Pankaj Shah

Chronic calcific pancreatitis of the tropics (CCPT): spectrum and correlates of exocrine and endocrine pancreatic dysfunction

The exocrine and endocrine pathophysiology of chronic calcific pancreatitis of the tropics (CCPT) remains elusive. The objective of this study was to evaluate the spectrum and correlates of the exocrine and endocrine pancreatic dysfunction in CCPT. Thirty-seven consecutive patients with a clinico-radiological diagnosis of CCPT were stratified into three subgroups: CCPT-normal glucose tolerance (NGT), CCPT-abnormal glucose tolerance (IGT) and CCPT-diabetes mellitus (DM). Ten ketosis resistant young diabetic (KRDY) patients, 10 classical insulin dependent diabetes mellitus (IDDM) patients and 18 healthy matched controls were included for comparison. Fecal chymotrypsin (FCT) levels and blood C-peptide levels (basal and post i.v. glucagon stimulation) were estimated for assessing the exocrine and endocrine pancreatic functions, respectively. Sonography was performed to evaluate the pancreatic size and ductal diameter. Pancreatic exocrine-endocrine correlation was examined by studying the C-peptide/fecal chymotrypsin ratio (CP/FCT) (CP/FCT of normal controls = 1). Mean FCT levels in all 3 subgroups of CCPT (NGT: 3.4 micrograms/g; IGT: 0.82 microgram/g; DM: 2.4 micrograms/g) were very low (87-96% reduction in exocrine pancreatic dysfunction; mean FCT in healthy controls was 22.8 micrograms/g) (P < 0.0001). In contrast, KRDY and IDDM patients displayed 50-54% reduction in pancreatic acinar function (P < 0.001). Basal and stimulated C-peptide levels progressively fell in the 3 CCPT subsets (NGT: 0.23 and 0.46 > IGT: 0.14 and 0.29 > DM 0.10 and 0.14) (P < 0.01). CCPT patients exhibited pancreatic atrophy and ductal dilation (> 3 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Self reported attitude and behavior of young diabetics about discussing their disease.

A performa-guided survey was conducted among 47 young patients of diabetes mellitus (onset of diabetes <30 years). Questions included were regarding the type of treatment, health status information about diabetes, and the assumptions and experiences of the patients on certain psychosocial behavior. A total of 59.6% subjects said that they could disclose everything about their disease to their friends and acquaintances. Twenty-seven percent felt that they could divulge only partial information and 12.8% did not want to discuss their disease with their friends and acquaintances. Subjects who said that they could disclose about their disease felt that they could do so because they were putting a lot of effort into achieving better control of their blood glucose. One of the fears expressed about not discussing their disease was that in doing so people would treat them differently or perceive them as sick. However only 38% experienced such a change in the behaviour of their acquaintances. Seventy-three percent of them had received unsolicited advice from others about food and dietary restrictions. Forty-three percent of the subjects had received instructions from acquaintances to stop all treatment and shift to household remedies. Hypoglycemia could be a motivating factor to help patients to discuss their illness with the acquaintances.

Sickle cell disease and pregnancy outcomes: a study of the community-based hospital in a tribal block of Gujarat, India

