Long-term follow-up after complete ablation of Barrett's esophagus with argon plasma coagulation

AIM: To report the long-term outcome of patients after complete ablation of non-neoplastic Barrett's esophagus (BE) with respect to BE relapse and development of intraepithelial neoplasia or esophageal adenocarcinoma.METHODS: In 70 patients with histologically proven nonneoplastic BE, complete BE ablation was achieved by argon plasma coagulation (APC) and high-dose proton pump inhibitor therapy (120 mg omeprazole daily). Sixty-six patients (94.4%) underwent further surveillance endoscopy. At each surveillance endoscopy four-quadrant biopsies were taken from the neo-squamous epithelium at 2 cm intervals depending on the pre-treatment length of BE mucosa beginning at the neo-Z-line, and from any endoscopically suspicious lesion.RESULTS: The median follow-up of 66 patients was 51 mo (range 9-85 mo) giving a total of 280.5 patient years.A mean of 6 biopsies were taken during surveillance endoscopies. In 13 patients (19.7%) tongues or islands suspicious for BE were found during endoscopy. In 8 of these patients (12.1%) non-neoplastic BE relapse was confirmed histologically giving a histological relapse rate of 3% per year. In none of the patients, intraepithelial neoplasia nor an esophageal adenocarcinoma was detected.Logistic regression analysis identified endoscopic detection of islands or tongues as the only positive predictor of BE relapse (P = 0.0004).CONCLUSION: The long-term relapse rate of nonneoplastic BE following complete ablation with high-power APC is low (3% per year).

Impact of body composition on survival and morbidity after liver resection in hepatocellular carcinoma patients

Background: Hepatocellular carcinoma is the most common innate liver tumor. Due to improved surgical techniques, even extended resections are feasible, and more patients can be treated with curative intent. As the liver is the central metabolic organ, preoperative metabolic assessment is crucial for risk stratification. Sarcopenia, obesity and sarcopenic obesity characterize body composition and metabolic status. Here we present the impact of body composition on survival after liver resection in patients with hepatocellular carcinoma. Methods: A retrospective database analysis of 70 patients who were assigned for liver resection due to hepatocellular carcinoma was conducted. For assessment of sarcopenia and obesity, skeletal muscle surface area was measured at lumbar vertebra 3 level(L3) in preoperative four-phase contrast enhanced abdominal CT scans, and L3 muscle index and body fat percentage were calculated. Results: Univariate analysis comparing the survival curves using the score test demonstrated superior postoperative overall survival for sarcopenic( P = 0.035) and sarcopenic obese( P = 0.048) patients as well as a trend favoring obese( P = 0.130) subjects. Whereas multivariate analysis could not identify significant difference in postoperative survival regarding sarcopenia, obesity or sarcopenic obesity. Only large tumor size, multifocal disease and male gender were risk factors for long-term survival. Conclusions: Sarcopenia, obesity and sarcopenic obesity are indeed no risk factors for poor postoperative survival in this study. Our data do not support the evaluation of sarcopenia, obesity and sarcopenic obesity before liver resection in hepatocellular carcinoma patients.

An Appraisal of Sexual Behaviors, STI/HIV Prevalence, and HIV Prevention Programs among Truckers in India: A Critical Literature Review

Background: A systematic review portraying the changing pattern of sexual behaviors, STI and HIV prevalence and key strategies curb HIV and STI among truckers in India is lacking. This paper therefore aims to present a chronological review of literature regarding sexual behaviors, STI/HIV prevalence, and various HIV prevention programs implemented among truckers in India. Methodology: Published and unpublished studies (1990-2011) were identified through electronic databases, and hand searching. Results: Most studies on sexual behaviors and STI/HIV prevalence among truckers focused only on drivers and ignored their helpers. Evidences suggest that consistent condom use by truckers with both paid and non-paid female partners has increased during the past decade. Many recent studies suggest that the HIV prevalence among truckers is about 2% and it has been declining slowly during the past decade. The HIV prevention programs among truckers which started with the aim of raising awareness about HIV during early 1990s, have grown multi-folds to encompass not only the standard strategies like mid-media events, interpersonal counselling and STI care for HIV prevention, but also innovations such as the use of business franchisee models, and integrated research and evidence based planning in the program. The possibilities of using new approaches such as male circumcision and the use of pre-exposure prophylaxes are underway. Conclusion: More studies are needed to explore helpers’ vulnerabilities to HIV. Very few studies have attempted to examine the impact of large-scale prevention programs among truckers. Efforts are required to examine the impact of different components of such programs to guide the HIV prevention efforts among truckers in India.

