Association of acute toxic encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study

Background Outbreaks of unexplained illness frequently remain under-investigated. In India, outbreaks of an acute neurological illness with high mortality among children occur annually in Muzaffarpur, the country’s largest litchi cultivation region. In 2014, we aimed to investigate the cause and risk factors for this illness. Methods In this hospital-based surveillance and nested age-matched case-control study, we did laboratory investigations to assess potential infectious and non-infectious causes of this acute neurological illness. Cases were children aged 15 years or younger who were admitted to two hospitals in Muzaffarpur with new-onset seizures or altered sensorium. Age-matched controls were residents of Muzaffarpur who were admitted to the same two hospitals for a non-neurologic illness within seven days of the date of admission of the case. Clinical specimens (blood, cerebrospinal fluid, and urine) and environmental specimens (litchis) were tested for evidence of infectious pathogens, pesticides, toxic metals, and other non-infectious causes, including presence of hypoglycin A or methylenecyclopropylglycine (MCPG), naturally-occurring fruit-based toxins that cause hypoglycaemia and metabolic derangement. Matched and unmatched (controlling for age) bivariate analyses were done and risk factors for illness were expressed as matched odds ratios and odds ratios (unmatched analyses). Findings Between May 26, and July 17, 2014, 390 patients meeting the case definition were admitted to the two referral hospitals in Muzaffarpur, of whom 122 (31%) died. On admission, 204 (62%) of 327 had blood glucose concentration of 70 mg/dL or less. 104 cases were compared with 104 age-matched hospital controls. Litchi consumption (matched odds ratio [mOR] 9·6 [95% CI 3·6 – 24]) and absence of an evening meal (2·2 [1·2–4·3]) in the 24 h preceding illness onset were associated with illness. The absence of an evening meal significantly modified the effect of eating litchis on illness (odds ratio [OR] 7·8 [95% CI 3·3–18·8], without evening meal; OR 3·6 [1·1–11·1] with an evening meal). Tests for infectious agents and pesticides were negative. Metabolites of hypoglycin A, MCPG, or both were detected in 48 [66%] of 73 urine specimens from case-patients and none from 15 controls; 72 (90%) of 80 case-patient specimens had abnormal plasma acylcarnitine profiles, consistent with severe disruption of fatty acid metabolism. In 36 litchi arils tested from Muzaffarpur, hypoglycin A concentrations ranged from 12·4 μg/g to 152·0 μg/g and MCPG ranged from 44·9 μg/g to 220·0 μg/g. Interpretation Our investigation suggests an outbreak of acute encephalopathy in Muzaffarpur associated with both hypoglycin A and MCPG toxicity. To prevent illness and reduce mortality in the region, we recommended minimising litchi consumption, ensuring receipt of an evening meal and implementing rapid glucose correction for suspected illness. A comprehensive investigative approach in Muzaffarpur led to timely public health recommendations, underscoring the importance of using systematic methods in other unexplained illness outbreaks

Evaluation of Integrated Counselling and Testing Centres (ICTC) for HIV in a District of India

ICTCs provide a critical entry point for prevention, care and support for both people affected by HIV/AIDS and general population. The study was conducted with the objective of evaluating ICTCs in terms of infrastructure and staffing, services provided, level of utilization and quality of counselling.The structure and process evaluation of 13 ICTCs under National AIDS control programme III (NACP III) was carried out in a Coastal District of South India. The evaluation was carried out using UNAIDS Tools between July and September of 2010.Twelve out of 13 ICTCs (92%) had adequate infrastructure and staff. Most of the general clients (75%) attending ICTCs were provider initiated and 84.5% of antenatal women in the district attended pre-test counselling and also underwent HIV testing. Twenty six pre-test counselling sessions and 12 post test sero-positive counselling sessions were observed. Pre-test counselling content assessment revealed that only 57.4% of sessions address all the issues whereas, 79% of post-test sessions addressed most of the issues during counselling. Counsellors’ skills assessment information gathering and information giving were found to be poorly done. It was found that post test counselling sessions were not conducted for clients with HIV negative report.The aspects of ICTCs such as services provided at the centers, utilization of services by the clients, infrastructure and staffing pattern were found to be adequate. Counselling forms the vital component of the ICTC needed improvement and post test counselling should be mandatory to all the clients

Opportunistic Infections among People Living with HIV (PLHIV) with Diabetes Mellitus (DM) Attending a Tertiary Care Hospital in Coastal City of South India.