BackgroundSickle cell disease (SCD) is a hereditary blood disorder prevalent in tribal regions of India. SCD can increase complications during pregnancy and in turn negatively influence pregnancy outcomes. This study reports the analysis of tribal maternal admissions in the community-based hospital of SEWA Rural (Kasturba Maternity Hospital) in Jhagadia block, Gujarat. The objective of the study is to compare the pregnancy outcomes among SCD, sickle cell trait and non-SCD admissions. This study also estimated the risk of adverse pregnancy outcomes for SCD admissions.MethodsThe data pertains to four and half years from March 2011 to September 2015. The total tribal maternal admissions were 14640, out of which 10519 admissions were deliveries. The admissions were classified as sickle cell disease, sickle cell trait and non-sickle cell disease. The selected pregnancy outcomes and maternal complications were abortion, stillbirth, Caesarean section, haemoglobin levels, blood transfusion, preterm pregnancy, newborn birth weight and other diagnosed morbidities (IUGR, PIH, eclampsia, preterm labour pain). The odds ratios for each risk factor were estimated for sickle cell patients. The odds ratios were adjusted for the respective years.ResultsOverall, 1.2% (131 out of 10519) of tribal delivery admissions was sickle cell admissions. Another 15.6% (1645 out of 10519) of tribal delivery admissions have sickle cell trait. The percentage of stillbirth was 9.9% among sickle cell delivery admission compared to 4.2% among non-sickle cell deliveries admissions. Among sickle cell deliveries, 70.2% were low birth weight compared to 43.8% of non-sickle cell patient. Similarly, almost half of the sickle cell deliveries needed the blood transfusion. The 45.0% of sickle cell delivery admissions were pre-term births, compared to 17.3% in non-SCD deliveries. The odds ratio of severe anaemia, stillbirth, blood transfusion, Caesarean section, and low birth weight was significantly higher for sickle cell admissions compared to non-sickle cell admissions.ConclusionsThe study exhibited that there is a high risk of adverse pregnancy outcomes for women with SCD. It may also be associated with the poor maternal and neonatal health in these tribal regions. Thus, the study advocates the need for better management of SCD in tribal Gujarat.

Changing epidemiology of maternal mortality in rural India: time to reset strategies for MDG-5.

To understand changes in epidemiology of maternal mortality in rural India in the context of increasing institutional deliveries and implementation of community‐based interventions that can inform policies to reach MDG‐5.

Thyrotoxicosis, rheumatic heart disease and fever

Case presentation of a 24-year-old unmarried lady admitted to hospital because of thyrotoxicosis, rheumatic heart disease, delirium, and fever.

Accessing completeness of pregnancy, delivery, and death registration by Accredited Social Health Activists [ASHA] in an innovative mHealth project in the tribal areas of Gujarat: A cross-sectional study

Background: The Innovative Mobile-phone Technology for Community Health Operation (ImTeCHO) is a mobile-phone application that helps Accredited Social Health Activists (ASHAs) in complete registration through the strategies employed during implementation that is linking ASHAs′ incentives to digital records, regular feedback, onsite data entry, and demand generation among beneficiaries. Objective: To determine the proportion of pregnancies, deliveries, and infant deaths (events) being registered through the ImTeCHO application against actual number of events in a random sample of villages. Materials and Methods: Five representative villages were randomly selected from the ImTeCHO project area in the tribal areas of Gujarat, India to obtain the required sample of 98 recently delivered women. A household survey was done in the entire villages to enumerate each family and create a line-listing of events since January 2014; the line-listing was compared with list of women registered through the ImTeCHO application. The proportion of events being registered through the ImTeCHO application was compared against the actual number of events to find sensitivity of the ImTeCHO application. Result: A total of 844 families were found during household enumeration. Out of actual line-listing of pregnancies (N = 39), deliveries (N = 102), and infant deaths (N = 5) found during household enumeration, 38 (97.43%), 101 (99.01%), and 5 (100%) were registered by ASHAs through the ImTeCHO application. Conclusion: The use of mobile-phone technology and strategies applied during the ImTeCHO implementation should be upscaled to supplement efforts to improve the completeness of registration.

Effectiveness and Feasibility of Weekly Iron and Folic Acid Supplementation to Adolescent Girls and Boys through Peer Educators at Community Level in the Tribal Area of Gujarat.

