Preventive Medicine

E-cigarette Use Among Young Adults in the U.S. Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Mark Olfson, Melanie M. Wall, Shang-Min Liu, Ryan S. Sultan, Carlos Blanco Introduction Use of e-cigarettes is increasing among young adults in the U.S. Whether e-cigarette use serves as an aid to smoking reduction or cessation among young adults remains a matter of contention. This analysis examines patterns of e-cigarette use in relation to cigarette smoking in a nationally representative sample of U.S. young adults. Methods Data were analyzed from nationally representative U.S. adults, aged 18 to 35years (N=12,415), in the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. Logistic regression assessed associations between e-cigarette use and smoking intensity, continuity, and reduction while controlling for several potential confounding factors. Data were analyzed in 2018. Results Among cigarette smokers, e-cigarette use was associated with higher odds of tobacco use disorder (AOR=2.58, 95% CI=1.73, 3.83) and daily cigarette smoking (AOR=1.67, 95% CI=1.73, 3.83). Among adults aged 26–35years, e-cigarette use was also associated with heavy cigarette smoking (AOR=2.01, 95% CI=1.09, 3.74). Among lifetime smokers, e-cigarette use was associated with lower odds of stopping smoking (AOR=0.14, 95% CI=0.08, 0.23) and lower odds of a 50% reduction in cigarettes smoked per day (AOR=0.63, 95% CI=0.43, 0.93). Only 13.1% of young adults who ever used e-cigarettes reported using them to help stop or quit smoking. Conclusions Use of e-cigarettes by U.S. young adults, most of which is not intended to help reduce smoking, is related to more rather than less frequent and intensive cigarette smoking.

Fall Prevention Self-Management Among Older Adults: A Systematic Review Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Kumiko O. Schnock, Elizabeth P. Howard, Patricia C. Dykes Context Adequate self-management could minimize the impact of falls in older adults. The efficacy of fall prevention self-management interventions has been widely studied, yet little is known about why some older adults engage in fall prevention self-management actions and behaviors, whereas others do not. Through a systematic review of fall prevention self-management studies, this study identified characteristics and the personal, social, and environmental factors of older adults who engage in self-management actions and behaviors. Evidence acquisition Medical and nursing literature related to fall prevention self-management was searched in PubMed, Embase, and CINAHL (1997–2017), and relevant publications were selected by three researchers to assess whether the papers included subject characteristics and their fall prevention self-management actions and behaviors. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used by the researchers to assess the quality of the included studies and to determine the significance of the extracted characteristics. Evidence synthesis Searching literature through 2017, a total of 972 papers were identified, and 28 papers remained after removing those that did not meet inclusion criteria. Nine papers that addressed subject characteristics in relation to the study outcomes were included in a sub-analysis. The authors identified the following characteristics of older adults who participated in fall prevention self-management actions and behaviors: younger males, not living alone and with self-reported good health, having greater fear of falling and high fall prevention self-efficacy, and possessing high motivation for engagement with self-management activities. Conclusions The systematic literature review revealed the personal characteristics of older adults who engage in fall prevention self-management actions and behaviors.

Food Security and 10-Year Cardiovascular Disease Risk Among U.S. Adults Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Kelsey A. Vercammen, Alyssa J. Moran, Amanda C. McClain, Anne N. Thorndike, Aarohee P. Fulay, Eric B. Rimm Introduction Cardiovascular disease is a leading cause of mortality in the U.S. Although the risk of cardiovascular disease can be mitigated substantially by following a healthy lifestyle, adhering to a healthy diet and other healthy behaviors are limited by reduced food security. This study aims to determine the association between food security and cardiovascular disease risk. Methods Three samples from the 2007–2014 National Health and Nutrition Examination Survey were examined: (1) 7,340 non-fasting adults (aged 40–79 years); (2) 13,518 non-fasting adults (aged 20–64 years); and (3) 6,494 fasting adults (aged 20–64 years). Food security was assessed using the U.S. Household Food Security Survey Module, with households categorized as having full, marginal, low, or very low food security. Regressions were conducted in 2018 to test the associations between food security status and odds of ≥20% 10-year cardiovascular disease risk among middle-aged to older adults (OR, 95% CI) and cardiovascular disease risk factors among all adults (β, 95% CI). Results Compared with adults with full food security, those with very low food security had higher odds of ≥20% 10-year cardiovascular disease risk (OR=2.36, 95% CI=1.25, 4.46), whereas those with marginal food security had higher systolic blood pressure (β=0.94 mmHg, 95% CI=0.09, 1.80). Compared with adults with full food security, adults with different levels of food security had higher BMIs (marginal: 0.76, 95% CI=0.26, 1.26; low: 0.97, 95% CI=0.34, 1.60; and very low: 1.03, 95% CI=0.44, 1.63) and higher odds of current smoking (marginal: OR=1.43, 95% CI=1.17, 1.75; low: OR=1.47, 95% CI=1.22, 1.77; and very low: OR=1.95, 95% CI=1.60, 2.37). Conclusions Adults with food insecurity have elevated cardiovascular disease risk factors and excess predicted 10-year cardiovascular disease risk. Substantially improving food security may be an important public health intervention to reduce future cardiovascular disease in the U.S. population.

State-Level Beer Excise Tax and Firearm Homicide in Adolescents and Young Adults Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Robert A. Tessler, Stephen J. Mooney, D. Alex Quistberg, Ali Rowhani-Rahbar, Monica S. Vavilala, Frederick P. Rivara Introduction This study sought to determine the association between changes in state-level beer excise tax and firearm homicide rates among individuals aged 15–34years. Methods A time series analysis with synthetic controls was conducted for the years 2003–2015. Exposed states changed the beer excise tax during the study period. Synthetic controls were weighted mimics that combined portions of unexposed states using state–year specific demographic and firearm covariates. Average annual incidence rate differences were calculated between each exposed state and its synthetic control. Alcohol taxes were available through the National Institute of Alcohol Abuse and Alcoholism and firearm homicide rates were obtained from the Centers for Disease Control and Prevention. States that changed the beer excise tax but for which <2years of pre-exposure data were available were excluded. Data were collected in 2017 and analyzed in 2018. Results Five states met inclusion criteria, and all raised the beer excise tax: Illinois (2009), New York (2009), North Carolina (2009), Connecticut (2011), and Rhode Island (2013). The percentage increase in beer excise tax ranged from 10% to 27%. Differences in pre-exposure firearm homicide rates between exposed states and synthetic controls were minimal. The increase in beer excise tax was associated with a lower average annual firearm homicide rate in all states except Illinois (Rhode Island: incidence rate difference= –2.48, Connecticut: incidence rate difference= –2.57, New York: incidence rate difference= –1.45, North Carolina: incidence rate difference= –0.45, and Illinois: incidence rate difference=1.54 per 100,000 population). Conclusions Among individuals aged 15–34years, price-sensitive consumption of beer may represent one feasible tool for policymakers seeking to reduce rates of firearm homicide.

Health Insurance Coverage Among U.S. Workers: Differences by Work Arrangements in 2010 and 2015 Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Chia-ping Su, Abay Asfaw, Sara L. Tamers, Sara E. Luckhaupt Introduction For most Americans, health insurance is obtained through employers. Health insurance coverage can lead to better health outcomes, yet disparities in coverage exist among workers with different sociodemographic and job characteristics. This study compared uninsured rates among workers with different work arrangements. Methods Data from the 2010 and 2015 National Health Interview Survey–Occupational Health Supplements were used to capture a representative sample of the U.S. civilian, non-institutionalized population. Associations between work arrangement and lack of health insurance were analyzed, adjusting for covariates. Analyses were performed during 2016–2018. Results The percentage of workers aged 18–64years without health insurance coverage decreased significantly by 6.8% among workers in all work arrangement categories between 2010 and 2015. However, workers in nonstandard work arrangements were still more likely than standard workers to have no health insurance coverage. In 2015, for workers to have no health insurance the ORs were 4.92 (95% CI=3.91, 6.17) in independent, 2.87 (95% CI=2.00, 4.12) in temporary or contract, and 2.79 (95% CI=0.34, 0.41) in other work arrangements. Standard full-time workers in small establishments and standard part-time workers were also more likely to have no health insurance coverage (OR=2.74, 95% CI=2.27, 3.31, and OR=1.65, 95% CI=1.25, 2.18, respectively). Conclusions Important disparities in health insurance coverage among workers with different work arrangements existed in 2010 and persisted in 2015. Further research is needed to monitor coverage trends among workers.

Public Health Workforce Development Needs: A National Assessment of Executives' Perspectives Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Jonathon P. Leider, Fatima Coronado, Kyle Bogaert, Elizabeth Gould Introduction Workforce development is one of the ten essential public health services. Recent studies have better characterized individual worker perceptions regarding workforce interests and needs, but gaps remain around workforce needs from program managers' perspectives. This study characterized management perspectives regarding subordinate's abilities and training needs and perceived challenges to recruitment and retention. Methods In 2017, the Directors Assessment of Workforce Needs Survey was sent to 574 managers at state health agencies across the U.S. Respondents were invited based on the positions they held (i.e., to be included, respondents had to be employed as managers and oversee specific program areas). In 2018, descriptive statistics were calculated, including Fisher's exact for inferential comparisons and Tukey's test for multiple comparisons, as appropriate. Results Response rate was 49% after accounting for undeliverable e-mails; 226 respondents met the inclusion criteria. The largest perceived barriers to staff recruitment were wages or salaries (74%) and private sector competition (56%). Similarly, wages or salaries were identified as the main cause of turnover by 70% of respondents, followed by lack of opportunities for advancement (68%), and opportunities outside the agency (67%). Conclusions The Directors Assessment of Workforce Needs Survey fills important knowledge gaps and complements previously identified evidence to guide refinement of workforce development efforts. Although competition from the private sector remains challenging, these findings indicate that recruitment and retention must be top priorities in state health agencies nationwide. Prioritizing individual state health agency workforce gaps and committing to provide specific local-level interventions to those priorities is crucial for individual health agencies.

