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Background: Serum insulin-like growth factor 1 (IGF-1) is an important biochemical tool to diagnose and monitor growth hormone (GH)-related disorders. However, ethnicity-specific Indian data, following consensus criteria for the establishment of normative data, are not available. Our objective was to generate chronological age (CA)-, bone age (BA)- and Tanner stage-specific normative data for IGF-1 in healthy Indian children and adolescents., Methods: A cross-sectional epidemiological study was conducted in schools and the community, which enrolled apparently healthy children and adolescents with robust exclusion criteria. The outcome measure was serum IGF-1 assessed using an electro-chemiluminescence immunoassay (ECLIA). The 2.5th, 5th, 10th, 25th, 50th (median), 75th, 90th, 95th, and 97.5th centiles for IGF-1 were estimated using generalized additive models., Results: We recruited 2226 apparently healthy participants and following exclusion, 1948 (1006 boys, 942 girls) were included in the final analysis. Girls had median IGF-1 peak at CA of 13 years (321.7 ng/mL), BA of 14 years (350.2 ng/mL) and Tanner stage IV (345 ng/mL), while boys had median IGF-1 peak at CA of 15 years (318.9 ng/mL) BA of 15 years (340.6 ng/mL) and Tanner stage III (304.8 ng/mL). Girls had earlier rise, earlier peak, and higher IGF-1 values. The reference interval (2.5th to 97.5th percentile) was broader during peripubertal ages, indicating a higher physiological variability., Conclusion: This study provides ethnicity-specific normative data on serum IGF-1 and will improve the diagnostic utility of IGF-1 in the evaluation and management of growth disorders in Indian children and adolescents., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com. See the journal About page for additional terms.)

Background: The design of health benefits package (HBP), and its associated payment and pricing system, is central to the performance of government-funded health insurance programmes. We evaluated the impact of revision in HBP within India's Pradhan Mantri Jan Arogya Yojana (PM-JAY) on provider behaviour, manifesting in terms of utilisation of services., Methods: We analysed the data on 1.35 million hospitalisation claims submitted by all the 886 (222 government and 664 private) empanelled hospitals in state of Punjab, from August 2019 to December 2022, to assess the change in utilisation from HBP 1.0 to HBP 2.0. The packages were stratified based on the nature of revision introduced in HBP 2.0, i.e., change in nomenclature, construct, price, or a combination of these. Data from National Health System Cost Database on cost of each of the packages was used to determine the cost-price differential for each package during HBP 1.0 and 2.0 respectively. A dose-response relationship was also evaluated, based on the multiplicity of revision type undertaken, or based on extent of price correction done. Change in the number of monthly claims, and the number of monthly claims per package was computed for each package category using an appropriate seasonal autoregressive integrated moving average (SARIMA) time series model., Findings: Overall, we found that the HBP revision led to a positive impact on utilisation of services. While changes in HBP nomenclature and construct had a positive effect, incorporating price corrections further accentuated the impact. The pricing reforms highly impacted those packages which were originally significantly under-priced. However, we did not find statistically significant dose-response relationship based on extent of price correction. Thirdly, the overall impact of HBP revision was similar in public and private hospitals., Interpretation: Our paper demonstrates the significant positive impact of PM-JAY HBP revisions on utilisation. HBP revisions need to be undertaken with the anticipation of its long-term intended effects., Funding: Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)., Competing Interests: The present manuscript was written as part of a project funded by ‘The Deutsche Gesellschaft für Internationale Zusammenarbeit’, also known as GIZ. The project funding was made to the institution –Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. We would like to note that the lead author—Shankar Prinja, has formerly served as the Executive Director at the National Health Authority (NHA), while Basant Garg is currently the Additional CEO of the NHA. The authors declare no other conflicts of interest., (© 2024 The Authors.)

Introduction: The most reliable indicator for anaemia diagnosis at the population level is haemoglobin (Hb) estimation. The direct cyanmethaemoglobin method is considered the gold standard method for haemoglobin estimation. However, for resource constraint areas like primary health care (PHC) level, either blood samples are transported on filter paper for Hb testing (indirect cyanmethaemoglobin method) in laboratory or point of care testing is commonly used. Therefore, a comparative analysis of haemoglobin estimation of direct with indirect cyanmethaemoglobin method and also with TrueHb (Wrig Nanosystems Pvt. Ltd.) haemometer was done to strengthen anaemia diagnosis at the PHC level., Materials and Methods: This was a cross-sectional study. A total of 90 participants above 9 years of age, who visited the outpatient department (OPD) of health centre, Kheri and gave consent were included. Comparative analysis was done between Hb concentration assessed by indirect cyanmethaemoglobin method and TrueHb haemometer device against the gold standard method., Results: The mean Hb value estimated by direct method, TrueHb haemometer and indirect methods (filter paper A, B and C) was 11.42 ± 1.59 g/dl, 11.52 ± 1.54 g/dl, 10.66 ± 1.52 g/dl, 9.84 ± 1.50 g/dl and 10.19 ± 1.62 g/dl, respectively. There was no significant difference found between the mean Hb concentration estimated by the direct method and the TrueHb haemometer device. However, there was a significant difference in mean Hb values between the direct method and the indirect method. Therefore, regression analysis was done to estimate the correction factor for the indirect method., Conclusion: TrueHb metre device gave promising results in comparison to the gold standard method and can be used if resource permits in PHC centres. Indirect methods of haemoglobin estimation can be an alternative in resource-constraint settings, specifically for surveys. However, further studies are required for the validation of the indirect method., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Family Medicine and Primary Care.)