Determinants of infant mortality in rural India: A three-level model

Taking into account the hierarchical structure of the data, through two-level analysis on infant mortality available under second round of National family Health Survey, the same group of authors recently reported determinants of infant mortality while examining possible changes in results under traditional regression analysis that ignores hierarchical structure of data. They reported that the community (e.g., state) level characteristics still have a major role regarding infant mortality in India. For better epidemiological understanding, the present study is to assess determinants of infant mortality in rural India, where three level considerations were possible. The results indicate that even after consideration of these covariates, variation in infant mortality remains significant not only between States but also between Districts. Further, as an additional observation, the probability of infant mortality is still high in rural areas of districts having health facility beyond three kilometers than their counterparts.

Quality Appraisal of Clinical Guidelines in Obstetrics and Gynecology in India

Background: Clinical practice guidelines are important for standard of care. This study was undertaken to assess the quality of Obstetrics and Gynecology guidelines in India. Objective Systematic appraisal of clinical practice guidelines (CPG) in obstetrics and gynecology in India uses Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Methods: All reported Indian guidelines in obstetrics and gynecology from 1st Jan. 2000 to 1st April 2018 were identified and subjected to inclusion using 3-point assessment criteria (relevance, clarity of intervention/outcome, and appropriate use of healthcare resources) using WHO AGREE-II instrument. Separate scores for the mean item, domain, and standardized were calculated by averaging the scores across two appraisers. Results & Discussion: Of 47 Clinical Practice Guidelines in Obstetrics and Gynecology (CPG) from India, 8 met the inclusion criteria. These were assessed using AGREE II checklist. Overall scores ranged from 8% to 22% (median 5%). No guideline received “Yes” for clinical use by either of the appraisers. Scores for scope and purpose and clarity were high but were very low for all the other domains. Only 1 review had identified cost as one of the focus areas as part of the guideline. Conclusion: Though being clinically relevant the clinical practice guidelines related to obstetrics and gynecology in India score poorly. There is a need for sensitization and capacity building of clinicians and public health professionals on the development of CPG related to obstetrics and gynecology in India.

Does Breastfeeding Have an Effect on Infant Mortality in India? An Analysis of National Family Health Survey Data

Introduction: Sub-optimal infant and early childhood feeding practices in India contribute to the high burden of child under-nutrition and infant death. Objective: To study the effect of breast-feeding duration on the survival of infants along with other demographic, socioeconomic and service related factors and to compare the decadal changes in the association. Methods: A total of 36,754 and 26,782 births less than 3 years of age from two rounds of the National Family Health Survey (NFHS) carried out in India during 1992-1993 (NFHS-1), and 2005-2006 (NFHS-3) respectively comprised the sample. Infant mortality was examined against a set of variables and breastfeeding as a time dependent covariate using multivariate extended Cox regression model. Results: Hazard of infant death observed in NFHS-3 (2005-2006) was 18 percent less [HR = 0.82;95% CI = 0.759 - 0.879] as compared to that observed in NFHS-1 (1992-1993). After adjustment of other factors, the risk of infant death was 97% less amongst children who were breastfed [HR = 0.03;95% CI = 0.029 - 0.033] as compared to those who were not breastfed. In contrast to rural area, babies belonging to urban area had an 18 percent less hazard of death during the infancy period [HR = 0.82]. Hazard of infant death was less among births to mothers with higher maternal education levels [HR = 0.93] and in those who were in gainful occupation [HR = 0.91]. The risk of infant death was higher in babies perceived to be small at birth [HR = 1.40] and belonging to states with medium post neonatal mortality rate (PNMR) [HR = 1.23;95% CI = 1.112 - 1.371] and high PNMR [HR = 1.46;95% CI = 1.327 - 1.609] in contrast to those born to women belonging to states with low post neonatal mortality. Conclusion: Promotion and implementation of evidenced based strategies are needed in India to combat the high rates of child under-nutrition and infant and child mortality.