Regular Sunscreen Use and Risk of Mortality: Long-Term Follow-up of a Skin Cancer Prevention Trial Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Akiaja R. Lindstrom, Lena A. von Schuckmann, Maria Celia B. Hughes, Gail M. Williams, Adele C. Green, Jolieke C. van der Pols Introduction Sunscreen is widely used to protect the skin from harmful effects of sun exposure. However, there are concerns that sunscreens may negatively affect overall health. Evidence of the general safety of long-term regular sunscreen use is therefore needed. Methods The effect of long-term sunscreen use on mortality was assessed over a 21-year period (1993–2014) among 1,621 Australian adults who had participated in a randomized skin cancer prevention trial of regular versus discretionary sunscreen use (1992–1996). In 2018, an intention-to-treat analysis was conducted using Cox proportional hazards regression to compare death rates in people who were randomized to apply sunscreen daily for 4.5years, versus randomized to use sunscreen at their usual, discretionary level. All-cause mortality and deaths resulting from cardiovascular disease, cancer, and other causes were considered. Results In total, 160 deaths occurred in the daily sunscreen group compared with 170 deaths in the discretionary sunscreen group (hazard ratio=0.94, 95% CI=0.76, 1.17); 59vs 76 cardiovascular disease deaths (hazard ratio=0.77, 95% CI=0.55, 1.08), 63vs 58 cancer deaths (hazard ratio=1.09, 95% CI=0.76, 1.57), and 45vs 44 deaths resulting from other causes (hazard ratio=1.02, 95% CI=0.67, 1.54) occurred respectively. Conclusions Regular use of a sun protection factor 16 sunscreen on head, neck, arms, and hands for 4.5years did not increase mortality.

Non-clinical Prevention Opportunities and Waste in the U.S. Healthcare System Publication date: Available online 14 March 2019 Source: American Journal of Preventive Medicine Author(s): J. Mac McCullough, Matthew Speer, Steven M. Teutsch, Jonathan E. Fielding

U.S. Emergency Department Visits Resulting From Nonmedical Use of Pharmaceuticals, 2016 Publication date: Available online 6 March 2019 Source: American Journal of Preventive Medicine Author(s): Andrew I. Geller, Deborah Dowell, Maribeth C. Lovegrove, Jana K. McAninch, Sandra K. Goring, Kathleen O. Rose, Nina J. Weidle, Daniel S. Budnitz Introduction National data on morbidity from nonmedical use of pharmaceuticals are limited. This study used nationally representative, public health surveillance data to characterize U.S. emergency department visits for acute harms from nonmedical use of pharmaceuticals and to guide prevention efforts. Methods Data collected in 2016 from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project were analyzed in 2018 to calculate national estimates of emergency department visits for harms from nonmedical use of pharmaceuticals. Results Based on 5,130 surveillance cases, there were an estimated 358,247 emergency department visits (95% CI=280,675, 435,819) in 2016 for harms from nonmedical use of pharmaceuticals and 41.1% resulted in hospitalization (95% CI=32.3%, 49.8%). One half (50.9%, 95% CI=46.6%, 55.3%) of estimated visits involved patients aged ≤34 years; more than one half of estimated visits also involved non-pharmaceutical substances (52.9%, 95% CI=49.7%, 56.1%), including illicit drugs in 34.1% (95% CI=30.9%, 37.2%) and alcohol in 21.8% (95% CI=19.8%, 23.9%). Overall, benzodiazepines were implicated in 46.9% (95% CI=42.5%, 51.2%) of estimated emergency department visits for nonmedical use of pharmaceuticals but were the only substance implicated in just 6.5% (95% CI=5.1%, 7.9%). Prescription opioids were implicated in 36.2% (95% CI=30.8%, 41.7%) of estimated emergency department visits and were the only substance implicated in 11.3% (95% CI=8.6%, 14.0%). Conclusions Although prescription opioids or benzodiazepines are frequently implicated in emergency department visits for nonmedical use, because other substances and additional pharmaceuticals are most often involved, prescribing clinicians should consider implementing specific screening to address polysubstance use and, when warranted, treatment interventions.

Wellness Committee Status and Local Wellness Policy Implementation Over Time Publication date: March 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 3 Author(s): Carolyn D. McIlree, Hannah G. Lane, Yan Wang, Erin R. Hager Introduction Local Wellness Policies are school-district documents containing guidelines for schools to promote nutrition/physical activity. In cross-sectional studies, schools with wellness committees are more likely to implement Local Wellness Policies. This prospective cohort study examines associations between wellness committee status over time and change in Local Wellness Policy implementation using a biennial, statewide survey. Methods School administrators completed surveys following the 2012–2013 (Wave I) and 2014–2015 (Wave II) school years, including a 17-item Local Wellness Policy implementation scale. Four wellness committee status categories included established (both Waves, 35%); new (Wave II only, 22%); discontinued (Wave I only, 13%); and never (neither Wave, 30%). Linear mixed models conducted in 2017–2018 compared LWP implementation change across status groups, accounting for clustering and school characteristics. Results Of 1,333 schools, 701 had Wave I data (53%); 748 Wave II (56%); and 441 both (33%). Schools were 69% elementary, 56% suburban, and 35% and 28% had majority (≥75%) African American/Hispanic or low-income student body, respectively. At Wave I, schools with wellness committees (established/discontinued groups) had higher Local Wellness Policy implementation (mean=32.0, SD=11.5, and mean=28.3, SD=11.4, respectively) compared with schools without committees (never/new: mean=15.4, SD=10.7 and mean=17.6, SD=11.4, respectively, F=64.9, p≤0.001). Over time, never and established groups maintained low and high Local Wellness Policy implementation, respectively. Compared with never, new committees increased implementation by 9.9 points (SE=1.8, p<0.001), and discontinued committees decreased by 11.2 (SE=2.1, p<0.001). Conclusions Forming and maintaining wellness committees encourages Local Wellness Policy implementation and should be a recommended strategy for school wellness promotion.

Medical Journal of Babylon (Med J Babylon)

The association between serum zinc levels and insulin resistance among polycystic ovary syndrome patients in Duhok City, Kurdistan Region, Iraq Lashkar Abdullah Jasem, Dhia Mustafa Sulaiman Medical Journal of Babylon 2019 16(1):1-4 Background: Polycystic ovary syndrome (PCOS) is a relatively common endocrine and metabolic problem. Patients with PCOS are known to have a higher incidence of insulin resistance. The homeostasis model assessment (HOMA) is an indirect, rapid, accurate, and cost-effective method of assessing insulin resistance based on patient's fasting plasma insulin and glucose concentrations. Several studies have reported a significant correlation between HOMA and the traditional hyperinsulinemic-euglycemic clamp method. Zinc deficiency promotes insulin resistance, and that zinc supplementation can prevent or, at least, alleviate insulin resistance in selected patient populations. Objective: The current study primarily aims at defining the association between insulin resistance and zinc deficiency among both PCOS and selected controls. It also looks at certain risk factors associated with obesity among the study population in Duhok City, Kurdistan Region, Iraq. Materials and Methods: The current case–control study was performed at Azadi Teaching Hospital/Gynecological Outpatient Clinic in Duhok City/Kurdistan Region/Iraq. The study included 80 women (40 cases with PCOS and 40 controls of healthy women). Results: There was no age difference between both groups (Mean = 26.77 years, standard deviation [SD] = 6.42 years for PCOS cases versus mean and SD of 27.57 years and 6.45 years, respectively; P= 0.48). Likewise, there was no difference in the serum zinc levels between cases and controls. However, patients with PCOS had significantly higher Body mass index and HOMA scores compared to the controls (P = 0.005 and 0.007, respectively). Conclusion: Higher serum zinc levels are independently associated with lower HOMA. Patients with PCOS had significantly higher insulin resistance when compared to the controls of similar age and zinc level.