HIV/AIDS and Diabetes Mellitus are the diseases' known to supress cell mediated immunity and predispose patients for opportunistic infections. Hence, we conducted a study to compare the common opportunistic infections (OIs) between People Living with HIV with DM (PLHIV-DM) and PLHIV without DM (PLHIV).PLHIV with DM and without DM (1:1) were prospectively included in the study from January 2011 to January 2012 at a tertiary care hospital in Mangalore city. Patients were classified as Diabetic if their fasting plasma glucose was ≥ 7.0 mmol/l (126 mg/dl) or 2-h plasma glucose was ≥11.1 mmol/l (200 mg/dl). Standard procedures and techniques were followed for diagnosis of OIs as per WHO guidelines. The data was entered and analyzed using Statistical Package for Social Sciences (SPSS) version 11.5.The study included 37 PLHIV with DM and 37 PLHIV without DM and both groups were treated with Anti-Retroviral Therapy (ART). The median age was 47 years (IQR: 41-55 years) for PLHIV-DM as compared to 40 years (IQR: 35-45.5 years) for PLHIV (p<0.0001). PLHIV-DM had median CD4 counts of 245 (IQR: 148-348) cells/μl compared to 150(IQR: 70-278) cells/μl for PLHIV (p = 0.02). Common OIs included oral candidiasis (49% of PLHIV-DM and 35% of PLHIV); Cryptococcal meningitis (19% of PLHIV-DM and 16% of PLHIV); Pneumocystis jiroveci pneumonia (5% of PLHIV-DM and 18% of PLHIV); extra pulmonary tuberculosis (22% of PLHIV-DM and 34.5% of PLHIV); and Cerebral toxoplasmosis (11% of PLHIV-DM and 13.5% of PLHIV). Microbiological testing of samples from PLHIV-DM, C krusei was the most common Candida species isolated from 9 out of 18 samples. Out of six pulmonary TB samples cultured, four grew Non-tuberculosis mycobacteria (NTM) and two Mycobacterium tuberculosis complexes.Study did not identify any significant difference in profile of opportunistic infections (OIs) between PLHIV with and without Diabetes

Psychiatric Co-morbidities among Patients with Select Non-communicable Diseases in a Coastal City of South India

Background: Psychiatric illnesses are an important group of co-morbidities that can occur among patients with non-communicable diseases (NCDs). Both these chronic conditions have an important implication in terms of quality of life, general well-being and cost of treatment and general longevity of the patient. The objectives of our study were to assess the burden of psychiatric co-morbidities among patients with select NCDs and to identify the determinants associated with them. Methods: A cross-sectional study was conducted at the outpatient departments (OPDs) of Government District Hospital, Mangalore. The study was conducted among patients with select NCDs viz. diabetes mellitus, hypertension, ischemic heart diseases and their combinations attending OPDs of Government District Hospital, Mangalore. Participants were interviewed using Patient Health Questionnaire-Somatic, Anxiety and Depressive Symptoms. Data analysis was performed using SPSS version 11.0 (SPSS Inc., 233 South Wacker Drive, 11 th floor, Chicago, IL 60606-6412). Bivariate and logistic regression analyses were performed to test the association between different variables. Results: Among the 282 study participants, psychiatric illnesses observed were somatization (n = 99, 35.1%), anxiety (n = 54, 19.1%) and depression (n = 82, 29.1%). Bivariate analysis showed significant negative association (P <0.05) between psychiatric illness and factors such as education, marital status, age <60 years, duration of illness of <10 years. However, on multivariate analysis only marital status (odds ratio [OR]: 0.500, confidence interval [CI]: 0.321-0.777, P = 0.002) and duration of illness (OR: 0.651, CI: 0.439-0.967, P = 0.032) were found to be significantly associated negatively with depression and anxiety

Common Opportunistic infections confirmed clinically or by culture among patients with PLHIV-Diabetic and PLHIV.