Knowledge and practice of periodic abstinence among women in India

The use of contraceptive method to avoid pregnancy is a multifaceted phenomenon. Worldwide, 20 percent of married women of reproductive age are currently using periodic abstinence. To assess the knowledge and practice of periodic abstinence among currently married pregnant women, data were collected from the pregnant women attending the Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India. One thousand three hundred and thirty one (1331) currently married pregnant women were interviewed face-to-face. Approximately 29.3 percent of women were aware of the abstinence method, 11.5 percent women had history of using it. In-depth finding shows that 84.9 percent women did not have correct knowledge of fertile window of a menstrual cycle. Counseling about the correct fertile window of a menstrual cycle may increase the effectiveness of methods and hence reduce the incidence of unwanted pregnancies.

Are Truckers Being over Stigmatized as HIV Carriers in India? Evidences from Behavioral and Biological Cross-Sectional Surveys among Clients of Female Sex Workers

This paper examines whether truckers have been over-stigmatized as HIV carriers in the country. Data were taken from cross-sectional surveys of clients of female sex workers conducted in 2006-2007 in 12 districts of the country. A total 4822 clients of female sex workers were covered in the survey. Low-income skilled/semi-skilled men, including non-agricultural/casual labor, and petty businessmen/small shop owners, have the largest share in the clients’ population. There was no significant difference between truckers and other sub-group of clients’ population in terms of consistent condom use with female sex workers and prevalence of HIV or STI. These evidences suggest that the contribution of truckers in HIV epidemic in India might to similar to other sub-groups of clients’ population. Thus, truckers might have been over-stigmatized as HIV carriers in the country. However, there is no doubt that truckers constitute an extremely important target group for the HIV prevention programs and these efforts must be continued to prevent new HIV infections in the country.

Causes of Death among HIV-Infected Adults Registered in Selected Anti-Retroviral Therapy Centers in North-Eastern India

Background: Causes of death related studies in HIV infected population are necessary to devise disease specific preventive interventions at both state and national level HIV programs. This study examines the causes of death among HIV-infected individuals registered at selected Anti-Retroviral Therapy (ART) centers in the era of treatment in north-eastern India. Data and Methods: A retrospective chart review of causes of death was undertaken among HIV-infected patients who were treated between January 2006 and November 2012 at three selected ART centers in Assam, a north-eastern state of India. Reported causes of death were coded as per the guidelines of the International Classification of Diseases (ICD-10) to determine the deaths to standard definitions. Results: Among 5612 HIV-infected patients registered over a period of 71 months, 370 deaths have occurred. Tuberculosis (28%) was the leading cause of death followed by death due to AIDS related complex (11%), wasting syndrome and multiple infections (9% each). Deaths due to selected causes were significantly associated with patient’s use of alcohol, WHO clinical stage, CD4 count at the time of diagnosis, presence of opportunistic infections during treatment and ART adherence. Median survival duration was shortest among patients who had CD4 count <50 at the start of ART (2.9 months) and patients who had multiple opportunistic infections during treatment (2.5 months). Discussion: Majority (67%) of deaths in our study were due to AIDS-related causes. Tuberculosis has remained the leading cause of death among the HIV patients on ART. Strengthening the linkages and referral between the HIV and TB program will be crucial to reduce the AIDS-related deaths attributed to tuberculosis.