Background: Undernutrition among children younger than 5 years is a subtle indicator of a country's health and economic status. Despite substantial macroeconomic progress in India, undernutrition remains a significant burden with geographical variations, compounded by poor access to water, sanitation, and hygiene services., Objective: This study aimed to explore the spatial trends of child growth failure (CGF) indicators and their association with household sanitation practices in India., Methods: We used data from the Indian Demographic and Health Surveys spanning 1998-2021. District-level CGF indicators (stunting, wasting, and underweight) were cross-referenced with sanitation and sociodemographic characteristics. Global Moran I and Local Indicator of Spatial Association were used to detect spatial clustering of the indicators. Spatial regression models were used to evaluate the significant determinants of CGF indicators., Results: Our study showed a decreasing trend in stunting (44.9%-38.4%) and underweight (46.7%-35.7%) but an increasing prevalence of wasting (15.7%-21.0%) over 15 years. The positive values of Moran I between 1998 and 2021 indicate the presence of spatial autocorrelation. Geographic clustering was consistently observed in the states of Madhya Pradesh, Jharkhand, Odisha, Uttar Pradesh, Chhattisgarh, West Bengal, Rajasthan, Bihar, and Gujarat. Improved sanitation facilities, a higher wealth index, and advanced maternal education status showed a significant association in reducing stunting. Relative risk maps identified hotspots of CGF health outcomes, which could be targeted for future interventions., Conclusions: Despite numerous policies and programs, malnutrition remains a concern. Its multifaceted causes demand coordinated and sustained interventions that go above and beyond the usual. Identifying hotspot locations will aid in developing control methods for achieving objectives in target areas., (©Lovely Jain, Sreya Pradhan, Arun Aggarwal, Bijaya Kumar Padhi, Ramaiah Itumalla, Mahalaqua Nazli Khatib, Shilpa Gaidhane, Quazi Syed Zahiruddin, Celso Augusto Guimarães Santos, Khalid AL-Mugheed, Tahani Alrahbeni, Neelima Kukreti, Prakasini Satapathy, Sarvesh Rustagi, Petra Heidler, Roy Rillera Marzo. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 24.05.2024.)

Objectives: Common mental disorders (CMDs), including depression, anxiety, and somatoform disorders, affect all stages of life and impact individuals, families, and communities. This study aimed to determine the magnitude of CMDs and their sociodemographic determinants in the adult population of a rural block in North India., Material and Methods: A cross-sectional, quantitative, community-based study was conducted among adult residents of a rural block in Haryana, North India, using a multistage random sampling technique. The Hindi version of the General Health Questionnaire (GHQ-12), a well-validated tool, was used to screen participants for CMDs. Scores of 4 or above denoted the presence of CMDs. Bivariate analyses were performed to determine the associations between CMDs and sociodemographic characteristics., Results: Of the 180 residents selected for the study, most were women (60.0%) and aged between 31 and 50 years (52.3%). The prevalence of CMDs symptoms in the study population was 20.0%. The presence of CMDs symptoms was significantly higher among those who were aged 60 years or older [OR=12.33, 95% CI 3.21-47.38], widowed, divorced or separated [OR=7.50, 95% CI 1.09-51.52], illiterate [OR= 6.25, 95% CI 2.84-13.77], had monthly family income below 10,000 INR [OR=3.33, 95% CI 1.54-7.20], had any chronic physical illness [OR=8.28, 95% CI 3.70-18.56] and had a family history of any psychiatric illness [OR=5.56, 95% CI 1.52-19.42]., Conclusion: The burden of CMDs was quite high among adults in rural North India. The presence of CMDs was closely associated with sociodemographic characteristics. Primary care and community-based settings need to screen for, diagnose, and manage CMDs to address this growing problem., Competing Interests: None., (©2024 The Japanese Association of Rural Medicine.)

