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10 July, 2014 Publications

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Int J Tuberc Lung Dis. 2008;12:1102.

 

By: Katiyar SK, Bihari S, Prakash S, Mamtani M, Kulkarni H

Influence of iron chelators on myocardial iron and cardiac function in transfusion-dependent thalassaemia: a systematic review and meta-analysis.

10 July, 2014 Publications

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Background: Iron chelators have dramatically prolonged the life expectancy of patients with transfusion-dependent thalassaemia, but their precise clinical benefit in reducing the myocardial iron burden and improving cardiac function is unknown. This systematic review and meta-analysis included published clinical trials that assessed the efficacy of iron chelators in regularly transfused patients of thalassaemia major for two commonly reported outcomes – myocardial iron content and left ventricular ejection fraction (LVEF). The meta-analysis of 392 patients for myocardial iron content and 291 patients for LVEF showed that (i) iron chelators reduced cardiac iron content by 23.9% (95% confidence interval 17.3-29.8%); (ii) there was no significant difference between the amount of iron reduced by deferoxamine and deferiprone (P = 0.9504); and (iii) LVEF was not significantly influenced by iron chelators – summary Hedges g 0.13 (95% confidence interval -0.10-0.36). A significant publication bias existed for LVEF (Eggers P = 0.049) but not for myocardial iron (Eggers P = 0.871). Our results indicate that iron chelators significantly reduce myocardial iron content. Further, the choice of deferoxamine versus deferiprone may rest on factors other than their efficacy to reduce cardiac iron load.
Br J Haematol. 2008;141:882-90.

 

By: Mamtani M, Kulkarni H

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Indian Pediatr 2008;75:193-4.

 

By: Mamtani M

A randomised controlled trial of high-dose isoniazid adjuvant therapy for multidrug-resistant tuberculosis.

10 July, 2014 Publications

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SETTING: Tertiary care hospital in Kanpur, India. BACKGROUND: The need for a standardised treatment protocol for multidrug-resistant tuberculosis (MDR-TB) in resource-limited countries is being increasingly recognised. OBJECTIVE: To assess the effectiveness of high-dose isoniazid (INH) (16-18 mg/kg) adjuvant to second-line therapy in documented cases of MDR-TB. DESIGN: The present study is a double blind, randomised controlled trial with three treatment arms, high-dose INH, normal-dose INH and placebo, in addition to second-line drugs. Primary outcomes of the study were time to sputum culture conversion and proportion with sputum culture negative 6 months after treatment initiation. Secondary outcomes were radiological improvement at 1 year post treatment and development of toxicity. RESULTS: After adjustment for potential confounders, subjects who received high-dose INH became sputum-negative 2.38 times (95%CI 1.45-3.91, P = 0.001) more rapidly than those who did not receive it, and had a 2.37 times (95%CI 1.46-3.84, P < 0.001) higher likelihood of being sputum-negative at 6 months. These subjects showed significantly better radiological improvement without an increased risk of INH toxicity. CONCLUSION: In low-resource scenarios where a standardised therapeutic protocol is used for MDR-TB, the protocol can be significantly improved by including high-dose INH as an adjuvant.
Int J Tuberc Lung Dis. 2008;12:139-45.

 

By: Katiyar SK, Bihari S, Prakash S, Mamtani M, Kulkarni H

Screening for HIV infection by health professionals in India.