Multiple Sexual Partners and Vulnerability to HIV: A Study of Patterns of Sexual Behaviour in the Slum Population of India

Globally, research indicates that monogamous married women living in slums are at heightened risk of HIV men’s risky sexual behaviour. Hence, to reduce the risk of HIV transmission, there is need to understand the number, nature and variation in transition of sexual partners of men in living in slums. This paper uses India’s National Family Health Survey-3 data to estimate the variation in the type of sexual partners among sexually active men age 15 - 54 with more than one sexual partner in last 12 months prior to the survey in eight slums?of India. Among sexually active men, 1.3 percent reported having more than one sexual partner in the last 12 months prior to the survey. Men who are more likely to have two or more partners are those who are young, especially below age 25 years, never married, educated up to 5 years, and from middle class. There is a higher increase in the probability of sex with spouse from second last to the last sexual partner in non-slum areas than slum areas. However, in case of transition from other friends/relatives and female sex workers to spousal partners, there is a major decline in probability among non-slum men than slum men. These transitions are extremely important from the perspective of curbing the spread of HIV epidemic, especially in situations where women lack control over their own sexuality and seldom use condom in marital sex. Therefore, strategies focused in slums should either consider reducing men’s risky sexual behaviour or build capacities of women to negotiate safe sex in marital relationships or consider a combination of both.

Does HIV Status Affect Utilization of Maternal Care Services among Women in India: An Analysis of NFHS 2005-2006

The objective of the study is to understand the relationship between HIV status, fertility and utilisa-tion of maternal care services in India using the NFHS 2005-2006 data. The mean number of children ever born (a measure of fertility) is substantially higher among HIV-negative women than among the HIV-positive women (2.8 and 2.1 respectively). Ten-year age specific fertility rates (ASFR) were calculated, there is no noticeable difference in pattern of ASFR between HIV-positive and HIV-negative category of women observed though the ASFRs were substantially lower among the HIV-positive women. The total fertility rate (TFR) among HIV-positive women (0.84) is substantially lower at one third of the TFR among HIV-negative women (2.78). The proportion of HIV-positive pregnant women utilising ANC services is 92 percent compared to 78 percent among HIV-negative women, who have alive birth during the 5-year preceding the survey. Similarly, the proportion of HIV-positive women (67%) delivering their babies in an institution is also much higher than among HIV-negative women (40%). This study concludes that the effort of the government to integrate ART services with maternity care services is likely to have benefited the HIV positive mothers.

An Assessment of Comprehensive Knowledge of HIV/AIDS among Slum and Non-Slum Populations in Delhi, India

In order to design appropriate HIV prevention programs, it is important to examine the perception and knowledge of HIV/AIDS and methods of preventive. This article explores comprehensive knowledge of HIV/AIDS prevention methods among women and men in slum and non-slum areas in the National Capital Territory of Delhi, India. Data were drawn from the National Family Health Survey, 2005-06 (NFHS-3). The sample included 3096 women aged 15 - 49 years and 1321 men aged 15 - 54 years. Pearson Chi-square test and logistic regression analyses were conducted to examine the association between the study variables and the background characteristics of the slum and non-slum populations. Comprehensive knowledge of HIV/AIDS prevention methods was significantly lower among women and men in slum areas as compared with non-slum areas. Compared to men, women had less comprehensive knowledge of HIV/AIDS prevention methods in slum and non-slum areas, even after controlling for various demographic and socio-economic and exposure variables. Findings indicate that comprehensive knowledge of HIV prevention methods is low among women in slum areas. Interventions are needed to build knowledge of HIV transmission and prevention methods in this vulnerable group. Strategies to build awareness of HIV/AIDS could include mass media campaigns HIV/AIDS, and information, education and communication programs (IEC) on HIV/AIDS in slum areas.

