Publications

Nocturnal hypertension, characterized by high blood pressure (BP) during nighttime, is a critical but often overlooked contributor to heart disease and organ damage. Globally, nocturnal hypertension is estimated to affect 6-20% of the population. Data indicating the prevalence of nocturnal hypertension in India is not available. Detection of nocturnal hypertension typically involves 24-hour ambulatory BP monitoring, which is a trusted method for detecting nocturnal BP variations such as nondipping and reverse-dipping that increase cardiovascular risk. Despite its clinical significance, nocturnal hypertension remains underdiagnosed due to various factors, and there are no specific Indian guidelines addressing its management. This expert consensus highlights key strategies for identifying and managing nocturnal hypertension in India. Lifestyle changes, such as reducing salt intake, managing stress, and improving sleep, are essential for treatment. Long-acting antihypertensive medications, including angiotensin receptor blockers, calcium channel blockers, and β-blockers, are recommended for better 24-hour BP control and reducing health risks. Additionally, newer therapies such as sodium-glucose cotransporter 2 inhibitors and angiotensin receptor-neprilysin inhibitors are promising options for patients with difficult-to-control BP or other conditions, such as diabetes or kidney disease. The consensus emphasizes the importance of tailored treatment strategies, regular BP monitoring, and integration of innovative therapies to address nocturnal hypertension effectively. These strategies aim to reduce the associated risks and improve health outcomes for patients in India.

Functional neurological disorders (FNDs) are altered voluntary symptoms incompatible with recognized medical or neurological conditions, causing significant distress to the patient. It is not a diagnosis of exclusion, but positive signs must be used to make a confident diagnosis and initiate appropriate management at the earliest. The understanding of FNDs has evolved over decades from supernatural power in the Mesopotamian age to the current neurocircuitry dysfunction and yet continues to be an area of active research. The evolution of various theories and terminologies for these disorders has been highlighted in this article in addition to key clinical signs for the diagnosis of various subsets of these disorders. In this article, FNDs are grouped into functional limb weakness, functional seizures, functional movement disorders, functional gait disorders, functional pseudosyncope, and functional cognitive dysfunction, and important clinical clues of diagnosis are discussed. FNDs contribute to about 5-10% of outpatient neurological consultations, and identification of appropriate positive clinical signs plays a key role in early diagnosis and judicious use of investigations (Bennett et al., 2021).1 Management of these disorders involves a multidisciplinary approach ranging from effective communication of the diagnosis and management of psychiatric comorbidities to individually tailored counseling and therapy sessions.

INTRODUCTION: India bears a dual burden of tuberculosis (TB) and mental health (MH) disorders, both of which are underdiagnosed due to stigma and diagnostic challenges. These conditions frequently coexist, forming a syndemic that has significant implications for public health.

OBJECTIVE: To explore the bidirectional relationship between TB and MH disorders, highlighting the impact on TB treatment outcomes, including higher risks of nonadherence, loss to follow-up, and mortality. This review emphasizes the need for integrating MH screening and support into TB programs to improve patient outcomes and ensure holistic care.

CONCLUSION: Despite the profound interplay between TB and MH disorders, MH remains inadequately addressed in TB care. Simple screening tools and community-based interventions can facilitate early detection and treatment. Integrating MH support, reducing stigma, and promoting collaboration between healthcare workers and MH professionals are vital to achieving World Health Organization (WHO)'s patient-centered care goals. Addressing this syndemic holistically is essential to improve outcomes for those affected and advance TB care standards in India.

INTRODUCTION: Fever and pain are natural body responses to infections and inflammation. This study aims to collect real-world data and compare the safety and effectiveness of nimesulide (100 mg), ibuprofen (400 mg) + paracetamol (325 mg), and paracetamol (650 mg) in individuals with fever or fever-related pain.

METHODS: A prospective, multicenter, comparative, and observational study was conducted in four centers across India with male and female subjects aged 18-60 years with fever or fever with pain. Fever reduction was assessed using a thermometer, and pain intensity was measured with the visual analog scale (VAS) at multiple intervals, up to 10 days.