Prevalence of symptomatic urinary tract infections and asymptomatic bacteriuria in Iraqi pregnant women of Babylon Governorate Najlaa Abass Al-Mamoryi, Abdulrazzaq Salman Al-Salman Medical Journal of Babylon 2019 16(1):5-12 Background: Urinary tract infections (UTIs) are the most common infections among pregnant women. It can be lead to poor maternal and perinatal outcomes. Objective: The objective of the study is to determine the prevalence rate of symptomatic UTIs and asymptomatic bacteriuria of pregnant women in the Babylon Governorate and to determine its association with sociodemographic, obstetrical, and other factors. Materials and Methods: Cross-sectional study between March 2018 and June 2018 involves examining 300 pregnant women at primary health centers; Maternity and Pediatrics Hospital of Hilla city, with and without symptoms of UTI were employed for this study. Midstream urine samples were taken, and general urine examination was performed. Results: The results of this study revealed that the overall prevalence of UTI among pregnant was 64.6% which include (symptomatic bacteriuria 8.0%, asymptomatic bacteriuria 6.3%, and UTI 50.3%). The higher rate of UTI was found in lower age, multiparous women, and during the second trimester. Factors such as socioeconomic status, history of UTI, dysuria, and positive laboratory results were found to be significantly associated with UTI. Conclusion: UTI is still the common health problem in pregnant women especially during their second trimester. Urinalyses are essential for all pregnant women during the antenatal period. The screening will be assisted to early detection and treatment of asymptomatic bacteriuria which prevent complication for mother and baby.

Knowledge, attitudes, and practice of complementary and alternative medicine among diabetic patients Esraa Kadhum Mehdi, Hadeel Fadhil Farhood Medical Journal of Babylon 2019 16(1):13-19 Background: Complementary and alternative medicine (CAM) is defined as a group of various medical and healthcare systems, practices, and products that are not generally considered part of conventional western medicine. Objective: This study was carried out to estimate the prevalence of CAM use among diabetic patients and to assess knowledge, attitudes, and practice of CAM among diabetic patients. Materials and Methods: This is a hospital-based cross-sectional study done at diabetic center of Merjan teaching hospital on 200 patients. Results: This study estimated that the prevalence of CAM use among diabetic patients at Babylon province was 48.5%; the most common type of CAM used by diabetic patients was Herbal products (24.7%), while nutritional supplements and spiritual healing together used by (18.6%)of (CAM) users, herbal products and nutritional supplements together at rate of (14.4%) and (40.2%) use the 3 types of CAM modalities together. The most common type of Herbal products used by diabetic patients were Garlic which used at (16.9%), while Lemon used by (19.1%) of Diabetic patients, Cinnamon (Darcin) (10.2%), Fenugreek (Helba) (8.8%), (7.3%) bitter gum, and (18.3%) were a mixture of herbs, (7.3%) black seed. (62%)of Subjects had good knowledge about (CAM),(28%) had fair knowledge and (10%) poor knowledge. (66%) of (CAM )users had negative attitudes toward (CAM) and (34%) had positive attitude. Conclusion: Our study estimated the prevalence of CAM use among diabetic patients, revealed good knowledge of the diabetic patients and negative attitudes of CAM users, and showed five significant associations with score of knowledge and attitudes (age, educational level, residence, family history of DM, and follow-up visits), which was consistent with some studies in other eastern and western countries.

Evaluation of the effect of dapagliflozin on atherosclerosis progression by interfering with inflammatory and oxidative stress pathways in rabbits Hajir Karim Abd-Ulhussein, Fadhil Abdul-Jabbar Rizij Medical Journal of Babylon 2019 16(1):20-24 Background: Atherosclerosis is a very common disease in which fat deposition in the inner layers of arteries leading to plaques formation. Dapagliflozin is one of a new class of drugs known as the sodium-glucose cotransporter-2 inhibitors, responsible for lowering of the blood glucose level, and enhancing urinary glucose excretion. Dapagliflozin may lower blood glucose levels and at the same time prevent cardiovascular diseases. Objective: The objective of this study was to assess the effect of dapagliflozin on atherosclerosis through interfering with inflammatory and oxidative pathways. Materials and Methods: Eighteen local domestic male rabbits were used in this study. The rabbits were randomly divided into three groups: Group I rabbits fed normal chow diet for 12 weeks; Group II rabbits fed with 0.5% cholesterol-enriched diet; and Group III rabbits fed with 0.5% cholesterol-enriched diet together with dapagliflozin (1 mg/kg once daily). Blood samples were collected before the study (zero time) and every 4 weeks for the measurement of serum total cholesterol, triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), very LDL-C (VLDL-C), tumor necrosis factor alpha (TNF-α), and endothelin-1 (ET-1). Results: Dapagliflozin treatment showed insignificant elevation in total cholesterol and LDL-C, significant decrease VLDL-C and TG, and significant elevation of HDL-C level (P < 0.05) compared with the induced untreated group. It was insignificantly decreased inflammatory markers (TNF-α and ET-1), increased aortic total antioxidant capacity, and significantly reduced aortic intima thickness compared with induced untreated group. Dapagliflozin, by slightly interfering with inflammatory and oxidative pathways, may show beneficial effects on atherosclerosis and can attenuate the atherosclerotic lesion formation. Conclusion: Dapagliflozin may have a beneficial effect on atherosclerosis by slightly interfering with inflammatory and oxidative pathways and can reduce the atherosclerotic lesion formation; however, our study needs further clinical studies to be carried out on large population.

Evaluation of the quality of maternal health services in primary health-care centers by using service provision Assessment Wedyan Ibrahim Ismael, Hadeel Fadhil Farhood Medical Journal of Babylon 2019 16(1):25-30 Background: The Service Provision Assessment (SPA) survey is a nationwide facility-based survey that measures the ability of health facilities to provide quality preventive, diagnostic, and treatment services for key maternal and child health and HIV/AIDS programs. Objective: The study was designed to assess some aspects of expressed maternal health services provided at ten primary health-care (PHC) centers in Babylon province, Iraq, using interviews with health service providers and clients and observations of provider–client consultations to obtain information on the capacity of facilities to provide quality services, and the existence of functioning systems to support quality services. Materials and Methods: A cross-sectional study was done in ten Babylon PHC centers from March to August 2018. The study included 165 pregnant women. The questionnaire included sociodemographic factors (age, residence, employment, parity, and education) and data related to Service Provision Assessment questionnaire which include a facility inventory, client exit interviews, and antenatal care (ANC) observation and consultation. Results: The mean age of pregnant women attending ANC was 25.29 ± 5.48, 66.1% came from urban areas, the majority were not employed (83%), their educational level was secondary (38.8%), and 57% were multipara. The findings showed that the majority (89.1%) of patients think that health facility services were good. A sizeable majority (83.0%) of women were satisfied regarding health services including availability of medicines at the facility (91.5%), cleanliness of the facility (100%), privacy (93.9%), charging or payment of fees for services received (0.6%), and discussion of problems related to the pregnancy (93.3%). Conclusion: This study showed a high level of satisfaction with the quality of maternal health services among antenatal attendees and highlighted the need to support interventions that increase the uptake of formal maternal health-care services.

Evaluation of serum level of soluble lectin-like oxidized low-density lipoprotein receptor-1 and its relationship with severity of preeclampsia and birth weight Hiba Ghassan Rajab, Mohammed A.M Ali, Hala Abdulqader Al-Moayad Medical Journal of Babylon 2019 16(1):31-35 Background: Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is one of the pattern recognition receptors that plays a critical role in vascular diseases and host immune response, LOX-1 can induce endothelial dysfunction through pathways implicated with oxidative stress and inflammation that ends with vascular lesions. Objective: The objective of the study is to evaluate the serum level of soluble LOX-1 (sLOX-1) in preeclampsia (PE) and normal pregnancy to study its relationship with the severity of PE and birth weight. Materials and Methods: A total of 56 patients with PE were allocated to the study together with 28 healthy pregnant women as normal controls. PE patients divided into 28 mild and 28 severe PE. Levels of serum sLOX-1 were measured by sandwich enzyme-linked immunosorbent assay technique. Results: Results showed a significant increase in the serum sLOX-1 in preeclamptic patients (P < 0.01) compared to normal controls. The significance increased in serum levels of sLOX-1, was noted in mild (P = 0.001) and severe patients (P = 0.001), compared to normal controls. There was a significant decrease in fetal birth weight in severe PE as compared to mild and control groups which was correlated with sLOX-1, furthermore, logistic regression of the variables for the presence of low birth weight <2.5 kg. Conclusion: High level of serum sLOX-1 is associated with the occurrence and severity of PE, which provides additional information for predicting of PE and preventing its complications and for better understanding pathogenesis of PE and the results highlight the involvement of innate immunity molecules and inflammation in pathogenesis of PE through binding to apoptotic cells and angiogenic process.

Study the relation between internet usage and the occurrence of depression among Kirkuk technical students Wafa Mahmood Jasim Medical Journal of Babylon 2019 16(1):36-40 Background: Internet is regarded as one of the most indispensable parts in our life, and majority of young and adolescent people interested in the usage of it, but in some cases, these uses are become out of the control which later on lead to a condition called internet addiction in which it will be the predominant life activity. Objective: A descriptive cross-sectional study was conducted on Kirkuk Technical Institute students from January 1, 2017, to May 30, 2017 to study, if there is any relation between the occurrence of depression and internet usage. Materials and Methods: The total number of students included in the study was 550 from different scientific departments after distributing a special questionnaire form prepared for that purpose, and face-to-face interview was conducted after receiving the written consent from them. Results: The study results show that 60.8% of technical study students and 47.3% of students from administrative departments used internet daily, while 46.0% of students of health department used it weekly. In addition to that 72.1% and 67.8% male students from technical and administrative departments used internet daily, while female students from all departments (technical, administrative, and health) used the internet monthly; in addition to that 53.1% of students from administrative departments have a depressive attempts which affects daily activity and work in comparison to 18.5% of students from technical departments. Conclusion: The study concluded that the time spent for internet was about 7–9 h/daily with the presence of a suggestive depressive symptom which affects daily activity and work. Recommendations: The study recommended that further advanced educational programs about the main adverse effects of the internet and the main possible ways to control its usage.

