Anupam Parashar

Scrub typhus associated acute kidney injury—a study from a tertiary care hospital from western Himalayan state of India

Abstract Objective: To report the clinical profile of acute kidney injury (AKI) associated with scrub typhus. Methods: Retrospective study of hospitalized patients of acute febrile illness who were diagnosed scrub typhus and had AKI. Results: 174 (35%) patients (75.9% female), mean age (41.4 ± 15.9 years) were studied. The laboratory abnormalities were: anemia (63.2%), leukocytosis (44.3%), thrombocytopenia (61.5%), hyponatremia (35.6%), hypernatremia (2.9%), and hypokalemia (12.1%), hyperkalemia (11.5%), hypoalbuminemia (56.9%), hepatic dysfunction (70%) and metabolic acidosis (28.7%). The complications of hypotension (5.7%), septic shock (3.4%), pneumonia (10.9%), acute respiratory distress syndrome (ARDS) (11.5%), meningoencephalitis (6.9%), encephalopathy (5.2%), gastrointestinal bleed (1.3%), myocarditis (3.4%), disseminated intravascular coagulation (2.9%) and multi organ failure (MOF) (10.3%) developed during course of hospitalization in these patients. Twenty-five (14.4%) patients required intensive care support (ICU) support and seven (4%) patients were dialyzed. 146 (83.9%) patients survived. Twenty-eight (16.1%) patients died. There was a significant difference in the age, various hematological & biochemical abnormalities, complications and need for ICU support in the non-survival group as compared the survival group. Conclusion: This study shows that AKI in scrub typhus is common and a severe disease. Age, a shorter hospital stay, severities of leukocytosis, thrombocytopenia, azotemia, hypoalbuminemia, hepatic dysfunction and the complications of ARDS, encephalopathy, MOF and need for ICU support are the factors associated with mortality.

Morbidity pattern and health-seeking behavior of aged population residing in Shimla hills of north India: A cross-sectional study

Background: Population aging is a global phenomenon. In India, the size of the elderly population is growing fast. Many older adults have multiple medical conditions. Understanding elderly health problems and health-seeking behavior is prerequisite for proving comprehensive geriatric care to them. Objectives: To assess the morbidity pattern and study the health-seeking behavior of the elderly people of Shimla district in Himachal Pradesh. Materials and Methods: A total of 400 elderly people aged 60 years and above were selected from urban and rural areas of Shimla hills in North India by simple random sampling. Statistical software Epi info software version 3.2 was used for analyzing data. Descriptive statistics were used to describe sociodemographic and morbidity variables. Results: The most common morbidity identified among them were musculoskeletal problems (55.0%) followed by hypertension (40.5%). Two third were seeking treatment for their health problems. Among older persons not seeking treatment for their medical condition, most considered these morbidities as an age-related phenomenon. Many perceived that the health services were too far. Conclusion: The high morbidity load among elderly in the present study stresses for efforts to provide better health care to them and thus ensure that they remain active members of our society. Residence emerged out to be most significant determinant of healthcare-seeking behavior. Policy makers must focus on rural elderly and their beliefs which prevent them from seeking healthcare.

Prevalence of cognitive impairment and related factors among elderly: A population-based study