RESULTS: The study enrolled 303 subjects, divided into three groups: (1) group I (nimesulide), (2) group II (ibuprofen + paracetamol), and (3) group III (paracetamol). Remarkable fever and pain reduction were exhibited in the nimesulide group. Its effect on fever reduction was observed within 15 minutes of administration, with a significant improvement in VAS scores. Patients on nimesulide showed greater fever reduction at 1, 2, 4, and 6 hours, continuing through day 8, and greater improvements in VAS, especially by day 1 (p < 0.0001). No serious adverse events or deaths were reported.

CONCLUSION: Nimesulide (100 mg) was superior to ibuprofen (400 mg) + paracetamol (325 mg) and paracetamol (650 mg) in managing fever or fever with pain, with a comparable safety profile.

BACKGROUND: The growing threat of antimicrobial resistance (AMR) poses a significant challenge globally in the treatment of respiratory tract infections (RTIs). The PERCEPT survey aimed to capture Indian healthcare practitioners' (HCPs) perspectives on the prevalence of RTIs, AMR patterns, AMR diagnosis, and clinical evaluation of cefpodoxime and its combination with clavulanic acid in managing RTIs.

MATERIALS AND METHODS: A structured questionnaire was used to conduct a cross-sectional survey among 1,000 healthcare professionals (HCPs) who manage RTIs in Indian adults and children, with 842 participants responding. The collected data were compiled and thoroughly analyzed.

RESULTS: Most HCPs reported RTIs in 26-50% of adult and pediatric patients, with the most common RTIs including pharyngitis/tonsillitis, bronchitis, and common cold. Streptococcus pneumoniae and Staphylococcus aureus were reported as the prevalent antibiotic-resistant microorganisms causing upper respiratory tract infections (URTIs) and lower respiratory tract infection (LRTIs). Antibiotic susceptibility testing (AST) is a common method to detect AMR in patients with RTIs. Among antibiotics, amoxicillin was the most common linked with resistance to microorganisms causing RTIs. Cefpodoxime alone or in combination with clavulanic acid was the most preferred drug for managing RTIs due to its high efficacy, broad-spectrum activity, safety, and better tolerability.

CONCLUSION: Indian practitioners find cefpodoxime monotherapy and its combination with clavulanic acid effective in managing RTIs compared to earlier-generation cephalosporins and amoxicillin.

BACKGROUND: Edaravone is recommended for amyotrophic lateral sclerosis (ALS) based on a study showing an effect on a defined subset of patients.

AIM: To document the effect of edaravone in a cohort of ALS patients from India to find out if, after starting edaravone, there is a plateau period or significant slowing from baseline to compare results with existing literature.

METHODS: This was a single-center, prospective observational study with no control arm (due to ethical reasons). ALS patients >18 years of age, not requiring respiratory support or tube feeding, were included. All patients were given edaravone infusion in addition to standard of care and oral riluzole 50 mg twice daily. This consisted of giving the drug in monthly cycles over 6 months. The first cycle consisted of daily infusion of the drug for 14 days followed by a drug-free interval for the remaining part of the month. From cycle 2 to cycle 6, the patients received the drug for the first 10 days of the month followed by a drug-free interval for the remaining part of the month. The primary outcome was a significant change in Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) score from baseline at 6 months. Secondary outcomes were monthly change in ALSFRS-R scores when compared with the previous month and baseline, change in the first 3 months compared to the change in the next 3 months, adverse drug effects, and number of deaths. The study was registered with the Indian Council of Medical Research Clinical Trial Registry of India with the trial number CTRI/2019/11/021838. Paired t-test was used for statistical analysis.

RESULTS: Thirty patients received the drug along with riluzole. Twenty-three patients completed all six monthly infusions. Two died (3 months), two developed adverse reactions (3 months) and did not want further infusions (one had breathing difficulty and the other had hypotension during infusion). Two withdrew consent due to perceived poor effectiveness of the drug. The mean ALSFRS-R at baseline was 35.17 [standard deviation (SD) 8.01; range 20-46]. The primary outcome showed a significant decline in the mean last available ALSFRS-R score 6 months by -4.9 (SD 1.21) (p < 0.01). For the secondary outcome measure, mean monthly ALSFRS-R score was calculated before each infusion after excluding dropouts. There was a significant monthly decline in ALSFRS-R score: -0.93 (SD 0.58), -1.0 (-0.52), -0.90 (SD 0.71), -0.87 (SD 0.61), -0.82 (SD 0.57), -0.95 (SD 0.63), respectively (p < 0.001). There was also a progressive monthly decline when compared to baseline. The rate of decline in the first 3 months was the same as in the remaining 3 months: -2.5 (SD 0.73) vs -2.6 (SD 0.98) (p = 0.3).