Cytogenetic effects of gestogens on women with threatened miscarriage in Duhok Province, Kurdistan Region, Iraq Hayat S Ahmed, Dian J Salih, Iman Yousif Abdulmalek, Asaad A Alasady Medical Journal of Babylon 2019 16(1):41-46 Background: Gestogens have been recommended to have a place in the prevention of threatened miscarriage and spontaneous pregnancy loss during the first 3 months of pregnancy. Certain studies consider that this steroid hormone has genotoxic effect because they directly involved in the change of DNA structure. Objectives: This study aims to investigate the cytogenetic effects of gestogens on peripheral blood lymphocytes of pregnant women, by damaged cells and chromosomal aberrations, as well as evaluate the models for hormonal therapy in vivo. Materials and Methods: Blood sample from 30 women with threatened miscarriage, who received gestogen therapy in the first 3 months, Were taken. Cytogenetic analyses and karyotyping were performed for Each patient Before and after therapy. Results: The numerical chromosomal aberrations which found in blood lymphocytes of women before taking gestogens were 44,XX and 48,XX. The same result was observed after taking gestogens. The percentage levels of structural chromosomal aberrations were ring chromosome (2.06%), chromatid breaks (12.47%), chromatid gaps (1.65%), dicentric (0.55%), acentric chromosome (4.02%), and interchange chromosome (12.5%). Whereas, the abnormalities after treatment with gestogens were ring chromosome (5.31%), chromatid breaks (42.19%), chromatid gaps (20.86%), dicentric (7.50%), acentric chromosome (17.75%), and interchange chromosome (43.97%). Conclusion: Gestogens as hormonal substitute therapy do not induce numerical chromosomal aberrations but have a significant increase of structural chromosomal aberrations Gestogens have genotoxic effects on human lymphocyte chromosomes at wide range of concentrations. So the potential benefits and side effects of it must be weighed up against the deleterious effects.

Correlation of bilirubin and alkaline phosphatase in infantile patients with cholestasis Mostafa M Al-Bassam, Hassan H Al-Saeed, Hala Sameh Arif Medical Journal of Babylon 2019 16(1):47-50 Background: Early and successful individualized management of infantile cholestasis depends on the time of diagnosis. Objective: The objective of the study is to assess the clinical value of serum total bilirubin, direct bilirubin, and alkaline phosphatase in children with cholestasis. Materials and Methods: Sixty patients with diseases and 25 healthy controls distributed into three groups – total/direct bilirubin, and alkaline phosphatase were measured for all case and control studies by enzyme-linked immunosorbent assay. Results: The results showed serum total, direct bilirubin, and alkaline phosphatase have a highly significantly elevated in intra- and extra-hepatic cholestasis groups when compared with control (P < 0.001). There was a significantly elevated serum total and direct bilirubin when compared the extrahepatic cholestatic group with intrahepatic cholestatic group (P = 0.002 and 0.017), and there was no statistical difference between the intrahepatic cholestatic patients and extrahepatic cholestatic group when serum alkaline phosphatase measured (P = 0.610). Conclusion: From these findings, it was concluded that the level of direct bilirubin in sera of extrahepatic cholestasis group when compared with intrahepatic cholestasis group is elevated, serum total bilirubin, and alkaline phosphatase levels are good markers in determining the poor prognosis of cholestasis disease.

Effect of Vitamin D deficiency on pulmonary function test in a normal population Hemin Khalid Saber, Hamanejm Faraj Jaff, Media Qader Hasan Medical Journal of Babylon 2019 16(1):51-54 Background: During the past years, the role of Vitamin D on wide biologic processes has received the attractiveness. Moreover, the role of Vitamin D in the prevention and treatment of respiratory infections has already been confirmed. Objective: In the present study, the pulmonary functions, including forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) ratio, and FEV1/FVC ratio were compared between healthy individuals with and without Vitamin D deficiency. Materials and Methods: In the current case–control study, the pulmonary functions of healthy individuals with normal Vitamin D (control = 51) and with Vitamin D deficiency (cases = 57) were compared through statistical analysis. The individuals recruited in the study were screened from the outpatient clinic of medicine department of a public hospital purposively. The Vitamin D level <50 nmol/L was considered deficient. The reference values of pulmonary functions were considered as follows: FVC between 80% and 120% as normal and <80% as reduced; FEV1 ≥75 as normal and <75 as reduced; FEV1/FVC between 80% and 120% as normal. Results: The present study showed that individuals with normal level of Vitamin D (control) and those with deficient level of Vitamin D (case) were comparable in age (39.09 vs. 41.33 years; P= 0.393), and body mass index (27.48 vs. 28.39; P= 0.475), respectively. In addition, both case and control groups were similar in FVC (93.98 vs. 93.12; P= 0.653), FEV1 (90.88 vs. 89.39L; P= 0.752), and FEV1/FVC (95.94 vs. 95.01%; P= 0.777) respectively. Conclusion: The study did not show a significant difference in baseline characteristics and of those spirometry functions (FVC, FEV1, and FEV1/FVC) between the healthy individuals with normal and deficient Vitamin D levels.

Noncommunicable Diseases

Inhaled corticosteroids in chronic obstructive pulmonary disease: Moving toward precision medicine Ashutosh Nath Aggarwal International Journal of Noncommunicable Diseases 2019 4(1):1-3

National accountability and response for noncommunicable diseases in the United Arab Emirates Ibtihal Fadhil, Buthaina Bin Belaila, Hira Abdul Razzak International Journal of Noncommunicable Diseases 2019 4(1):4-9 Noncommunicable diseases (NCDs) remain significant health and developmental challenge in the United Arab Emirates (UAE). The four main NCDs accounted for 77% of all deaths in UAE and 17% of premature deaths (30–70 years). The UAE National Agenda 2021 reflects high-level political commitment demonstrating strong leadership to address the national challenge and meet the global commitments providing a clear roadmap to guide planning, implementation, multisectoral response, and accountability for NCD Prevention and Control. This paper, therefore, aims to present the national response to NCD highlighting the strong leadership of the government at the highest level in the UAE, together with multisectoral engagements, thus establishing a national accountability framework.

Innovative approaches to implement MPOWER policies in low-resource settings: A significant reduction in tobacco use (21.2%–16.1%) since Global Adult Tobacco Survey-1 in Himachal Pradesh, India Gopal Chauhan, Jarnail Singh Thakur International Journal of Noncommunicable Diseases 2019 4(1):10-14 MPOWER is the evidence-based toolkit for effective tobacco control under the WHO-framework convention on tobacco control (FCTC). Indian Tobacco Control Law (COTPA, 2003) and National Tobacco Control Program (NTCP, 2006) are not fully compliant to FCTC. Himachal Pradesh a northern hilly state in India with a population of about 7 million was not included under NTCP till 2014 whereas as per the Global Adult Tobacco Survey (GATS) 2009–2010 the prevalence of smoking among males (33.4%) was much higher than the national average (24.3%) with high exposure of passive smoking (82.5%) at homes. Implementing MPOWER without technical and financial support was a huge challenge. The multisectoral engagement especially the partnership between the local NGO (HPVHA) and the State Health Department under the guidance of the International Union against TB and Lung Diseases New Delhi helped in bridging the policy gaps through advocacy and capacity building. Building partnerships, sharing the responsibilities, and empowering the key stakeholders to utilize the funds collected as fine for tobacco control helped in policy implementation effectively. MPOWER implementation has achieved substantial progress in all six demand and supply reduction strategies of tobacco in the state of Himachal Pradesh. GATS, 2016–2017 shows a significant decline (21.2%–16.1%) in tobacco use and passive smoking at homes (82.5%–32.9%) in the state. Innovative approaches of implementing MPOWER policies are the way forward for effective tobacco control in low resource settings.

Effect of nutritional counseling on body mass index of adult hypertensive attending general outpatient clinic, federal medical center, Ido-Ekiti South-Western Nigeria Taiwo Adebayo Olukokun, Abayomi Olusola Ayodapo, Kehinde Fasasi Monsudi International Journal of Noncommunicable Diseases 2019 4(1):15-20 Background: Achieving target blood pressure (BP) control has become an important management challenge, as the prevalence of hypertension increases in adult Nigerians. Overweight/obesity and lack of lifestyle behaviors are associated with difficulty in achieving target BP control. This study aim at determine the effect of nutritional counseling on body mass index (BMI) of adult hypertensive attending general outpatient clinic. Materials and Methods: An interventional study was performed on 322 adult patients (161 in the intervention group and 161 in the control group) with hypertension who had been on treatment for at least 3 months. Relevant data were collected using interviewer-administered the semi-structured questionnaire and clinical parameters were measured pre- and post-intervention. The intervention group was given nutritional counseling. Results: The mean BMI in the intervention group decreased to a statistically significant level (P < 0.001), from 25.42 ± 3.99 to 24.89 ± 3.64 compared to an increase in the control group from 25.36 ± 3.73 to 25.39 ± 3.74. The mean change in BMI of the intervention group (−0.53 ± 0.59) was higher than the mean change in BMI of the control group (0.03 ± 0.45), which was statistically significant (P < 0.001). More than two-third of the intervention group 135 (83.9%) had good BP control, compared to 68 (42.2%) of the control group. Conclusion: The nutritional status of the respondents in the intervention group is better than in the control group at the end of the study. Improved nutritional status led to better BMI. Family physicians will do well to counsel hypertensive patients on nutritional and lifestyle behavior with a view to improving BP control in them.

