Vivek Gupta

Radial artery in CABG: could the early results be comparable to internal mammary artery graft?

BACKGROUND The accidental detection of patency of radial artery grafts, by Acar, which had been labeled as blocked 18 years earlier, has led to its revival as a conduit in coronary artery bypass surgery. We used radial artery as one of the grafts in 287 patients from February 1996 to June 1998. Here we present our early clinical experience and the midterm angiographic follow up of the initial 62 patients. METHODS A no touch, atraumatic harvesting technique coupled with gentle hydrostatic and pharmacological dilatation of the radial artery graft was employed. Radial artery was used to revascularize coronary vessels with >80% proximal stenosis. Postoperatively, the patients were administered a low dose nifedipine that was continued for 6 months thereafter. The patients were followed up clinically after discharge from the hospital and angiographic evaluation of the grafted radial artery by selective injection was done at a mean interval of 16.2 +/- 5.1 months (3-24 months) postoperatively. RESULTS There was no perioperative or late myocardial infarction or mortality. No significant complications related to the harvesting of radial artery were encountered. Angiographically, the radial artery grafts were found to be patent in 96.8% of patients (60/62). Mild distal anastomotic narrowing was seen in angiogram of one patient with good filling of the target vessel. Another patient showed diffuse spasm of radial artery graft. The patency of the pedicled left internal mammary grafts was also 98.2% (56/57). All the patients were asymptomatic. CONCLUSIONS Radial artery seems to be an excellent alternate arterial conduit for myocardial revascularization with early and midterm patency rates equivalent to that of pedicled internal mammary artery, and it should be used more often for myocardial revascularization as an adjunct to pedicled internal mammary artery graft.

Giant-cell tumour of the tendon sheath: IS RADIOTHERAPY INDICATED TO PREVENT RECURRENCE AFTER SURGERY?

Giant-cell tumour of the tendon sheath, also called pigmented villonodular synovitis, is a benign tumour with a high incidence of recurrence. We have tried to identify risk factors for recurrence. Of the 48 patients included in the study, 14 received radiotherapy after surgery. Only two (4%) had a recurrence. This compares favourably with previously reported incidences of between 25% and 45%.

Patterns of Tobacco Use Across Rural, Urban, and Urban-Slum Populations in a North Indian Community

Background: Tobacco is the leading cause of mortality globally and in India. The magnitude and the pattern of tobacco consumption are likely to be influenced by the geographical setting and with rapid urbanization in India there is a need to study this differential pattern. Aim: The aim was to study the rural, urban, and urban-slum differences in patterns of tobacco use. Settings: The study was conducted in Ballabgarh block, Faridabad district, Haryana, and was a community-based cross-sectional study. Materials and Methods: The study was conducted in years 2003-2004 using the WHO STEPS approach with 7891 participants, approximately equal number of males and females, selected using multistage sampling from urban, urban-slum, and rural strata. Statistical Analysis: The analysis was done using the SPSS 12.0 statistical package (SPSS Inc., Chicago, IL, USA). Direct standardization to the WHO world standard population was done to and chi-square and ANOVA tests were used for comparison across three study settings. Results: Self-reported tobacco use among males was as follows: urban 35.2%; urban-slums 48.3%; and rural 52.6% (P value <0.05). Self-reported tobacco use among females was as follows: Urban 3.5%; urban-slums 11.9%; and rural 17.7% (P value <0.05). More males reported daily bidi (tobacco wrapped in temburini leaf) smoking (urban 17.8%, urban-slums 36.7%, rural 44.6%) than cigarette use (urban 9.6%, urban-slums 6.3%, rural 2.9%). Females using smoked tobacco were almost exclusively using bidis (urban 1.7%, 7.9%, 11% in rural). Daily chewed tobacco use had urban, urban-slum, and rural gradients of 12%, 10.5%, and 6.8% in males respectively. Its use was low in females. Conclusion: The antitobacco policies of India need to focus on bidis in antitobacco campaigns. The program activities must find ways to reach the rural and urban-slum populations.

Revitalizing Rural Health Care Delivery: Can Rural Health Practitioners be the Answer?