CONCLUSION: Edaravone infusion does not stop or significantly slow progression of disease from baseline but is safe.

BACKGROUND: Sepsis results from the body's extreme response to pathogens and is associated with high mortality rates. Autoimmune diseases, treated with immunosuppressive medications, can weaken immune responses and increase susceptibility to sepsis. While older studies linked autoimmune disease and immunosuppressive treatment with higher mortality and longer hospital stays in sepsis patients, recent research suggests that these patients may not always have worse outcomes, in fact, they might have better outcomes, highlighting the need for further investigations.

OBJECTIVES: (1) To investigate predictive factors of sepsis outcomes in individuals with underlying autoimmune diseases. (2) To quantify the severity of sepsis in the context of autoimmune diseases using the Sequential Organ Failure Assessment (SOFA) scoring system. (3) To evaluate the influence of autoimmune disease therapy on sepsis outcomes.

MATERIALS AND METHODS: A 6-month prospective, observational cohort study was conducted with 83 participants at a single center. Patients were nearly evenly divided into autoimmune and nonautoimmune groups. Key variables including SOFA score at admission, sex distribution, mortality, and effect of autoimmune treatment regimens were analyzed using statistical methods such as Chi-squared tests, t-tests, analysis of variance (ANOVA), and post hoc Bonferroni tests.

RESULTS: A comparison between patients with autoimmune conditions and those without revealed a significant difference in sex distribution, with 73.2% of autoimmune patients being female compared to 42.9% in the nonautoimmune group (χ2 = 7.818, p = 0.005). Analysis of the SOFA scores showed that the nonautoimmune group had significantly higher mean scores (6.05) compared to autoimmune group (4.15) (p = 0.006). Septic shock occurred less frequently in the autoimmune group (26.8%) than in the nonautoimmune group (42.9%) but was not statistically significant (χ2 = 2.345, p = 0.126). Mortality was lower in individuals with autoimmune diseases (14.6%) compared to those without (23.8%), but lacked statistical significance (χ2 = 1.122, p = 0.289). Different treatment types for autoimmune diseases did not significantly affect mean SOFA scores (F = 1.918, p = 0.144), indicating no major impact on sepsis outcomes. However, post hoc analyses suggested that untreated autoimmune patients had higher average SOFA scores than those on disease-modifying antirheumatic drugs (DMARDs), warranting further investigation into treatment effects.

CONCLUSION: Our study showed significantly low SOFA scores and better sepsis outcomes in patients with autoimmune diseases, highlighting the mitigating effects of autoimmune diseases and their treatment in sepsis. Even though many observed differences, including mortality, septic shock, and autoimmune disease treatment effects on sepsis, were not statistically significant, it highlights the need for further research to confirm these trends and understand the underlying mechanisms.

AIMS AND BACKGROUND: The King's Brief Interstitial Lung Disease (K-BILD) questionnaire, used to evaluate health-related quality of life (HRQoL) in interstitial lung diseases (ILDs), has been translated and validated in multiple languages. However, there is currently no validated Hindi translation available.

METHODS: This study aimed to translate and validate the K-BILD questionnaire into Hindi for ILD patients. Using a forward-backward translation method after approval from the original developers, we created the Hindi version and provided it to patients alongside the St George's Respiratory Questionnaire (SGRQ). We evaluated the Hindi K-BILD's reliability and validity by examining internal consistency, concurrent validity, and effect size (ES).