Insulin resistance and cardiovascular risk in older adult Nigerians with type 2 diabetes Ifeoma Christiana Udenze, Idowu A Taiwo, Joseph B Minari, Wasiu Lanre Adeyemo International Journal of Noncommunicable Diseases 2019 4(1):21-26 Background: Insulin resistance (IR), which refers to decreased metabolic response to normal concentrations of insulin, has been associated with increasing age and is a trigger to the cascade of cardiometabolic abnormalities hence increasing cardiovascular disease (CVD) risk in elderly populations with type 2 diabetes (T2D). Strategies targeting IR may be key to mitigating excess CVD morbidities in elderly patients with T2D. Aim: The aim of this study is to evaluate the relationship between IR and CVD and also to identify cardiometabolic risk (CMR) factors as primary targets of CVD reduction in the older populations of Nigerians with T2D. Settings and Design: Lagos, Nigeria. Cross-sectional, analytical. Subjects and Methods: A total of 363 adult Nigerians with T2D aged between 40 and 100 years old were consecutively recruited for this study. T2D was defined according to the WHO criteria. Data were collected using a questionnaire and fasting blood samples were collected for analysis. Statistical Analysis Used: The data were analyzed using the IBM SPSS statistical package. Statistical significance was set at value of P < 0.05. Results: T2D patients in the age group of 60–80 years had significantly higher blood pressure than those in the younger age group, (P = 0.009). Fasting plasma glucose (FPG) and glycated hemoglobin were the highest in the age group of 40–60 years, (P = 0.016). IR was associated with older age in the T2D (P = 0.026). IR showed a significant correlation with CMR factors. Multivariate regression showed FPG to be independently associated with IR (P = 0.003). Conclusion: IR correlated with CMR factors and was independently associated with FPG, re-emphasizing focus on short-term blood glucose control in elderly diabetic populations.

Examining depression and quality of life in patients with thalassemia in Sri Lanka Priya Patel, Paul Beamish, Tricia L da Silva, Dewmi Kaushalya, Anuja Premawardhena, Shehan Williams, Arun V Ravindran International Journal of Noncommunicable Diseases 2019 4(1):27-33 Background: With more effective treatments and improved outcomes in thalassemia, there is increasing focus on its psychological sequelae. Most published data on this topic are from high-income countries and much less so from low- and middle-income countries, where thalassemia is more prevalent. Aim: The aim of this study was to systematically evaluate the psychiatric morbidity and quality of life in relation to demographic- and illness-related variables among Sri Lankan patients with thalassemia. Methods: This cross-sectional investigation was conducted at the University of Kelaniya Teaching Hospital in Sri Lanka. Patients with all forms of thalassemia, over 12 years of age, and in stable medical condition (n = 120) were recruited. Assessment tools included a general demographic questionnaire, the Beck Depression Inventory-II, and the World Health Organization Quality of Life Measure–Brief. Statistical analysis was conducted using linear regressions, Chi-squares, and analyses of variance. Results: Lack of family support, longer duration of inpatient admission, and female gender were associated with higher depression scores and reduced quality of life. Environmental and social quality of life were positively correlated with levels of peer support in males, while increased support from religion correlated with lower depression scores and higher satisfaction with environmental and psychological quality of life in women. There was no association between the type of thalassemia and either depression or quality of life measures. Conclusion: Several factors may influence the psychological state and well-being of patients with thalassemia in Sri Lanka. Specific service innovations (some gender-specific) may help to address these factors to improve treatment outcome and well-being.

Microbiology

IAMM recommended modification of MD microbiology curriculum to MD clinical microbiology as a speciality of medicine under consideration of MCI and Niti Ayog: Time has come to move on! Are we ready? Chand Wattal Indian Journal of Medical Microbiology 2018 36(4):453-457

Respiratory syncytial virus infections in India: Epidemiology and need for vaccine Shobha Broor, Shama Parveen, Megha Maheshwari Indian Journal of Medical Microbiology 2018 36(4):458-464 Respiratory syncytial virus (RSV) has been identified as a leading cause of lower respiratory tract infections in young children and elderly. It is an enveloped negative-sense RNA virus belonging to Genus Orthopneumovirus. The clinical features of RSV infection range from mild upper-respiratory-tract illnesses or otitis media to severe lower-respiratory-tract illnesses. Current estimates show that about 33.1 million episodes of RSV-acute lower respiratory infection (ALRI) occurred in young children in 2015, of these majority that is, about 30 million RSV-ALRI episodes occurred in low-middle-income countries. In India, the rates of RSV detection in various hospital- and community-based studies mostly done in children vary from 5% to 54% and from 8% to 15%, respectively. Globally, RSV epidemics start in the South moving to the North. In India, RSV mainly peaks in winter in North India and some correlation with low temperature has been observed. Different genotypes of Group A (GA2, GA5, NA1 and ON1) and Group B (GB2, SAB4 and BA) have been described from India. The burden of RSV globally has kept it a high priority for vaccine development. After nearly 50 years of attempts, there is still no licensed vaccine and challenges to obtain a safe and effective vaccine is still facing the scientific community. The data in this review have been extracted from PubMed using the keywords RSV and Epidemiology and India. The data have been synthesised by the authors.

Pneumococcal vaccines Anand Manoharan, Ranjith Jayaraman Indian Journal of Medical Microbiology 2018 36(4):465-474 Streptococcus pneumoniae continues to take a heavy toll on childhood mortality and morbidity across the developing world. An estimated 10.6 million invasive pneumococcal diseases (IPDs) occur every year, with nearly 1 million deaths in children under 5 years of age. Introduction of vaccines in the childhood immunisation programme in developed world has brought down the incidence of the disease considerably. However, childhood immunocompromising illnesses including HIV have increased the risk of IPD several folds. There is also a growing concern on the increasing antibiotic resistance among these invasive strains to penicillin, other beta-lactams and macrolides, making treatment difficult and expensive. It is estimated that about 62% of IPD worldwide is caused by the 10 most common serotypes. Although the ranking of individual pneumococcal serotypes causing serious disease varies among nations, the 7–13 serotypes included in pneumococcal conjugate vaccines (PCVs) may prevent 50%–80% of all paediatric pneumococcal diseases globally. The World Health Organization has recommended the use of PCV-10/13 in the national immunisation programmes (NIPs) of developing countries. Four doses of PCV-13 have been recommended by the US Association of Pediatrics and Centers for Disease Control and Prevention, at intervals of each 2 months for the first 6 months and by the 12th to 15th months after birth. This is expected to reduce the morbidity and mortality associated with IPD and simultaneously decrease colonisation with circulating antibiotic-resistant strains in immunized communities. Nevertheless, continued surveillance of antimicrobial resistance in non-vaccine serotypes is necessary to prevent the resurgence of resistance. Other virulence factors which are not serotype specific also need to be studied to overcome the drawbacks of serotype-specific pneumococcal vaccines. PCV-13 was launched during May 2017 under the NIP of five Indian states with the highest pneumococcal diseases in the country and is expected to be rolled out in the other parts of the country in the coming days.

Prosthetic joint infection: A major threat to successful total joint arthroplasty Sujeesh Sebastian, Rajesh Malhotra, Benu Dhawan Indian Journal of Medical Microbiology 2018 36(4):475-487 Total joint arthroplasty (TJA) is one of the most common and reliable orthopaedic procedures that has significantly improved the quality of life of patients with degenerative joint diseases. Following the increase in the ageing population, availability of trained orthopaedic surgeons and advances in implantation procedures, demand for TJA both globally and in India is significantly increasing. Though TJA is one of the most cost-successful orthopaedic procedures, prosthetic joint infection (PJI) is one of the major complications of joint arthroplasty. Accurate diagnosis of PJI is challenging. Since total hip and knee arthroplasties comprises the majority of TJAs, this review focuses on the current understanding of incidence, risk factors, pathogenesis, causative microorganisms, diagnosis, treatment and prevention of PJI related to these two procedures.