10 July, 2014 Publications

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BACKGROUND: Stigma and discrimination, particularly in access to healthcare, remains a major problem for people Infected with HIV in most parts of India. METHODS: We did a multicentre study (n = 10) with a cross-sectional survey design using a standardized, interviewer-administered questionnaire. RESULTS: A total of 2200 healthcare providers participated. The knowledge, attitude and practice (KAP) related to HIV service delivery were very poor with a mean overall KAP score of only 49.7% (CI: 49.1-50.3). Only 5%, 5% and 1% of the participants scored more than 75% separately for the dimensions of knowledge, attitude and practice, respectively. Only 24.4% and 36.7% of responders knew that HIV screening was not recommended prior to surgery and pre-employment check-up. Many doctors (19.4%) had refused treatment to people living with HIV/AIDS (PLHA) at least some of the time and nearly half (47.2%) identified and labelled them; 23.9% isolated them in separate care areas and 13.3% postponed or changed treatment based on the patients HIV status. Screening for HIV prior to elective surgery was done by 67% of providers. While 64.7% of responders were aware of the existence of national guidelines on and recommendations for HIV testing, only 38.4% had read the policy document. CONCLUSION: There is a growing need to provide care, support and treatment to a large number of PLHA. The capacity of healthcare providers must be urgently built up so as to improve their knowledge of and attitude to HIV to enable them to deliver evidence-based and compassionate care to PLHA in various healthcare settings.
Natl Med J India. 2007;20:59-66.

 

By: Kurien M, Thomas K, Ahuja RC, Patel A, Shyla PR, Wig N, Mangalani M, Sathyanathan, Kasthuri A, Vyas B, Brogen A, Sudarsanam TD, Chaturvedi A, Abraham OC, Tharyan P, Selvaraj KG, Mathew J; IndiaCLEN HIV Screening Study Group

Is NESTROFT sufficient for mass screening for beta-thalassaemia trait?

10 July, 2014 Publications

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Objectives: Prevention of beta-thalassaemia trait will, for the foreseeable future, hinge on effective screening strategies. Routine use of haematological data from automated cell counters may complement the results of the Naked Eye Single Tube Red cell Osmotic Fragility Test (NESTROFT), especially because of the high cost of a false-negative error. Our objective was to assess the potential additive value of routine haematological data in screening for beta-thalassaemia trait. SETTINGS: Community survey of asymptomatic volunteers. METHODS: Using the NESTROFT results, haematological data and haemoglobin A(2) concentration from 1435 young, asymptomatic Sindhi subjects recruited in a population-based survey, and statistical analysis by classification tree approach, we examined whether haematological parameters have discriminatory utility additional to that of NESTROFT in screening for beta-thalassaemia trait. RESULTS: We observed that in the derivation subset from which the classification tree was generated, there was only a marginal–albeit statistically significant–improvement in the screening performance of NESTROFT, whereas there was no such improvement attributable to the use of haematological parameters in a separate validation subset. CONCLUSION: Our results further substantiate the claim that the use of NESTROFT is highly indicated for screening for beta-thalassaemia trait in regions where the prevalence is high and the resources are constrained.
J Med Screen. 2007;14:169-73.

 

By: Mamtani M, Das K, Jawahirani A, Rughwani V, Kulkarni H

Prognostic value of direct bilirubin in neonatal hyperbilirubinemia.

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Objective: To determine the prognostic value of indirect and direct hyperbilirubinemia in neonates with jaundice. METHODS: A cohort of 92 consecutive neonates reporting with hyperbilirubinemia to a tertiary care center were followed up till well and discharged, or, till death to assess risk and rate of mortality. RESULTS: The baseline median values of total, direct and indirect bilirubin in the cohort of 21.8, 1.6 and 18.6 mg/dl, respectively, were used as cut-offs for high and low levels. Using survival analyses i.e. Kaplan-Meier plots, logrank tests and multivariate Cox proportional hazards regression models to adjust for other strong predictors such as receipt of breastfeeding, being small for gestational age (SGA) and exchange transfusion, high direct bilirubin (> or = median value of 1.6 mg/dl) was independently associated with a higher and faster mortality. CONCLUSION: This study showed that direct bilirubin has independent and additive prognostic value and due attention should be given to newborns with raised levels.
Indian J Pediatr. 2007;74:819-22.

 

By: Mamtani M, Patel A, Renge R, Kulkarni H

Impact of training on observer variation in chest radio graphs of children with severe pneumonia.