<p>^#Pearsons Chi square and Fisher exact tests</p><p>* 3 out of 8 cases diagnosed histo-pathologically</p><p>**diagnosed clinically.</p><p>Common Opportunistic infections confirmed clinically or by culture among patients with PLHIV-Diabetic and PLHIV.</p

Profile of substance use among patients attending De-addiction centres in a coastal city of southern India.

Drug dependence is still to be recognized in developing countries as a significant public health problem and literature on the magnitude of this problem is limited. The present research was planned to study the socio-demographic profile and the reasons for substance use among patients admitted at De-addiction centres in Mangalore, India. In this cross-sectional study, all the patients admitted at the De-addiction centres during the study period were interviewed. The data was analyzed and the results obtained were expressed in proportions. A total of 83 patients were included in the study, all of whom were males. A positive family history of substance use was evident in 63% of the respondents. The mean age of the study participants was 41.9 (SD±11.2) years and the mean age for starting substance use was 20.9 (SD±7.7) years. The most common substance used was alcohol (95.2%). Majority of the subjects (56.6%) cited peer pressure as a reason for initiating substance use. Our findings suggest that the initiation of substance use occurs during late teenage years and mostly due to peer pressure. Our observations point towards the vulnerability of younger age towards substance use and hence, it is proposed that the preventive health policies in this regard should be targeted specifically during teenage years

Perceptions and practices of self-medication among medical students in coastal South India.

Self-medication is a common practice worldwide and the irrational use of drugs is a cause of concern. This study assessed the prevalence of self-medication among the medical students in South India. The data was analysed using SPSS version 11.5. A total of 440 students were included in the study. The prevalence of self-medication was 78.6%. A larger number of females were self-medicating (81.2%) than males (75.3%). The majority of the students self-medicated because of the illness being too trivial for consultation (70.5%). Antipyretics were most commonly self-medicated by the participants (74.8%). Only 47% of the participants opined that self-medication was a part of self-care and it needs to be encouraged. 39.3% of the participants perceived that the supply of medicine without prescription by the pharmacist can prevent the growing trend of self-medication. Easy availability and accessibility to health care facilities remains the cornerstone for reducing the practice of self-medication

Prevalence and risk factors for adult pulmonary tuberculosis in a metropolitan city of South India.

The present study measured the community prevalence and risk factors of adult pulmonary tuberculosis (PTB) in Chennai city, and also studied geographical distribution and the presence of different M. tuberculosis strains in the survey area.A community-based cross sectional survey was carried out from July 2010 to October 2012 in Chennai city. Prevalence of bacteriologically positive PTB was estimated by direct standardization method. Univariate and multivariate analyses were carried out to identify significant risk factors. Drug susceptibility testing and spoligotyping was performed on isolated M. tuberculosis strains. Mapping of PTB cases was done using geographic positioning systems.Of 59,957 eligible people, 55,617 were screened by X-ray and /or TB symptoms and the prevalence of smear, culture, and bacteriologically positive PTB was estimated to be 228 (95% CI 189-265), 259 (95% CI 217-299) and 349 (95% CI 330-428) per 100,000 population, respectively. Prevalence of smear, culture, and bacteriologically positive PTB was highest amongst men aged 55-64 years. Multivariate analysis showed that occurrence of both culture and bacteriologically positive PTB disease was significantly associated with: age >35 years, past history of TB treatment, BMI <18.5 Kgs/m2, solid cooking fuel, and being a male currently consuming alcohol. The most frequent spoligotype family was East African Indian. Spatial distribution showed that a high proportion of patients were clustered in the densely populated north eastern part of the city.Our findings demonstrate that TB is a major public health problem in this urban area of south India, and support the use of intensified case finding in high risk groups. Undernutrition, slum dwelling, indoor air pollution and alcohol intake are modifiable risk factors for TB disease

Characteristics of the study population (N = 440).

<p>Characteristics of the study population (N = 440).</p