Multidrug-resistant Enterobacteriaceae colonising the gut of adult rural population in South India Sherly Antony, Kandasamy Ravichandran, Reba Kanungo Indian Journal of Medical Microbiology 2018 36(4):488-493 Background: Multidrug-resistant (MDR) colonisers act as a reservoir for transmission of antibiotic resistance and are a source of infection. Exposure to antibiotics by the commensal flora renders them resistant. Antibiotic consumption and hospitalisation are two major factors influencing this. We studied, antibiotic-resistant bacteria colonising rural adult population who had restricted access to health care and presumably had low consumption of antibiotics. Aim: Detection of multidrug resistance genes of extended spectrum β-lactamase (ESBL-CTX-M), AmpC β-Lactamase (CIT), Klebsiella pneumoniae carbapenemase (KPC) and New Delhi Metallo β-lactamase (NDM) in Enterobacteriaceae colonising the gut of adult population in a South Indian rural community. Methodology: Faecal samples of 154 healthy volunteers were screened for Enterobacteriaceae resistant to commonly used antibiotics by standard methods, followed by phenotypic detection of ESBL by double disk synergy method, AmpC by spot inoculation and carbapenemases by imipenem and ethylenediaminetetraacetic acid + imipenem combined E-test strips and modified Hodge test. Polymerase chain reaction was done to detect blaCTX-M,blaCIT,blaKPC-1 and blaNDM-1 genes coding for ESBL, AmpC, KPC and NDM, respectively. Results: Colonisation rate of enteric bacteria with MDR genes in the community was 30.1%. However, phenotypically, only ESBL (3.2%) and NDM (0.65%) were detected. While the genes coding for ESBL, AmpC and NDM were detected in 35.6%, 17.8% and 4.4% of the MDR isolates, respectively. Conclusions: Carriage of MDR strains with a potential to express multidrug resistance poses a threat of dissemination in the community. Awareness for restricted use of antibiotics and proper sanitation can contain the spread of resistant bacteria.

Characterization of In vitro inhibitory effects of consensus short interference RNAs against non-structural 5B gene of hepatitis C virus 1a genotype Imran Shahid, Waleed Hassan Almalki, Munjed M Ibrahim, Sultan Ahmad Alghamdi, Mohammed H Mukhtar, Shaia Saleh R. Almalki, Saad Ahmed Alkahtani, Mohammad S Alhaidari Indian Journal of Medical Microbiology 2018 36(4):494-503 Purpose: Chronic hepatitis C has infected approximately 170 million people worldwide. The novel direct-acting antivirals have proven their clinical efficacy to treat hepatitis C infection but still very expensive and beyond the financial range of most infected patients in low income and even resource replete nations. This study was conducted to establish an in vitro stable human hepatoma 7 (Huh-7) cell culture system with consistent expression of the non-structural 5B (NS5B) protein of hepatitis C virus (HCV) 1a genotype and to explore inhibitory effects of sequence-specific short interference RNA (siRNA) targeting NS5B in stable cell clones, and against viral replication in serum-inoculated Huh-7 cells. Materials and Methods: In vitro stable Huh-7 cells with persistent expression of NS5B protein was produced under gentamycin (G418) selection. siRNAs inhibitory effects were determined by analysing NS5B expression at mRNA and protein level through reverse transcription-polymerase chain reaction (PCR), quantitative real-time PCR, and Western blot, respectively. Statistical significance of data (NS5B gene suppression) was performed using SPSS software (version 16.0, SPSS Inc.). Results: siRNAs directed against NS5B gene significantly decreased NS5B expression at mRNA and protein levels in stable Huh-7 cells, and a vivid decrease in viral replication was also exhibited in serum-infected Huh-7 cells. Conclusions: Stable Huh-7 cells persistently expressing NS5B protein should be helpful for molecular pathogenesis of HCV infection and development of anti-HCV drug screening assays. The siRNA was effective against NS5B and could be considered as an adjuvant therapy along with other promising anti-HCV regimens.

Validation of pneumococcal iron acquisition (piaA) gene for accurate identification of Streptococcus pneumoniae Sreeram Chandra Murthy Peela, Sujatha Sistla, Kadhiravan Tamilarasu, Sriram Krishnamurthy, B Adhishivam Indian Journal of Medical Microbiology 2018 36(4):504-507 Purpose: The pneumococcal iron acquisition (piaA) gene is found to be highly specific and hence proposed as a diagnostic marker for identification of pneumococci. The objective of the present study was to evaluate the piaA gene as a genetic marker for the identification of pneumococci. Methods: Twenty isolates were initially sequenced for lytA gene using published primers. PiaA-PCR (piaA polymerase chain reaction) was performed using in-house primers and protocol. Based on the sensitivity and specificity results, a final sample of 30 pneumococcal isolates and 11 non-pneumococcal isolates confirmed with lytA- sequencing were selected. Statistical analyses were performed using OpenEpi v3.01 and GraphPad Quickcalc at P < 0.05 as the level of statistical significance. Results: Of the initial 20 samples tested, piaA PCR was positive in only 71.43% (10/14) of the pneumococcal isolates but was 100% specific (0/6 non-pneumococcal isolates) P = 0.011. When the PCR was performed on 41 samples, the sensitivity increased to 73.33% (95% of confidence interval [CI] = 55.55–85.82) and specificity remained the same P < 0.001. The level of agreement between the PCR and lytA-sequencing was found to be moderate (κ = 0.694; 95% CI = 0.432–0.955). Conclusions: PiaA-PCR can be used as a specific marker for the identification of pneumococcus, though it is less sensitive. As the level of agreement was moderate, further analyses on a large number of samples can give conclusive evidence for its use as a diagnostic marker for pneumococcus.

A road less travelled: Clinical comparison of HIV seropositive and seronegative patients with cystoisosporiasis – An 11-year experience from a tertiary care centre in Northern India Ujjala Ghoshal, Vidhi Jain, Nidhi Tejan, Sonali Khanduja Kalra, Prabhat Ranjan, Richa Sinha, Dinesh Gangwar, Uday C Ghoshal Indian Journal of Medical Microbiology 2018 36(4):508-512 Background: Cystoisospora is a well-known opportunistic enteric parasite among human immunodeficiency virus (HIV) seropositive patients but there is a paucity of data among HIV negative patients. This study investigated Cystosporiasis on both HIV positive and negative patients, with or without diarrhea, presenting to a tertiary care and super specialty center of northern India. Methodology: Oocysts of Cystoisospora were detected on light microscopy, by modified Kinyoun staining of stool specimens, over an 11-year study period. Results: Of the 10,233 stool specimens evaluated, Cystoisospora was detected in 64 patients, 37 (57.81%) of whom were HIV positive. Year-wise analysis showed an overall declining trend of cystoisosporiasis. Maximum cases were detected in May and June in HIV positive patients and February and September among HIV negative patients. Among HIV positive patients, the mean CD4 count was 152.04 ± 81.12cells/μL, mean absolute eosinophil count (AEC) was 229.16 ± 175.62 cells/μL and 12.5% patients had mild eosinophilia. Tuberculosis was the most common co-morbidity. Dual infections of Cystoisospora with Cryptosporidium and Giardia were also seen. Among HIV negative patients, eight had primary autoimmune disorders, seven were solid organ transplant recipients and the rest had chronic bowel diseases. The mean AEC was 485.47 ± 414.88 cells/μL, with 14.81% patients showing mild and 11.11% showing marked eosinophilia. Dual infection with Giardia was seen. Recurrent cystoisosporiasis was noted, despite cotrimoxazole treatment in a single case. Conclusion: The epidemiology of cystoisosporiasis differs between HIV seropositive and seronegative patients in terms of year-wise and month-wise trends, co-infections and most importantly, AECs.

Dual therapy with lopinavir/ritonavir plus lamivudine could be a viable alternative for antiretroviral-therapy-naive adults with HIV-1 infection regardless of HIV viral load or subgenotype in resource-limited settings: A randomised, open-label and non-inferiority study from China Linghua Li, Haolan He, Yun Lan, Jinfeng Chen, Huolin Zhong, Jingmin Nie, Xiejie Chen, Fengyu Hu, Xiaoping Tang, Weiping Cai Indian Journal of Medical Microbiology 2018 36(4):513-516 Backgrounds: This randomised controlled, open-label, non-inferiority trial was conducted in antiretroviral-naïve HIV-1-infected patients to assess the efficacy and safety of 48-week dual therapy of LPV/r plus 3TC (DT group) compared with Chinese first-line triple-therapy regimen (TT group). Methods: 198 were randomised to DT (n = 100) or TT (n = 98). Results: Ninety-two DT patients (92%) and 88 TT patients (89.8%) achieved HIV-1 RNA <50 copies/ml at week 48 (P = 0.629). Moreover, the safety profile was similar between two groups, and no secondary HIV resistance was observed. Conclusion: The results suggest that dual therapy of LPV/r plus 3TC is non-inferior to the first-line triple-therapy regimen in China.

Human papillomavirus prevalence and genotype distribution among Turkish women with or without cervical lesion Mehmet Demirci, Aylin Dag Guzel, Aynur Adeviye Ersahin, Eda Yorulmaz, Suat Suphan Ersahin, Baris Ata Borsa Indian Journal of Medical Microbiology 2018 36(4):517-521 Context: Human papillomavirus (HPV) infection is the main cause of cervical cancer, but the risk is associated with the various HPV genotypes which may be found in women with or without clinical findings. Aims: We aimed to identify HPV prevalence and genotype distribution in women with or without cervical lesions admitted to Gynaecology and Obstetrics Clinics of one of the largest private hospitals in Istanbul between 2013 and 2017. Subjects and Methods: In the present study, cervical cytobrush samples collected from 2464 women with different cytological conditions, and investigated for the presence of HPV, and the different genotypes. Results were evaluated based on the HPV positivity in different cytological findings, and ages. Furthermore, distribution of high-risk (HR) and low-risk (LR) genotypes in different groups was investigated. Results: Among all participants, 1925 (78.1%) was with the normal cytological condition, 354 (14.4%) with ASC-US; 151 (6.1%) with low-grade squamous intraepithelial lesion (LSIL), and 34 (1.4%) with high-grade squamous intraepithelial lesion (HSIL). Our results showed that 649 out of 2464 patients (26.3%) were positive, and 1815 (73.7%) were negative for the presence of HPV. Among 649 positive patients, 223 (34.3%) were found positive for more than one genotype. HPV 16 was found the most common HR-HPV type in ASC-US and LSIL whereas HPV 18 was the most common in HSIL. HPV 6 was found the most common LR-HPV type in ASC-US and LSIL whereas HPV 11 was the most common in HSIL. 26.9% of women <50 years old, and 22.3% of women ≥50 years old was positive for HPV. The most common HR-HPV genotype was 16 in both groups with (19%) or without (17%) abnormal cytology. Conclusions: We concluded that HPV prevalence and genotype distribution in women with or without clinical findings is an important predictor of cervical cancer.