Background: Anemia during adolescence affects growth and development of girls and boys increasing their vulnerability to dropping out-of-school. Hence investing in preventing anemia during adolescence is critical for their survival, growth and development. Objective: To find out the burden of anemia on adolescent age group in the tribal area of Jhagadia block and to assess the change in the hemoglobin level through the weekly Iron and Folic Acid IFA (DOTS) directly observed treatment supplementation under Supervision by Peer Educators at Community level among adolescents. Methods: Community based intervention study conducted with adolescents (117 girls and 127 boys) aged 10-19 years, through supplementation of IFA (DOTS) by trained Peer Educators for 52 weeks in 5 tribal villages of Jhagadia. Hemoglobin level was determined by HemoCue method before and after intervention and sickle cell anemia by Electrophoresis method. Primary data on hemoglobin and number of tablets consumed was collected and statistically analyzed in SPSS 16.0 software by applying paired t-test. Results: The overall findings suggest that the prevalence of anemia reduced from 79.5% to 58% among adolescent girls and from 64% to 39% among boys. Mean rise of hemoglobin seen was 1.5 g/dl among adolescent boys and 1.3 g/dl among girls. A significant association was found in change in hemoglobin before and after intervention (P = 0.000) Conclusion: Prevalence of anemia among girls and boys can be reduced in their adolescent phase of life, through weekly supplementation of iron folic acid tablets under direct supervision and Nutrition Education by Peer Educator at community level.

Why must Indian diabetic children continue to have retarded growth

Sir, Childhood onset (<20 years) diabetes mellitus (CDM) has been grossly neglected in India, with scant epidemiologic or clinical data, medical care or social support. Young diabetics tend to be poorly controlled, running a greater risk of acute and chronic complications. Growth retardation has life-long consequences, which recent reports suggest need not occur in CDM (1, 2). We studied the growth performance in diabetics registered at the Diabetes of Young Clinic at our center. Heights were recorded using a wall stadiometer, and height SD scores (HTSDS) calculated using recently published Indian standards (3). Prepuberty was taken as 11 years or under in girls and 14 years or under in boys; final height was assumed to have been attained by 15 and 18 years, respectively. HTSDS was correlated with growth potential (SDS for mid-parental height (MPSDS)), diabetes duration and economic status (per capita monthly family income), using multiple regression analysis. F-tests and &tests were used for joint and individual coefficient significance. All tests for individual coefficients were two-tailed t-tests. Data for 212 diabetics (124M, 88 F) were available. Age at onset was <5 years in 11%, 5-10 years in 30%, 1015 years in 31 YO and 15-20 years in 28% of patients. Diabetes duration was <1 year in 1370, 1-5 years in 35%, 5-10 years in 36% and >10 years in 16% of patients. A total of 68% of our patients were from Delhi and the surrounding areas, while the remaining patients were from all over India. Patients were equally spread across all economic strata, but girls/women had a higher average income. Diabetics with prepubertal onset had a mean (SD) HTSDS of -0.67 (1.67) in boys (n = 80) and -0.44 (1.37) in girls (n = 49). Boys whose growth was likely to be affected (prepubertal onset and diabetes duration >1 year: n = 57) had a HTSDS of -0.77 (1.77); those who had prepubertal onset and attained final height (n = 18) were even shorter (HTSDS -1.25). Girls in these two subgroups (n = 37 and n = 15) had HTSDS of -0.61 (1.39) and -0.57 (1.57), respectively. Overall, 11% of girls and 14.2% of boys had marked growth retardation (height <-2 SD). Diabetics with postpubertal onset had HTSDS of +0.16 in males (n = 11) and -0.19 in females (n = 22). Therefore, where diabetes was not influencing growth, this group was representative of normal, well nourished Indians. MPH was available for 104 children: MPSDS correlated significantly with HTSDS in the entire group ( p = 0.001), and in various subgroups in girls, suggesting little deviation from genetic potential. Boys with prepubertal onset were shorter than expected from parental height. The lesser retardation of height in girls and the closeness to genetic potential appear to be contrary to the male bias seen all over India. We hypothesize that we see more girls who are cared for, as they are more likely to survive, have regular medical attention and better metabolic control. This hypothesis is supported by their better economic status. HTSDS had a significant negative correlation with duration, more so among boys (Table 1). The earlier the onset of diabetes, therefore, the greater the chance and degree of growth retardation. Income correlated very significantly with HTSDS ( p < O.OOl), but not with MPSDS, so the two variables influenced growth independently (Table 1). The impact of higher income in a country such as India is easy to understand: it implies better education, awareness, access to medical care and ability to cope with the costs of diabetes and its complications, and sometimes less social stigma, all of which mean a better chance of good metabolic control. However, after taking into account both MPH and income, boys showed a small but significant degree of retardation, suggesting a role for better metabolic control independent of income. Glycated hemoglobin levels would have reflected glycemic control directly; unfortunately, frequent levels during the growing years were available in too few diabetics for meaningful statistical analysis. Our data suggested that diabetics, particularly boys, who have not completed their growth were significantly shorter than their peers, more so with longer duration and lower economic status. Young, diabetics in India appear to have preventable growth retardation: they