10 July, 2014 Publications

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Background: Pneumonia diagnosed using chest radiographs is often used as a study end point in trials and epidemiological studies. We studied whether training of the end-users in 172 standardized chest radiographic features will decrease variability in the interpretation. METHODS: Inter-observer variation of 3 observers in recognizing standardized radiographic features for pneumonia was studied in 172 chest radiographs of children with clinical severe pneumonia. (as per WHO definition). The observers were then trained using a software with a repository of normal and abnormal films showing a spectrum of radiological changes in pneumonia. The interobserver variation in recognizing the same standardized radiographic features was recorded after this training. For each radiographic feature, Cohens kappa statistics to assess the between-observer agreement and Fleisss multiple rater kappa statistics to assess agreement among all three clinicians was used. RESULTS: The uniterpretable films reduced from 16.6% (95% CI 0%-34.1%) before training to 8.1% (95% CI 0%-17.7%) after training. The adequate films increased from 54.2% (95% CI 12.5%-95.9%) before training to 70% (95% CI 46.5%-93.4%) after training. For all features, agreement between observers 1 with 2 and 1 with 3, the Cohens kappa improved from poor to moderate agreement. The Fleiss kappa values before training were 0.1 to 0.2 and after training ranged from 0.37 to 0.52 indicating moderate to good agreement after training. CONCLUSIONS: Training of the doctors using standardized features with the help of a software improves agreement substantially in identifying radiological pneumonia.
Indian Pediatr. 2007;44:675-81.

 

By: Patel AB, Amin A, Sortey SZ, Athawale A, Kulkarni H

Comparative study of four candidate strategies to detect cervical cancer in different health care settings.

10 July, 2014 Publications

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Aim: Considering the differing but potentially supplementary properties of visual inspection of the cervix with acetic acid (VIA) and the cytological examination (CYTO) of cervical smears for the screening of cervical cancers, we examined the performance of these two tests and their combinations for the screening of cervical cancer in different health care settings. METHODS: In this cross-sectional diagnostic test performance evaluation study of 4235 female subjects in the reproductive age group, we assessed the screening performance of four strategies: VIA alone, CYTO alone, VIA and CYTO combined in a parallel fashion, and VIA and CYTO combined in tandem. Subjects were recruited from three settings: Hospital, Urban Community and Rural Community. Colposcopy was used as the reference standard. Screening performance was assessed using sensitivity, specificity, post-test probabilities and likelihood ratios (LR), diagnostic odds, area under receiver operating characteristic curve and LR chi(2). RESULTS: Both VIA and CYTO when used alone had a low sensitivity but high specificity, especially in the Rural Community setting. A combination of the results of VIA and CYTO improved the diagnostic accuracy but the strategy using a parallel combination of VIA and CYTO was the most accurate. In general, all screening strategies using VIA and CYTO showed a modest screening performance. CONCLUSIONS: In the settings of varying levels of health care and low resources, caution is needed for a generalized use of VIA for cervical cancer screening. Further evaluation of the cost-effective ways of combining VIA and CYTO is needed in these circumstances.
J Obstet Gynaecol Res. 2007;33:480-9.

 

By: Kamal MM, Sapkal RU, Sarodey CS, Munshi MM, Alsi YD, Chande MA, Hingway SR, Dandige S, Kane US, Kshirsagar R, Tangsale M, Zodpey S, Patel AB, Mamtani M, Kulkarni H

Association of the pattern of transition between arousal states in neonates with the cord blood lead level.

10 July, 2014 Publications

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Background: In this study of 167 neonates who demonstrated a total of 1010 transitions between arousal states, we considered whether specific state transitions were associated with umbilical cord blood lead levels. We found that the arousal patterns of neonates with varying levels (<1, 1-10 and >10 microg/dL) of lead exposure could not be distinguished based on the NBAS scoring system alone, but their transition state patterns revealed striking differences. Specifically, the neonates with the highest lead levels were more fidgety, had more state transitions from state 5 or 6, and were least likely to fall from awake states back into lower states. Arousal state transition pattern is thus a novel correlate of umbilical cord blood lead that may be useful for risk stratification of the neonates.
Early Hum Dev. 2008;84:231-5.

 

By: Mamtani M, Patel A, Kulkarni H