Background: Older persons are at a risk of developing cognitive impairment, which is often considered a precursor to more serious conditions, such as dementia, depression or even Alzheimers disease. Mini Mental State Exam (MMSE), a cognitive screening tests rated on a 30-point scale is most widely used to study cognitive measures. Aims and Objectives: The aim of our study was to determine the prevalence of cognitive impairment among older adults, to describe the pattern of cognitive impairment in rural and urban elderly population and to investigate the influence of socio-demographic and other variables on it. Materials and Methods: A cross-sectional study was carried out between January 2010 and July 2010, in urban and rural areas of Shimla district of Himachal Pradesh. Four hundred elderly people were included in the study. Cognitive levels were assessed with the MMSE scale (cut-off score 23). Data were analysed with SPSS 17.0 software for windows. Results: The prevalence of cognitive impairment was 3.5%. It was higher in rural (2.3%) than in urban population (1.3%), with a rural/urban prevalence ratio (PR) of 1.8 (95%CI 0.6-5.7). In the logistic regression model, old-old, illiterate and widowed showed a higher probability of cognitive impairment. It was not associated with use of alcohol, cigarette smoking or under nutrition. Conclusion: Knowing the prevalence rate of cognitive impairment in elderly, together with the associated factors may inform policy makers and aid in designing better geriatric friendly health services. When planning elderly health services priority should be given to the elderly who are old-old, widowed and those who are illiterate.

Functional status and its predictor among elderly population in a hilly state of North India

Background: Functional status can be conceptualized as an individuals ability to manage activities related to personal self-care and self-maintenance. Functional status assessment is fundamental aspect of geriatric examination. This assessment helps clinicians and policymakers to design and implement interventions that help elderly to live safely and independently. Aims and Objectives: The primary aim was to assess the prevalence of limitation in activities of daily living (ADL) and instrumental ADL (IADL) among elderly population. The secondary aim was to identify the factors that predict IADL limitation among them. Materials and Methods: A total of 400 community dwelling elderly persons residing in Shimla hills of North India were interviewed using valid and reliable functional assessment scales namely Katz ADL and Lawton and Brody IADL. Statistical procedures for the analyses included descriptive statistics and logistic regression. Results: The prevalence of ADL and IADL activity limitation was 5.5% (22/400) and 21.8% (87/400), respectively. The results of logistic regression analysis revealed that advancing age (70 years and above), poor self-rated health and ailments namely musculoskeletal problems and cataract significantly predict functional limitation. Conclusions and Recommendation: Elderly having musculoskeletal problems should be provided with rehabilitative support in the community settings. Cataract surgeries patients should be identified and operated upon so as to improve visual functioning and thus their functional ability. Further, cities, towns, and rural areas should be made age-friendly.

Anemia among adolescent girls in Shimla hills of north India: Does BMI and onset of menarche have a role?

BACKGROUND Anemia is a global public health problem. Adolescents are vulnerable to iron deficiency because of increased iron requirements related to rapid growth. AIMS AND OBJECTIVES To estimate the prevalence of anemia among adolescent girls and to study whether anemia is associated with body mass index and the attainment of menarche. MATERIALS AND METHODS A cross-sectional descriptive survey was conducted in selected schools of Shimla district. One thousand five ninety-six (10-19 yrs old) school girls were included in the study. The study was conducted from June 2011 to May 2012 (1 year). Data analysis was done using SPSSS software version 18 for windows. RESULTS Prevalence of anemia was found to be 21.4%. It was seen that among the anemic adolescent girls, 77.3% had mild anemia, 21.9% had moderate anemia, and 0.5% had severe anemia. BMI and onset of menarche had no significant effect on the prevalence of anemia. In bivariate logistic regression, age and urban residence were significantly related to anemia. CONCLUSION We observed a low prevalence of anemia among adolescent girls. We recommend that adolescents be screened periodically for anemia and multi-sectoral, community-based approach be adopted to combat this serious public health issue.

Prevalence and severity of disordered mineral metabolism in patients with chronic kidney disease: A study from a tertiary care hospital in India

