100 food stores in four zones of Chennai, south India. Morphological features of market millet samples were compared with that of unpolished millets under stereo-zoom microscope, and the claims declared on the pack were evaluated. A consumer perception survey was conducted among 20 minor millet-consuming female homemakers. Finally, the GI of unpolished LM and FXM was evaluated using a validated protocol in 12 healthy volunteers. Results: Forty eight brands of minor millets were available, with LM and FXM being the most common. Most of the millet samples were identified as highly polished grains using stereo-zoom microscope. The product labels were misleading and showed no scientific backing for claims mentioned on the label. Most participants (12 of 20) were unaware of the fact that millets can also be polished like rice. Both LM and FXM exhibited high GI (88.6±5.7 and 88.6±8.7, respectively). Interpretation & conclusions: The availability and knowledge regarding unpolished millets was low. Both LM and FXM exhibited high GI. Hence, substituting millets for WR might be of limited benefit considering the glycaemic property in the prevention and management of chronic non-communicable diseases such as T2DM.
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Evaluation of first information reports of Delhi police for injury surveillance: Data extraction tool development & validation p. 410
Sajjan Singh Yadav, Phil Edwards, John Porter
DOI:10.4103/ijmr.IJMR_442_20  PMID:33380706
Background & objectives: Policymakers and health professionals need to know the distribution, patterns, trends and risk factors of injury occurrence to develop strategies that reduce the incidence of injuries. The first information report (FIR) of Indian police is one potential source of this information. The aims of this study were to identify the minimum data set (MDS) recommended for injury surveillance, to develop a tool for data extraction from FIRs, to evaluate whether FIRs contain this MDS and to assess the inter-rater reliability of the tool. Methods: This was a cross-sectional study of incidents reported to Delhi Police in 2017. A systematic literature search was conducted to identify the MDS recommended for injury surveillance. A tool was designed for extraction of data, and its inter-rater reliability was assessed using Cohen's kappa and the percentage availability of each MDS data item in the FIRs, was calculated. Results: The literature review identified 24 reports that recommended 12 MDS for injury surveillance. The FIRs contained complete information on the following five MDS: sex/gender (100%), date of injury (100%), time of injury (100%), place of injurious event (100%) and intent (100%). For the following seven MDS, information was not complete: name (93.1%), age (67.2%), occupation (32.8%), residence (86.2%), activity of the injured person (86.2%), cause of the injury (93.1%) and nature of the injury (41.4%). The inter-rater reliability of the data extraction tool was found to be almost perfect. Interpretation & conclusions: Information on injuries can be reliably extracted from FIRs. Although FIRs do not always contain complete information on the MDS, if missing data are imputed, these could form the basis of an injury surveillance system. However, use of FIRs for injury surveillance could be limited by the representativeness of injuries ascertained by FIRs to the population. FIRs thus have the potential to become an important component of an integrated injury surveillance system.
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A study of collaborative telepsychiatric consultations for a rehabilitation centre managed by a primary healthcare centre p. 417
Karishma R Kulkarni, R P.S Shyam, Virupakshappa Irappa Bagewadi, Guru S Gowda, BR Manjunatha, Harihara N Shashidhara, Vinay Basavaraju, Narayana Manjunatha, Sydney Moirangthem, Channaveerachari Naveen Kumar, Suresh Bada Math
DOI:10.4103/ijmr.IJMR_676_18  PMID:33380707
Background & objectives: Telepsychiatric methods can be used for the purpose of providing clinical care comparable to in-person treatment in various settings including rehabilitation. Previous evidence has shown that clinical outcomes for both are comparable. In view of challenges posed in the implementation of traditional psychiatric care in India, telepsychiatry offers an avenue to provide feasible, affordable and clinically useful psychiatric services. This study was conducted to examine the utility, feasibility and clinical effectiveness of providing collaborative telepsychiatric services with a primary care doctor for inpatients in a rehabilitation centre through a telepsychiatrist of estabilished psychiatry department in a tertiary care centre in south India in a collaborative care model with a primary care doctor. Methods: Patients at the rehabilitation centre attached to an urban primary healthcare centre received collaborative care using telepsychiatry for a period from January 2013 to December 2016. A retrospective review of their charts was performed and sociodemographic, clinical and treatment details were collected and analyzed. Results: The sample population (n=132) consisted of 75 per cent males, with a mean age of 43.8 ± 12.1 yr. Each patient received an average of 7.8 ± 4.9 live video-consultations. Initially, an antipsychotic was prescribed for 84.1 per cent (n=111) of patients. Fifty four patients (40.9%) had a partial response and 26 (19.7%) patients showed a good response. Interpretation & conclusions: The study sample represented the population of homeless persons with mental illness who are often brought to the rehabilitation centre. This study results demonstrated the successful implementation of inpatients collaborative telepsychiatry care model for assessment, follow up, investigation and treatment of patients through teleconsultation.
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Quality of life after coronary artery bypass graft & percutaneous transluminal coronary angioplasty: A follow up study from India p. 423
Sharda Singh, Vinod Kumar Sinha, Shashikala Singh, Lalit Kapoor, Samir Kumar Praharaj, Sai Krishna Tikka, Lokesh Kumar Singh
DOI:10.4103/ijmr.IJMR_1310_18  PMID:33380708
Coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are treatments of choice for coronary artery disease. Quality of life (QoL) is an important factor in determining optimum treatment. This study was aimed to compare changes in QoL, six months post procedure, between CABG and PTCA, and to understand the confounding effect of various contributing factors. Thirty stable angina patients each in CABG and PTCA groups, were followed up for six months. QoL was assessed with WHO-QoL-BREF. Depression was rated on the Hamilton Depression Rating Scale. Changes in QoL and depression within and between CABG and PTCA groups were compared. Multinomial logistic regression was used to measure the predictive strength of treatment type (CABG and PTCA) on QoL, controlling for significant confounders. Although scores of QoL and depression significantly changed over time in both the groups, time×group interaction did not reach to a significance. Significant confounding effects of diabetes (P<0.01), hypertension (P<0.05) and diet restriction (P<0.05) were found. Controlling for confounding effects of these factors, group distribution to PTCA, compared to CABG, significantly predicted greater improvements in QoL (P<0.01).
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CORRESPONDENCES Top

Indian Council of Medical Research consensus guidelines on 'Do Not Attempt Resuscitation': Communication is key p. 427
Jenifer Jeba, Ashita Singh, Dan Munday
DOI:10.4103/ijmr.IJMR_2119_20  PMID:33380709
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Authors' response p. 428
R Mathur, P Garg, V Muthuswamy, P Mathur
DOI:10.4103/0971-5916.305171  PMID:33380710
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Unmasking fibromyalgia as a mitochondrial disorder requires search for more than a single variant or single mtDNA deletions p. 429
Josef Finsterer
DOI:10.4103/ijmr.IJMR_1039_19  PMID:33380711
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Authors' response p. 430
S Danda, BM Thomas, G Paramshivam, Raji Thomas, John Mathew, D Danda
DOI:10.4103/0971-5916.305172  PMID:33380712
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CLINICAL IMAGE Top

Extensive palpebral molluscum contagiosum in an immunocompetent child p. 432
Om Prakash, Maansi Sethi
DOI:10.4103/ijmr.IJMR_584_19  PMID:33380713
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OBITUARY Top

Obituary p. 434
Lalit Kant
DOI:10.4103/ijmr.IJMR_4320_20  PMID:33380714
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BOOK REVIEW Top

Textbook of microbiology: An integrated and clinical case based approach p. 437
Amita Jain
DOI:10.4103/ijmr.IJMR_1337_19  
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