Endocrinology and Metabolism

Anaplastic cancer of the thyroid: The viper in the pit Krishna G Seshadri Indian Journal of Endocrinology and Metabolism 2019 23(1):1-2

Stretched penile length and testicular size from birth to 18 years in boys from Western Maharashtra Vijay K Jaiswal, Vaman Khadilkar, Anuradha Khadilkar, Nikhil Lohiya Indian Journal of Endocrinology and Metabolism 2019 23(1):3-8 Background: Genital stage and testicular volume examination and assessment are essential for assessment of growth puberty in boys. There is paucity of Indian data for penile and testicular parameters particularly in pubertal years. Aim: The aim of this study is to present normative data for penile length, testicular volume, and testicular length from birth to 18 years in boys from western Maharashtra and to correlate these parameters with sexual maturity staging (SMR) (Tanner staging). Materials and Methods: A cross-sectional observational study was undertaken in apparently healthy boys from 0 to 18 years of age from western Maharashtra from October 2016 to October 2017. Age, anthropometric parameters, stretched penile length (SPL), testicular volume, and testicular length were measured. Pubertal stage was categorized using Tanner staging. Data were entered in Microsoft excel 2013 and using SPSS version 16. LMS method was used to construct age-specific Z-scores for SPL, testicular volume, and testicular length. Results: A total of 843 boys were enrolled in the study. Mean SPL was 4.1 ± 0.4, 5.4 ± 0.8, and 10.2 ± 1.7 cm at 1, 10, and 18 years of age, respectively, and showed a gradual rise from birth to 18 years. Mean testicular volume was 1.8 ± 0.5, 3.3 ± 1.2, and 24.1 ± 3.5 ml, whereas testicular length was 1.3 ± 0.4, 2.1 ± 0.5, and 4.4 ± 0.7 cm respectively, at 1, 10, and 18 years, respectively. The magnitude of increase for SPL and testicular volume was greater around 9–10 years. The increase in SPL and testicular size was hand in hand with SMR for genital development as well as for axillary and pubic hair stages. Conclusion: Normative data on SPL, testicular volume, and testicular length from western Maharashtra are presented. These data may be useful in disorders of puberty and genitalia in boys.

High prevalence of genital mycotic infections with sodium-glucose co-transporter 2 inhibitors among Indian patients with type 2 diabetes Ajay Aggarwal, Roopak Wadhwa, Dheeraj Kapoor, Rajeev Khanna Indian Journal of Endocrinology and Metabolism 2019 23(1):9-13 Introduction: Genital mycotic infections are common among patients with poorly controlled diabetes. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) induced pharmacological glycosuria increases the risk of these infections (2–3 fold) among patients with type 2 diabetes (T2D). The data about incidence of these infections in Indian setting is unclear. Aim: To study the prevalence of genital mycotic infections caused by SGLT2i among Indian patients with T2D. Materials and Methods: We collected data of 205 patients with T2D on SGLT2i for more than 1-month duration. Patients with symptoms and/or signs suggestive of genital mycotic infections and who had positive response to antifungal treatment were considered to have infection. Data were collected for a period of 2 months from July to August 2017. Results: Among 205 patients, mean age was 52.4 ± 8.7 years and percentage of females was 52.2%. Among SGLT2i, empagliflozin, canagliflozin and dapagliflozin were prescribed to 50.7%, 30.2% and 19.1% patients, respectively. The mean duration of treatment with SGLT2i was 7.6 ± 5.9 months. At least, one episode of genital mycotic infection occurred in 53 (25.9%) patients and 25 (12.2%) had second episode. Incidence of these infections was marginally higher in females than males with no statistically significant difference (P = ns). There was no significant correlation between age, sex, duration of disease, duration of treatment, glycaemic control, type and dose of SGLT2i used with the incidence of genital mycotic infections (P = ns). The patients who had knowledge of side effects of the drug and observed precautions had significantly lesser incidence of infections (P < 0.001). Majority of the infections were mild in nature and responded well to treatment. Conclusion: There is a very high risk of genital mycotic among Indian patients with T2D on SGLT2i. All patients should be educated about the risk of genital mycotic infections when on SGLT2i and precautions needed to minimise the risk.

Evaluation of changes in insulin sensitivity in prepubertal small for gestational age children treated with growth hormone Carmen Sydlik, Claudia Weissenbacher, Julia Roeb, Susanne Bechtold-Dalla Pozza, Heinrich Schmidt Indian Journal of Endocrinology and Metabolism 2019 23(1):14-21 Background: Although growth hormone (GH) therapy for children born small for gestational age (SGA) has been approved for many years, there are still concerns about increasing their risk for insulin resistance and diabetes mellitus type 2. Monitoring of glucose homeostasis is therefore generally recommended, but there is no consensus on either the methods or consequences. Methods and Aims: The aim of our study was to analyze the oral Glucose Tolerance Tests (oGTTs) which were performed yearly from baseline to 4 years of GH therapy in a collective of 93 SGA children, who were prepubertal during the whole follow-up. We looked for correlations with auxological and laboratory data as well as predictive baseline results for glucose homeostasis during further treatment. Results: While glucose levels remained constant, insulin secretion increased from baseline to the first year of GH therapy. Insulin sensitivity index (ISI) showed no significant change afterwards; HOMA1, HOMA2, and QUICKI stabilized after the second year. For all indices mean values never reached pathological levels and no cases of diabetes mellitus were induced. Higher gestational age, lower birth length, and older age at start of GH therapy were associated with lower insulin sensitivity. No predictive factors for later insulin resistance could be found. Conclusion: As expected, in GH-treated prepubertal SGA children insulin resistance was induced, but not to pathological levels. No special risk factors for disturbed glucose homeostasis could be identified. Based on our opinion, performing oGTTs in GH-treated SGA children at baseline and in puberty should remain mandatory, but the current study recommendations regarding further surveillance of glucose homeostasis are questionable.

Coexistence of autoimmune disorders and type 1 diabetes mellitus in children: An observation from Western Part of India Balram Sharma, Hardeva R Nehara, Sanjay Saran, Vijay K Bhavi, Anshul K Singh, Sandeep K Mathur Indian Journal of Endocrinology and Metabolism 2019 23(1):22-26 Introduction: Type 1 diabetes mellitus (T1DM) is associated with various autoimmune disorders like celiac disease, thyroid disorder, adrenal failure, etc. However, how common is this association in Indian children is not clearly known. Objective: To assess the prevalence of other coexisting autoimmune disorders in children with T1DM. Materials and Methods: In this cross-sectional study, patients requiring insulin and ketosis-prone diabetic and with history of diabetic ketoacidosis/undetectable fasting C-peptide levels were included. Beside demographic and clinical data, detailed biochemistry evaluations were performed. Celiac disease was diagnosed as per the ESPGHAN diagnostic criteria. ACTH stimulation test was done to confirm the adrenal insufficiency in patients with basal serum cortisol <5 μg/dL. Thyroid function test (TSH) and anti-TPO antibody were assessed in all patients. Screening for other autoimmune disorders was done only when clinically indicated or symptoms or family history was suggestive of presence of such disorder. Results: Among 150 patients enrolled, 64.66% were males and mean age was 13.48 ± 3.29 years (range 3–18 years). Mean age at diagnosis of T1DM was 10.0 ± 3.63 years and duration of diabetes was 3.46 ± 3.18 years. The prevalence of antibodies positive against autoimmune diseases was anti-tTG IgA (20.7%), anti-TPO (33.7%), anti-CCP ab (1.3%), and ANA (0.7%). Significantly higher proportion of females had raised anti-TPO antibodies than males (47.2% vs. 25.8%, P = 0.006). Celiac disease was most common association (24.8%) followed by hypothyroidism (14.1%) and Grave's disease (3.3%). Significantly higher proportion of females had hypothyroidism than males (25.0% vs. 8.2%, respectively, P = 0.005). Prevalence of raised anti-tTG and anti-TPO did not differ significantly by the age (P = 0.841 and P = 0.067) or duration of T1DM (P = 0.493 and P = 0.399). Conclusion: In this part of country, celiac disease, hypothyroidism, and Graves's disease are common associations in children with T1DM.