Background: Disordered mineral metabolism is common complications of chronic kidney disease (CKD). However, there are limited data on the pattern of these disturbances in Indian CKD population. Materials and Methods: This was a prospective observational study of CKD-mineral and bone disorder (CKD-MBD) over a period of 3 years. The biochemical markers of CKD-MBD, namely, calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone (iPTH), and 25-hydoxyvitamin Vitamin D3 (25OHD), were measured in newly diagnosed CKD Stage 3–5 and prevalent CKD Stage 5D adult patients. Results: A total of 462 patients of CKD Stage 3–5D were studied. The frequency of various biochemical abnormalities was hypocalcemia (23.8%), hypercalcemia (5.4%), hypophosphatemia (2.8%), hyperphosphatemia (55.4%), raised alkaline phosphatase (56.9%), secondary hyperparathyroidism (82.7%), and hypoparathyroidism (1.5%). 25OHD was done in 335 (72.5%) patients and 90.4% were found to have Vitamin D deficiency. About 70.6% of the patients had iPTH levels were above kidney disease outcomes quality initiative (KDOQI) target range. Nondiabetic CKD as compared to diabetic CKD had a higher alkaline phosphatase (P = 0.016), a higher iPTH (P = 0.001) a higher proportion of patients with iPTH above KDOQI target range (P = 0.09), and an elevated alkaline phosphatase (P = 0.004). The 25OHD levels were suggestive of severe Vitamin D deficiency in 33.7%, Vitamin D deficiency in 45.4%, and Vitamin D insufficiency in 11.3% patients. There was a significant positive correlation between iPTH with alkaline phosphatase (r = 0.572, P = 0.001), creatinine (r = 0.424, P = 0.001), and phosphorus (r = 0.241, P = 0.001) and a significant negative correlation with hemoglobin (r = −0.325, 0.001), age (r = −0.169, P = 0.002), and 25OHD (r = −0.126, P = 0.021). On multivariate logistic regression analysis, an elevated alkaline phosphatase was a significant predictor of hyperparathyroidism (odds ratio 9.7, 95% confidence interval 4.9–19.2, P = 0.001). Conclusions: There was a high prevalence of CKD-MBD in Indian CKD patients. CKD-MBD is more common and more severe and has an early onset as compared to the western populations.

Two Cases of Acute Kidney Injury Due to Multiple Wasp Stings

Acute kidney injury (AKI) is an unusual complication of wasp stings. Treatment of established AKI is largely supportive but the preventive strategies are not well documented. This is a report of 2 human cases that developed AKI after multiple wasp stings (Vespa magnifica). Each patient reached the hospital early in their clinical course and was treated with intravenous hydration and urine alkalization. In both the cases the severity of AKI, morbidity, and duration of hospitalization were reduced. The requirement of dialysis therapy was avoided. We propose early treatment with intravenous hydration, diuretic administration, and urine alkalization in such cases to prevent systemic and renal complications.

Acute kidney injury due to multiple Hymenoptera stings—a clinicopathological study

Abstract Background Acute kidney injury (AKI) after multiple Hymenoptera stings is well known but still a rare phenomenon. Methods We conducted a retrospective study of the clinicopathological spectrum of AKI due to multiple Hymenoptera stings over 13 years (July 2003–June 2016). Results A total of 35 patients were diagnosed with AKI due to multiple Hymenoptera stings. The mean age of the patients was 44.7 ± 17.4 years and the majority (60%) were men. Haematological and biochemical laboratory abnormalities included anaemia (97.1%), leucocytosis (54.3%), hyperkalaemia (68.6%), severe metabolic acidosis (51.4%), hepatic dysfunction (74.3%), haemolysis (91.4%) and rhabdomyolysis (62.9%). The main complications included acute respiratory distress syndrome (ARDS) and encephalopathy in four (11.4%) patients each; gastrointestinal bleeding, hypertension and panniculitis in two (5.7%) patients each and one (2.9%) patient each developed intra-abdominal bleeding, stroke and polyserositis. Twenty-nine (83%) patients required dialysis. Ten (29%) patients died. A higher white blood cell count (P = 0.05) and the complications of ARDS (P = 0.004) and encephalopathy (P = 0.004) were associated with mortality. The kidney functions normalized at 5.5 ± 2.6 weeks in patients who survived. Kidney biopsy was done in 13 patients. The predominant lesion was acute tubular necrosis (ATN) with or without pigmented granular cast in 10 (77%) patients. In four (30.8%) patients, the kidney biopsy showed severe ATN and in the other six (46.2%), the kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis (AIN). In three (23%) patients the histopathological examination revealed only moderate AIN and these patients were treated with a short course of steroids. Conclusions AKI due to multiple Hymenoptera stings is severe and is associated with high mortality. On renal histology, ATN and AIN are common.