The rural health system of India is plagued by serious resource shortfall and underdevelopment of infrastructure leading to deficient health care for a majority of India. The differences in urban-rural health indicators are a harsh reality even today; infant mortality rate is 62 per thousand live births for rural areas as compared to 39 per thousand live births for urban areas (2007). (1) Only 31.9% of all government hospital beds are available in rural areas as compared to 68.1% for urban population. When we consider the rural-urban distribution of population in India, this difference becomes huge. Based on the current statistics provided by the Government of India, we have calculated that at a national level the current bed-population ratio for Government hospital beds for urban areas (1.1 beds/1000 population) is almost Þ ve times the ratio in rural areas (0.2 beds/1000 population). (2,3) Apart from this shortfall in infrastructure, shortfall in trained medical practitioners willing to work in rural areas is also one of the factors responsible for poor health care delivery systems in rural areas. The number of trained medical practitioners in the country is as high as 1.4 million, including 0.7 million graduate allopaths. (4) However, the rural areas are still unable to access the services of the qualiÞ ed doctors. A total of 74% of the graduate doctors live in urban areas, serving only 28% of the national population, while the rural population remains largely unserved. (4) There’s shortfall of 8% doctors in Primary Health Centres (PHC), 65% for specialist at Community Health centres (CHC), 55.3% for health workers (male), 12.6% for health workers (female) (2007). (5) This shortfall in human resources in rural areas is only going to increase in future, more so with corporatization and privatization of health systems. The already dwindling number of doctors in government sector and rural areas would further decrease owing to greater opportunities in private sector both in urban and peri-urban areas, and much higher remunerations. In absence of qualiÞ ed doctors, predominant providers of health care in rural areas are unqualiÞ ed private practitioners, who have either no training or training in alternate system of medicine but prescribe allopathic medicines. Such providers are able to attract clientele for two reasons: Þ rstly, non-availability of qualiÞ ed doctors; and, secondly, because most of the medical conditions for which services are sought are of the common type, for which the quasi-trained practitioners can often offer some relief. However, the medical services provided by practitioners, who largely practice in a discipline in which they have no training is, in the broader context, highly damaging. For example, indiscriminate and injudicious use of antibiotics by these unqualified medical practitioners is giving rise to new mutant resistant micro-organisms. All of us in the country, and particularly the graduate doctors’ fraternity, need to reflect on why such an iniquitous and harmful mode of health service delivery exists over much of the country. Often it is argued that the Þ nancial rewards in the public health sector are too low to attract the graduate doctors to the scattered rural areas. Another reason cited is that the absence of minimal physical and social infrastructure makes it impossible for young medical graduates to serve in the rural areas, whether in public or private assignments. The qualiÞ ed medical professionals willing to serve in rural areas are scarce and whatever trained doctors are available in rural areas are in government service. It is important to note here that doctors/specialists in position do not necessarily mean that doctors/specialists are physically present at their respective centres and performing their duties; in fact, absenteeism is very high. We have to be realistic and accept that trained doctors who have put in 10 years or so in training and are predominantly from urban areas are unlikely to want to go to villages. It has been suggested in various quarters that to ensure medical personnel’s stay in rural areas they would have to be provided special incentives, pay hike or the basic amenities like electricity and water have to be improved

Validity of clinical case definitions for influenza surveillance among hospitalized patients: results from a rural community in North India

Objective:  Clinical case definitions used for influenza surveillance among hospitalized patients vary and need systematic evaluation.

Prevalence of knee osteoarthritis amongst perimenopausal women in an urban resettlement colony in South Delhi

A community-based cross-sectional study was carried out in an urban resettlement colony in South Delhi to study the prevalence of knee osteoarthritis in women aged ≥40 years and treatment seeking behavior of women suffering from osteoarthritis. Osteoarthritis was diagnosed by using clinical criteria given by American College of Rheumatology for diagnosis of Idiopathic Osteoarthritis of knee joints. A total 260 women were interviewed out of which 123 (47.3%) women were found to be suffering from knee osteoarthritis. Prevalence of osteoarthritis found to be increased with age. Less than half of those with osteoarthritis underwent treatment. With this high prevalence of osteoarthritis, there is need to spread awareness about the disease, its prevention, and rehabilitation in the community.