An epidemiological study on delay in treatment initiation of cancer patients

Early diagnosis and timely initiation of treatment of cancer patients may improve survival and quality of life. Various measures of delay can be made during diagnosis and treatment initiation. Most of the studies were based on single type of cancer with different definitions and measurements of delay in diagnosis and treatment. Thus, it has been difficult to synthesize results and generalize to other types of cancer. The study proposes to measure total duration between onsets of symptom to start of treatment into three components, namely primary, secondary and tertiary delays. Primary delay is defined as onset of symptoms to contacting the first medical person, secondary delay is from first medical contact to confirmed diagnosis, and tertiary delay is from confirmed diagnosis to treatment initiation. The aim of this study is to determine factors associated with primary, secondary and tertiary delays in cancer patients. This study was planned as a cross-sectional study. Data was collected from patients admitted to the surgical wards of Department of Surgical Oncology, Institute Rotary Cancer Hospital, New Delhi during 2006-2007. Gamma regression and quantile regressions at 25th, 50th and 75th percentile of each of the delays were used to determine related factors. A total of 403 patients were included in the analysis. The median tertiary delay was found almost two folds (59;Interquartile range: 26 - 101 days) than the primary and secondary delays. Extremity cancer patients had longest primary, secondary and tertiary delays. Shortest primary, secondary and tertiary delays were observed for gastrointestinal cancer, breast and genitourinary cancer respectively. There is an urgent need and scope to reduce delay at each level primary, secondary and tertiary delay. Intervention studies are needed through information, education and communication/screening programs to reduce the diagnostic and treatment delays in cancer patients.

Factors Associated with Under-Five Mortality: A Comparison between Empowered Action Group (EAG) and Non-EAG States of India

Background: In India under-five mortality (U5MR) has declined by 71% from 126 to 37 deaths per 1000 live births between 1990 and 2018. The Empowered Action Group (EAG) states accounts for 74% of the under-five deaths as compared to 26% among Non-EAG states. Method: National Family Health Survey round fourth (NFHS-4), 2015-16 was used for this study. A life table method and Cox Proportional Hazard (PH) model was used to examine the various factors associated with U5MR in EAG and Non-EAG states of India. Result: Overall, it was observed that U5MR is much higher in EAG compared to Non-EAG states. Absolute difference varies according to background characteristics. The highest difference was among mothers who had never breastfed (316 vs 150 U5MR per 1000 live births in EAG & Non-EAG states respectively). Factors—total children ever born to mother, household members, children never breastfed and size of the baby were found to be statistically significantly associated with under-five mortality after controlling for other factors in both EAG and Non-EAG states. Hazard of U5MR was two and half-times higher among birth order 4+ (AHR = 2.5, 95% CI = 1.8 - 3.3) compared to birth order ≤2 after controlling for other factors in EAG states. The risk of under-five mortality was found three times higher among mother having up to primary or no education (AHR = 2.9, 95% CI = 1.4 - 5.9) compared to mother having higher education in non-EAG states. Conclusion: The study revealed that both groups of states need health program interventions focused on high risk mothers, TT immunization and promoting basic health services and breastfeeding practices for the reduction U5MR.

Towards Developing Communication Strategies for HIV/AIDS Control among the Scheduled Tribes and Scheduled Castes Women in Three Northeastern States of India

HIV/AIDS spread has opened a Pandora of medical and health problems apart from creating serious socio-psychological trauma for the victims and their families. Despite the governmental effort to curve the growing infection, very little success has been achieved. The northeastern region of India presents a very peculiar situation due to recurrent insurgency in all its states for long time and thus it became instrumental in paralyzing the social and health machineries to an extent, which still deteriorated the futile national effort to check the deadly infection. The study tried to understand the level of awareness and correct knowledge among the underprivileged scheduled tribes and scheduled castes women in the age group 15 -44 by exploring data from district level of Rapid Household Reproductive and Child Health Project Phase I (1998) and Phase II (1999) for Assam, Manipur and Nagaland and suggested a strategy to control the infection in the region. It is found that HIV/AIDS awareness was 59% among the women in all the three states with very few among them who had correct understanding of its prevention. A pronounced difference in the level of awareness was observed with respect to age, economy and residential status of the respondents.