Integrated interventions for child survival : a case study

Integrated interventions for child survival as carried out in community health project of SEWA-Rural, a voluntary organisation working in tribal area of Gujarat, were discussed, They were introduced in phased manner over a period of ten years. It throws considerable light on field problems and how they can be overcome. The interventions mainly related to development of local manpower, appropriate technology like delivery pack and pictorial cards, functional referral support and linkages with other agencies, particularly with government. The latter is quite unprecedented in which the state government handed over entire PHC to a voluntary organisation.Utilisation of majority of Maternal & Child Health services has reached up to the target to be achieved by 2000 A.D. There is near-eradications of measles mortality, newborn tetanus and dramatic fall in the prevalence of vitamin A deficiency, complication of childhood tuberculosis and dehydration death.2.7 The childhood & infant mortalities have reduced to less then half, but after an initial fall there was very little further improvement in perinatal and neonatal mortality. There is an immediate need to strengthen the existing facilities of neonatal and perinatal care at all level. Those who conduct most of the deliveries in rural area, i.e. TBAs and nurses at home and in health center required appropriate training to improve their skill and knowledge. There is a need to design safe, simple, cheap but efficient technology to diagnose and manage low birth weight babies and birth asphyxia at community level.

Rates, indications, and outcomes of caesarean section deliveries: A comparison of tribal and non-tribal women in Gujarat, India

Background Even though the caesarean section is an essential component of comprehensive obstetric and newborn care for reducing maternal and neonatal mortality, there is a lack of data regarding caesarean section rates, its determinants and health outcomes among tribal communities in India. Objective The aim of this study is to estimate and compare rates, determinants, indications and outcomes of caesarean section. The article provides an assessment on how the inequitable utilization can be addressed in a community-based hospital in tribal areas of Gujarat, India. Method Prospectively collected data of deliveries (N = 19923) from April 2010 to March 2016 in Kasturba Maternity Hospital was used. The odds ratio of caesarean section was estimated for tribal and non-tribal women. Decomposition analysis was done to decompose the differences in the caesarean section rates between tribal and non-tribal women. Results The caesarean section rate was significantly lower among tribal compared to the non-tribal women (9.4% vs 15.6%, p-value < 0.01) respectively. The 60% of the differences in the rates of caesarean section between tribal and non-tribal women were unexplained. Within the explained variation, the previous caesarean accounted for 96% (p-value < 0.01) of the variation. Age of the mother, parity, previous caesarean and distance from the hospital were some of the important determinants of caesarean section rates. The most common indications of caesarean section were foetal distress (31.2%), previous caesarean section (23.9%), breech (16%) and prolonged labour (11.2%). There was no difference in case fatality rate (1.3% vs 1.4%, p-value = 0.90) and incidence of birth asphyxia (0.3% vs 0.6%, p-value = 0.26) comparing the tribal and non-tribal women. Conclusion Similar to the prior evidences, we found higher caesarean rates among non-tribal compare to tribal women. However, the adverse outcomes were similar between tribal and non-tribal women for caesarean section deliveries.