Rates of respiratory virus-associated hospitalization in children aged <5 years in rural northern India

Summary Objectives Though respiratory viruses are thought to cause substantial morbidity globally in children aged <5 years, the incidence of severe respiratory virus infections in children is unknown in India where 20% of the worlds children live. Methods During August 2009–July 2011, prospective population-based surveillance was conducted for hospitalizations of children aged <5 years in a rural community in Haryana State. Clinical data and respiratory specimens were collected. Swabs were tested by RT-PCR for influenza and parainfluenza viruses, respiratory syncytial virus (RSV), human metapneumovirus, coronaviruses, and adenovirus. Average annual hospitalization incidence was calculated using census data and adjusted for hospitalizations reported to occur at non-study hospitals according to a comunity healthcare utilization survey. Results Of 245 hospitalized children, respiratory viruses were detected among 98 (40%), of whom 92 (94%) had fever or respiratory symptoms. RSV accounted for the highest virus-associated hospitalization incidence (34.6/10,000, 95% CI 26.3–44.7) and 20% of hospitalizations. There were 11.8/10,000 (95% CI 7.9–18.4) influenza-associated hospitalizations (7% of hospitalizations). RSV and influenza virus detection peaked in winter (November–February) and rainy seasons (July), respectively. Conclusion Respiratory viruses were associated with a substantial proportion of hospitalizations among young children in a rural Indian community. Public health research and prevention in India should consider targeting RSV and influenza in young children.

Hypertension Vaccine may be a boon to millions in developing world

Hypertension affects around 40% adults aged 25 years and more worldwide, and accounts for 7% of total disability-adjusted life-years. A simple algorithmic program is required to manage hypertension consisting of screening, life style measures, treatment and follow-up, a reliable drug supply and distribution system, and a credible health information system. Despite availability of effective antihypertensive drugs, long term treatment is still costly, tedious, and at the population level rather unsuccessful. Hypertension leaves patients and families with an avoidable heavy economic burden due to failure to control blood pressure. Health policy needs to address gross imbalance between prevention and management by increasing contribution to the preventive programs. During 21st century, the risk factors for morbidity and mortality have been changed, and researchers have started to work upon vaccines against lifestyle diseases like hypertension, diabetes etc. Researchers began experimenting with vaccines against the renin-angiotensin system to control hypertension around six decades ago. The vaccine candidates against hypertension namely ATR12181, pHAV-4Ang IIs, CYT006-AngQb, AngI-R, ATRQβ-001 have shown promising results. A candidate vaccine, CYT006-AngQb, has crossed initial phase and moved into phase 2 trials. However, more human studies in subsequent phases of trials are required to establish the safety and efficacy of anti-hypertensive vaccine. If proved safe and cost effective, a vaccine even with 50% efficacy against hypertension may protect about 90 million people from hypertension and its heavy economic burden. It can be an appropriate solution for low compliance to antihypertensive drug therapy as well as an avalanche to induce efforts on various chronic disease vaccine development programs.

Vascularised Joint Transfer in the Management of Recurrent Giant Cell Tumour of the Second Metacarpal

This paper presents the medium-term follow-up results (34 and 40 months, respectively) of two cases of recurrent giant cell tumour of the head of the second metacarpal, treated by marginal excision and reconstruction with a vascularised toe joint transfer. Both patients had painless, stable joints with excellent ranges of motion at the metacarpophalangeal joint of 80° and 70°, respectively, no degenerative changes and no recurrence of the tumours.

Design and initiation of a study to assess the direct and indirect effects of influenza vaccine given to children in rural India.

The burden of disease due to influenza is not well characterized for children in developing countries and the effectiveness of available influenza vaccines in lower resource settings has not been established. We initiated a prospective, longitudinal, phase IV, household-randomized, controlled, observer-blinded three year study (2009-2011) in a rural community of India to measure the total and indirect household protective effects of immunizing children ages 6 months through 10 years with seasonal inactivated trivalent influenza vaccine (TIV) or a control vaccine (n=3697). Active weekly surveillance was conducted year round with home visits for identification of febrile acute respiratory illness (FARI) conducted for all vaccine recipients and household members (n=18,220). Nasal and throat swabs were collected from each FARI episode for influenza detection by real-time reverse transcription polymerase chain reaction. The primary outcome was reduction in laboratory confirmed influenza infections in the influenza vaccine versus control vaccine group, with secondary outcome assessing indirect effects among the entire study population. This report describes the study site, cluster study design, choice of study and control vaccines, and the initial enrollment in the study.