Impact of TI Programmes Intervention under National AIDS Control Programme among Female Sex Workers in India: Evidence from Integrated Biological and Behavioural Survey, 2014-15

Background: A better understanding of the impact of Targeted Interventions (TI) services on Female Sex Worker (FSW) behaviours can help in informing and strengthening future TI efforts under National AIDS Control Programme (NACP). Methods: National Integrated Biological and Behavioural Survey (IBBS) 2014-15 has been analysed in the paper. Descriptive statistics and logistic regression analysis were used to understand factors affecting condom use. Propensity score matching (PSM) was done to understand the impact of the TI services on condom use at the last act and consistent condom use in the last three months among FSWs. Results: Younger FSWs aged 15 - 25 years were 1.4 times (95% CI: 1.04 - 1.77) more likely to use consistent condoms in the last three months compared to older over 45 years after controlling for other socio-economic and programme variables. The matched samples estimate ATET i.e. the average treatment effect on treated for consistent condom use in the last three months shows that a 6.0% (CI: 4.7 - 7.3) increase in consistent condom use in the last three months in the FSWs who received information on STI/HIV from peer educator and outreach worker. There is also a 6.0% (4.7 - 7.2) increase in condom use in the last act for FSWs who received the referral services at STI clinics, HIV testing, and detox centres. Conclusions: It is evident that the TI programme has a positive impact on behavior change among FSWs which can prove beneficial to curtail the spread of HIV to the partners and onward transmission to the general population.

The Treatment of Peripheral Vestibular Dysfunction Using Caloric Vestibular Stimulation in Patients with Cerebral Hypertensive Crisis

Background: To verify the efficacy of caloric vestibular stimulation in patients with peripheral vestibular dysfunction after cerebral hypertensive crisis. Methods: Enrolled in the study were 60 patients with peripheral vestibular dysfunction caused by a cerebral hypertensive crisis, docu-mented by vestibulometry. Thirty patients underwent standard treatment plus caloric vestibular stimulation, and 30 control group patients received standard treatment alone. Results: After the two-week treatment course, the sensation of vertigo was observed in 40.0% ± 8.9% of treatment group patients compared with 80.0% ± 7.3% of control group patients (t = 3.46;p < 0.001). Spontaneous vestibular somatic reactions were found in 46.7% ± 9.1% of the study treatment group in contrast to 86.7% ± 6.2% of the control group (t = 3.63;p < 0.001). Spontaneous nystagmus was seen in 40.0% ± 8.9% of treatment group patients compared with 93.3% ± 4.6% of control subjects (t = 5.31;p < 0.001). Spontaneous vestibular vegetative reactions were observed in 33.3% ± 8.6% of patients receiving study treatment in contrast to 93.3% ± 4.6% of control group patients (t = 6.16;p < 0.001). Also, 53.3% ± 9.1% of study treatment group patients showed asymmetry of labyrinths compared with 86.7% ± 6.2% of patients from the control group (t = 3.03;p < 0.001). Conclusion: Caloric vestibular stimulation was shown to be an effective treatment for peripheral vestibular dysfunction in patients with cerebral hypertensive crisis. During the 14-day treatment of cerebral hypertensive crisis, complete labyrinthine function recovery occurred in 46.7% of treatment group patients who underwent caloric vestibular stimulation as opposed to 13.3% of control group patients who received standard treatment alone.