RESULTS: About 86 patients completed the Hindi version of the K-BILD questionnaire, demonstrating good internal consistency in the total score, breathlessness and activities, and psychological domains (Cronbach's α = 0.939, 0.916, and 0.928, respectively) and acceptable consistency in the chest symptoms domain (Cronbach's α = 0.732). Concurrent validity with the SGRQ domains and total scores was strong to very strong (p < 0.001). The K-BILD score also distinguished disease severity, notably in forced vital capacity (FVC) Z score (0.257) and diffusion capacity of lung for carbon monoxide (DLCO) Z score (0.181).

CONCLUSION: The Hindi language-translated K-BILD questionnaire was well accepted by patients and showed excellent validity, comparable to the original version of K-BILD in English language.

CLINICAL SIGNIFICANCE: The validated Hindi K-BILD enhances patient care, communication, and research for Hindi-speaking ILD patients by providing a reliable, culturally relevant tool for assessing health status and disease severity.

BACKGROUND: Healthcare practitioners (HCPs) face high stress levels at work due to the demanding nature of their profession, making them more susceptible to burnout. The objective of the study is to assess the prevalence of burnout among HCPs in India and to examine its relationship with age, gender, and working hours.

MATERIALS AND METHODS: A descriptive cross-sectional, pan India study was conducted from October 6 to 26, 2022. A total of 763 Indian HCPs participated in the study. The prevalence of burnout among HCPs was assessed using the Copenhagen Burnout Inventory (CBI). The CBI is a validated instrument that measures three dimensions of burnout: personal, work-related, and patient-related burnout. Data collected from the survey responses were analyzed using the Statistical Package for the Social Sciences (SPSS) version 18. Descriptive statistics were calculated to summarize the participants' demographic characteristics and burnout levels, including means, standard deviations (SD), frequencies, and percentages. A Chi-squared test was employed to examine associations and predictors of burnout among Indian HCPs.

RESULTS: Out of the 763 HCPs, 577 (76%) were males and 186 (24%) were females. The average age of the HCPs was 43.4 years. The prevalence of personal, work-related, and patient-related burnout was 47, 31, and 35%, respectively, with 24.9% experiencing all three types of burnout. Burnout was more common among female and younger practitioners. HCPs who spent longer hours a day treating patients and those with night duties and night calls reported higher burnout levels. A larger proportion of smokers reported work-related burnout. Regular exercise of at least 45 minutes and 6 hours of sleep was associated with lower burnout levels. Additionally, HCPs with anxiety as a medical condition were more likely to experience all three types of burnout.

CONCLUSION: This study reveals a significant prevalence of burnout among HCPs, with approximately 25% experiencing all three types of burnout. This raises concern, as burnout can have negative implications for the healthcare system. Further research is necessary to understand the impact of physician burnout on healthcare delivery and outcomes.

BACKGROUND: The diagnosis of hypertension (HTN) is best achieved by ambulatory blood pressure monitoring (ABPM) as it helps differentiate sustained hypertension (SH) from white coat hypertension (WCH).

AIM: To diagnose SH and WCH in newly diagnosed hypertensive patients.

MATERIALS: All newly diagnosed hypertensive patients with office blood pressure measurement (OBPM) ≥140/90 mm Hg, attending the medical outpatient department and not on any antihypertensive treatment, were included in the study.

OBJECTIVES: To evaluate the clinical utility of ABPM in newly diagnosed hypertensive subjects by comparing OBPM with ABPM readings.

METHODS: This descriptive cross-sectional study was carried out on 196 newly diagnosed HTN patients over a period of 18 months. All hypertensive patients were subjected to ABPM. Patients with persistent HTN on ABPM were labeled as SH, whereas those with normal blood pressure on ABPM were labeled as WCH.

RESULTS: SH was diagnosed in 143 out of 196 (73%) patients. WCH was detected in 53 patients (27%). Patients with SH had a significant family history of HTN compared to patients with WCH (82.5 vs 45.3%, p = 0.00), higher office diastolic blood pressure (DBP) compared to WCH (96.56 ± 4.63 vs 94.13 ± 3.23, p = 0.000), and significant nondipping pattern compared to WCH (37.1 vs 18.9%, p = 0.015).

CONCLUSION: ABPM should be performed in all newly diagnosed hypertensive patients, especially if they have no family history of HTN and DBP is <95 mm Hg, to rule out WCH.