Effect of vitamin D supplementation on bone turnover markers in children and adolescents from North India Raman K Marwaha, MK Garg, A Mithal, Sushil Gupta, Manoj Shukla, Aditi Chadha Indian Journal of Endocrinology and Metabolism 2019 23(1):27-34 Objectives: Vitamin D is known to play an important role in bone mineral metabolism. Its deficiency may affect growth and status of bone markers in children. Hence, we undertook to study the status of bone markers in children with vitamin D deficiency (VDD) and impact of vitamin D3 supplementation on them. Materials and Methods: Total 468 out of 615 children and adolescents with VDD, who were given either of the three doses (600, 1000, and 2000) of vitamin D supplementation, were included in the study. These 468 children with pre- and postsupplementation preserved samples with available anthropometry, serum biochemistry, 25-hydroxy-vitamin D, and parathormone were evaluated for bone formation (procollagen type 1 amino-terminal propeptide [P1NP]) and resorption (β-cross laps [CTx]) markers. Results: The mean age and body mass index of these children were 11.3 ± 2.3 years (boys: 11.5 ± 2.4; girls: 12.2 ± 1.2 years; P = 0.03) and 18.1 ± 3.8 kg/m2 (boys: 18.2 ± 3.9; girls: 17.6 ± 3.2 kg/m2; P = 0.208), respectively. There were 8.8% subjects with severe, 42.7% with moderate, and 48.5% with mild VDD. There was a significant decline in serum P1NP (from 691 ± 233 ng/ml to 640 ± 259 ng/ml, P < 0.001) and CTx (from 1.67 ± 0.53 ng/ml to 1.39 ± 0.51 ng/ml, P < 0.001) following supplementation. Though decline in serum P1NP and CTx levels was observed in both boys and girls, among all three supplementation groups and VDD categories, the effect was more marked in serum CTx than P1NP levels. Conclusions: Vitamin D supplementation in VDD children resulted in decrease in both bone formation (P1NP) and resorption (CTx). The impact, however, was more marked on bone resorption than bone formation.

Evaluation of vitamin D status and its impact on thyroid related parameters in new onset Graves' disease- A cross-sectional observational study Swayamsidha Mangaraj, Arun K Choudhury, Basanta M Swain, Pradosh K Sarangi, Binoy K Mohanty, Anoj K Baliarsinha Indian Journal of Endocrinology and Metabolism 2019 23(1):35-39 Aims and Objective: We aimed to compare serum vitamin D level in new onset Graves' disease versus age and sex matched controls. Furthermore, we assessed the correlation of vitamin D with hormonal parameters and antibody titers in Graves' disease. Materials and Methods: In total, 84 patients of new onset Graves' disease and 42 age and sex matched healthy individuals were recruited. Biochemical and hormonal investigations that included serum calcium, phosphorous, free triiodothyronine (FT3), free thyroxine (FT4), thyroid stimulating hormone (TSH), 25 hydroxy vitamin D (25(OH) D), and parathyroid hormone (PTH) were done for all subjects. Thyrotropin receptor antibody (TRAb) was measured only for Graves' disease patients. Results: The patients with Graves' disease had significantly lower 25(OH) D levels (19.2 ± 8.9 ng/ml) as compared to control subjects (23.8 ± 12.5 ng/ml) (P = 0.019). Thyroid hormone levels, thyroid volume, and TRAb titers did not differ significantly between vitamin D deficient Graves' disease group (25(OH)D <20 ng/ml) and vitamin D non deficient Graves' disease group (25(OH)D ≥20 ng/ml). Furthermore, serum vitamin D level did not correlate significantly with thyroid hormones, thyroid volume, or TRAb titers among Graves' disease. The odds ratio (OR) for association of vitamin D deficiency (VDD) state and Graves' disease was 1.62 (95% CI 0.77–3.41). Vitamin D sufficiency state was associated significantly with lower risk of Graves' disease (OR = 0.38, 95% CI 0.15–0.95). Conclusion: Serum vitamin D levels are significantly lower in new onset Graves' disease. No significant correlation between vitamin D and thyroid hormones, thyroid volume, or TRAb titers was found in these patients. VDD state is not associated with Graves' disease.

Drug prescription patterns and cost analysis of diabetes therapy in India: Audit of an endocrine practice Rajiv Singla, Jatin Bindra, Ankush Singla, Yashdeep Gupta, Sanjay Kalra Indian Journal of Endocrinology and Metabolism 2019 23(1):40-45 Drug therapy in diabetes care along the duration of diabetes has been documented scarcely in literature, especially from Indian subcontinent. An audit of an endocrine practice from New Delhi was conducted to understand the current diabetes practice and its direct cost to the patient. Aims: The aim of this study was to analyze the current trend in the use of antidiabetes as well as other drugs for comorbidities along the duration of diabetes. The study also aimed to analyze the direct drug cost to patients. Settings and Design: Retrospective cross-sectional study. Subjects and Methods: Data captured in clinic electronic medical records of an endocrine practice was analyzed. Statistical Analysis Used: Data was analyzed descriptively using machine learning codes on python platform. Results: Records of 489 people who attended the clinic during the 6-month period were retrieved. Data of 403 people with diabetes were analyzed after exclusion of incomplete data. Use of antidiabetic drug increased from 1.44 (0.78) [mean (standard deviation)] in people with a duration of diabetes <5 years to 3.18 (1.05) in people with 20+ years of diabetes. The mean number of antidiabetic drug usage seems to plateau at 15 years of diabetes. About 46% of people with 20+ years of diabetes required insulin therapy. Prescription patterns involving a combination of different drug classes in patients were also analyzed. The cost of diabetes therapy increases linearly along the duration of diabetes. Conclusion: This study provides valuable insights on temporal prescription patterns of antidiabetic drugs from an endocrine practice. Metformin remains the most preferred drug across the entire duration of diabetes. Dipeptidyl peptidase-4 inhibitors seem to be fast catching up with sulfonylureas as a second-line treatment after metformin. After 20 years or more of diabetes duration, 46% people would require insulin for glycemic control.

A comparison between silent and symptomatic renal stones in primary hyperparathyroidism Raiz Ahmad Misgar, Ashish Sehgal, Shariq Rashid Masoodi, Arshad Iqbal Wani, Mir Iftikhar Bashir, Ajaz Ahmad Malik, Munir Ahmad Wani, Muzaffar Maqsood Wani, Imtiyaz Ahmad Wani Indian Journal of Endocrinology and Metabolism 2019 23(1):46-49 Background: Nephrolithiasis is a common complication of primary hyperparathyroidism (PHPT), and in a subgroup of patients stones are clinically silent. Patients with silent and symptomatic stones may differ biochemically. There is a scarcity of data available comparing patients with silent and symptomatic renal stones in PHPT. Aims: To characterize patients with PHPT with nephrolithiais and to compare patients with silent and symptomatic stones. Materials and Methods: We reviewed clinical data of 186 patients with PHPT managed at our center from January 1996 to December 2017. Silent renal stones were defined as ultrasonography finding of renal stones without symptoms. Symptomatic renal stones were defined as those with symptoms or a history of graveluria or any procedure for nephrolithiasis. A 5-mm diameter was set as the cut-off between micro- and macrolithiasis. We compared those with (n = 95) and without (n = 91) stones, and, among stone formers, those with symptoms (n = 66) and silent (n = 29) were compared. Results: There was no significant difference between stone formers and nonstone formers with respect to biochemical parameters. Patients with silent renal stones had significantly lower serum calcium and higher phosphate, than those with symptomatic stones. Most (75%) patients with silent renal stones had microlithiais, while only a fifth (22%) with symptomatic renal stones had microlithiasis. Conclusion: Nephrolithiasis is a common complication of PHPT. Most patients with silent renal stones had microlithiasis and biochemical features of less severe disease. Patients with silent renal stones may represent early mild stage of PHPT.

Adverse effect profile and effectiveness of sodium glucose co-transporter 2 inhibitors (SGLT2i) - A prospective real-world setting study Harmandeep Kaur Gill, Parjeet Kaur, Shama Mahendru, Ambrish Mithal Indian Journal of Endocrinology and Metabolism 2019 23(1):50-55 Background: Clinical trials have shown promising results in terms of glycemic control and weight reduction with the use of sodium glucose co-transporter 2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2DM). However, real-world evidence from standard clinical practice especially from Asia is still limited. The aim of this study was to evaluate the safety and effectiveness of SGLT2i in patients with T2DM in real-world setting. Methods: This was a prospective observational longitudinal study involving consecutive patients with T2DM, initiated on SGLT2i from 1 April 2015 to 31 March 2016. The adverse effects and metabolic parameters were evaluated at 3 monthly intervals up to 1 year. Results: Total 486 patients were initiated on SGLT2i. At baseline, mean age, glycosylated haemoglobin (HbA1c), and weight was 51.03 ± 9.82 years, 8.76 ± 1.59%, and 89.32 ± 16.04 kg, respectively. Data of 388 patients were available at 6 months of follow-up for analysis of adverse effects profile. About 38.6% patients experienced adverse effects. Genitourinary tract infection was the most common adverse effect (20.6%) followed by generalized weakness (10.5%). Significant reduction in mean weight and HbA1c reduction seen at 6 months (n = 202): 3.2 kg and 1.26%, respectively, and at 12 months (n = 104): 3.9 kg and 1.27%, respectively. Conclusion: In this real-world study of patients with T2DM living in hot climate, use of SGLT2i was associated with adverse effects in higher proportion of patients than those reported in clinical trials, but effectiveness was comparable. Patient guidance regarding adequate hydration and hygiene can maximize the benefits of this promising class of drugs.