Commercially available probiotic drinks containing Lactobacillus casei DN-114001 reduce antibiotic-associated diarrhea

AIM:To investigate the effect of Lactobacillus-containing commercially available probiotic formulations in Germany during antibiotic treatment with an analysis of cost-efficiency.METHODS:In an observational study,we analyzed the frequency of bowel movements from 258 patients with infections in a primary care hospital in western Germany;107 of the patients were offered a probiotic drink containing at least 10 billion cultures of Lactobacillus casei DN 114001 b.i.d.The economic analysis was based on the costs of patient isolation vs preventive intake of probiotics.In a second pilot study,two commercially available probiotic drinks with different Lactobacillus casei strains were directly compared in 60patients in a randomized controlled fashion.RESULTS:In the first study,the incidence of antibioticassociated diarrhea(AAD)was significantly reducedin the intervention group(6.5%vs 28.4%),and the duration of AAD in days was significantly shorter(1.7±1.1 vs 3.1±2.1).Higher age and creatinine and lower albumin were identified as risk factors for AAD.Ampicillin was the antibiotic with the highest rate of AAD(50%)and with the greatest AAD reduction in the probiotic group(4.2%,relative risk reduction 92%).The economic analysis showed a cost advantage of nearly60000€/year in a department of this size.The second study confirmed the preventive effect of the drink with Lactobacillus casei DN114001;however,there were no advantages found for the other tested probiotic drink containing Lactobacillus casei Shirota.CONCLUSION:In contrast to a drink containing Lactobacillus casei Shirota,a commercially available probiotic drink containing Lactobacillus casei DN 114001 costefficiently reduces the prevalence of AAD during antibiotic treatment.

Is the schatzki ring a unique esophageal entity?

AIM:To study,whether the association of Schatzki rings with other esophageal disorders support one of the theories about its etiology.METHODS:From 1987 until 2007,all patients with newly diagnosed symptomatic Schatzki rings (SRs) were prospectively registered and followed.All of them underwent structured interviews with regards to clinical symptoms,as well as endoscopic and/or radiographic examinations.Endoscopic and radiographic studies determined the presence of an SR and additional morphological abnormalities.RESULTS:One hundred and sixty-seven patients (125 male,42 female) with a mean age of 57.1±14.6 years were studied.All patients complained of intermittent dysphagia for solid food and 113 (79.6%) patients had a history of food impaction.Patients experienced symptoms for a mean of 4.7±5.2 years before diagnosis.Only in 23.4% of the 64 patients who had endoscopic and/or radiological examinations before their first presentation to our clinic,was the SR previously diagnosed.At presentation,the mean ring diameter was 13.9±4.97 mm.One hundred and sixty-two (97%) patients showed a sliding hiatal hernia.Erosive reflux esophagitis was found in 47 (28.1%) patients.Twenty-six (15.6%) of 167 patients showed single or multiple esophageal webs;five (3.0%) patients exhibited eosinophilic esophagitis;and four (2.4%) had esophageal diverticula.Four (7%) of 57 patients undergoing esophageal manometry had nonspecific esophageal motility disorders.CONCLUSION:Schatzki rings are frequently associated with additional esophageal disorders,which support the assumption of a multifactorial etiology.Despite typical symptoms,SRs might be overlooked.

Community effects on public health in India: A hierarchical model

The data on any aspect of public health, including that on infant mortality, has inbuilt hierarchical structure. Using traditional regression approach in data analysis, i.e., ignoring hierarchical structure, either at micro (individual) or at macro (community) level will be avoiding desired assumption related to independence of records. Accordingly, this may result into distortion in the results due to probable underestimation of standard error of the regression coefficients. To be more specific, an irrelevant co-variate may emerge as an important covariate leading to inappropriate public health implications. To overcome this problem, the objective of the present work was to deal with multilevel analysis of the data on infant mortality available under second round of National family Health Survey and notify changes in results under traditional regression analysis that ignores hierarchical structure of data. This method provides more accurate results leading to meaningful public health implications. In addition, estimation of variability at different levels and their covariance are also obtained. The results indicate that the community (e.g., state) level characteristics still have major role regarding infant mortality in India. Further, if computational facilities are available, multilevel analysis may be preferred in dealing with data involving hierarchical structure leading to accurate results having meaningful public health implications.