Pre-lacteal feeding practices and associated factors in Himachal Pradesh

BACKGROUND: Prelacteal feeds are dangerous for newborn health and thus should not be given. Studying the enabling factors of this harmful practice can help determine ways of how to get rid of it. AIMS AND OBJECTIVES: This study aims to assess the pattern of prelacteal feeding in a district of Himachal Pradesh and to study its predictive factors. SETTINGS AND DESIGN: A cross-sectional study was conducted among 200 mothers attending Anganwadi centers in Shimla district of Himachal Pradesh. MATERIALS AND METHODS: Data were obtained by trained field investigator using a pretested interview schedule. In-depth interviews were held to find out the reasons for providing prelacteal feeds. STATISTICAL ANALYSIS: Data were analyzed using Epi Info software for windows (Centre for Disease Control and Prevention, Atlanta). Logistic regressions were used to find out the adjusted odds ratios (AORs) for factors associated with the practice of giving prelacteal feed. RESULTS: The prevalence of prelacteal feeding was 49.5% (confidence interval [CI] = 42.5%–56.4%). In logistic regression analysis, living in joint family (AOR = 2.5, CI = 1.3–4.9) and higher socioeconomic status (AOR = 3.8, CI = 1.1–13.1) were positively associated with prelacteal feeding practice. Mothers who delivered by cesarean section were more likely to give prelacteal feeds to their baby (AOR = 3.4, CI = 1.3–8.8) as compared to those who delivered by normal vaginal delivery. CONCLUSIONS: It is concluded that prelacteal feeding is commonly practiced in both urban and rural areas of Shimla hills of Himachal Pradesh. Child health programs in the study area should use behavior change communication to decrease the harmful practice of giving prelacteal feeds to newborns.

Role of intensive training in strengthening the skills of HIV counselors for imparting quality ICTC services

Counseling is a confidential dialogue between a client and counselor aimed at enabling the client to cope with stress and make personal decisions related to HIV/AIDS. When Voluntary Counseling and testing centers (VCTC) centers were started initially, their focus was on prevention of HIV infection, HIV testing, and dealing with social and emotional impact of a HIV positive test. The scope of services being provided has over the years expanded rapidly, with addition of prevention of parent-to-child transmission (PPTCT), access to anti retroviral therapy (ART), and better linkages with directly observed treatment short course (DOTS) centers.(1–4) In the third phase of National AIDS Control Program (NACP-111), these VCTC services are being further expanded to Community Health Center (CHC) and Primary Health Center (PHC) levels and clients will be provided comprehensive, quality services under one roof of integrated counseling and testing centers (ICTC). This planned expansion puts pressure on NACP-111 to recruit and train a large number of qualified and skilled counselors who will be the most important functionaries of these VCTCs, PPTCTs, and ICTCs throughout the country.(5) The HIV counselor needs to equip the client to prevent HIV infection, to make an informed choice about HIV testing, to cope with an HIV test result and to understand the implications of lifelong treatment.(6) National AIDS Control Organization (NACO) has developed an intensive 12 days training schedule for developing and fine tuning the counseling skills of these counselors so as to produce counselors who are sensitive to their clients problems, are well informed and can provide high quality VCT, PPTCT, and ART counseling. For this purpose, NACO has identified 18 institutes across the country who will impart trainings to HIV counselors. Our institute was selected to train counselors from Himachal and Haryana state. We tried to study the impact of 12-day intensive training program in enhancing the skills of these counselors.