Introduction: Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support., Objectives: We evaluated the feasibility, acceptability, and potential efficacy of a codesigned digital health intervention to support patients with chronic pain during voluntary prescription opioid tapering., Methods: In a pilot randomised controlled trial, participants received a psychoeducational video and 28 days of text messages (2 SMS/day) in addition to their usual care (intervention) or usual care alone (control). The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy., Results: Of 28 randomised participants, 26 completed the study (13 per group). Text message delivery was high (99.2%), but fidelity of video delivery was low (57.1%). Most participants rated the messages as useful, supportive, encouraging, and engaging; 78.5% would recommend the intervention to others; and 64.2% desired a longer intervention period. Tapering self-efficacy (Cohen d = 0.74) and pain self-efficacy ( d = 0.41) were higher, and pain intensity ( d = 0.65) and affective interference ( d = 0.45) were lower in the intervention group at week 4., Conclusion: First evidence supports the feasibility, acceptability, and potentially efficacy of a psychoeducational video and SMS text messaging intervention to support patients with chronic pain during voluntary prescription opioid tapering. Definitive trials with longer intervention duration are warranted., Competing Interests: Dr. Darnall is Chief Science Advisor at AppliedVR, and her consulting role with this company (personal fees) is unrelated to the current research. Dr. Darnall receives royalties for 4 pain treatment books she has authored or coauthored. She is the current principal investigator for 2 pain research awards from the Patient-Centered Research Outcomes Research Institute and 2 NIH pain research grants. She serves on the Board of Directors for the American Academy of Pain Medicine, the Board of Directors for the Institute for Brain Potential, and the Medical Advisory Board for the Facial Pain Association. Dr. Darnall is a scientific member of the NIH Interagency Pain Research Coordinating Committee, a former scientific member of the Centers for Disease Control and Prevention Opioid Workgroup (2020–2021), and a current member of the Pain Advisory Group of the American Psychological Association. Other Authors have no conflict of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.)

Introduction: With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings., Methods: A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance., Results: Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level., Conclusion: IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation., (© 2024. The Author(s).)

Background: Despite advancement in methods and application of economic evaluations (EEs), there are several uncertainties., Objectives: To assess the impact of alternate methodological and structural assumptions for four key principles of EE, on the results of cost-effectiveness analysis., Materials and Methods: Three previously published model-based EEs were used: (1) Integrated Management of Neonatal and Childhood Illnesses (IMNCIs) intervention; (2) intervention for multiple myeloma, and (3) safety-engineered syringes (SES) intervention. A series of empirical analyses was undertaken to assess the impact of alternate assumptions for discount-rate, time-horizon, study perspective, and health outcome measure, on incremental cost-effectiveness ratio (ICER), and interpretation of cost-effectiveness., Results: Increasing discount rate resulted in an increase in ICERs, for all three case-studies; however, there was no change in the conclusions. Using shorter time-horizons resulted in a significant increase in ICERs, the multiple myeloma intervention remained cost-ineffective, SES intervention became cost-ineffective, whereas IMNCI intervention remained cost-effective, despite a three-fold increase in ICER. On using disability adjusted life years instead of quality adjusted life years, ICERs increased to 0.04, 2 and 4 times for SES, IMNCI and multiple myeloma interventions, respectively. On analyzing results from a societal perspective, a decline in ICERs was observed. The decline was significant for IMNCI where the intervention turned dominant/cost-saving. In the other two case-studies decline in ICERs was modest, 32% for multiple myeloma, and 4% for SES., Conclusion: We observed a significant impact of using alternate assumptions on ICERs which can potentially impact resource-allocation decisions. Our findings provide strong argument in favor of standardization of processes and development of country-specific guidelines for conduct of EE., (Copyright © 2024 Copyright: © 2024 Indian Journal of Public Health.)

Introduction: Appropriate care and treatment of a wound is the need of the hour whether it is an infected or a non-infected wound. If wound healing is delayed for some reason, it leads to serious complications and further increases the hospital stay and cost of treatment. Herein, we describe a novel antimicrobial wound dressing formulation (VG111), with an objective to generate the preliminary data showing the distinct advantages in various types of wounds.

Method: This case series involved the treatment of acute cases of wounds or chronic wounds that did not respond well to conventional wound healing treatments with VG111 in patients with different etiologies. Thirteen cases of patients that included patients with diabetes, pressure ulcers, burns, trauma, and others treated with VG111 showed rapid wound healing in all the cases, even obviating the need for a graft when complete skin regeneration occurred.

Result: This was illustrated by clearing of the wound infections, reduction/disappearance of the exudate, appearance of intense granulation, epithelialization, and anti-biofilm activity followed by complete wound closure. This VG111 precludes the need for systemic antimicrobial agents in localized infections and therefore, this single agent is an attempt to address the limitations and the drawbacks of the available products.

Conclusion: Despite patients belonging to the old age group and having comorbidities like diabetes, still VG111 showed effective rapid wound healing, and that too without any scar formation in hardto- heal, infected, and non-infected wounds.

In September 2022, Panchkula Civil Hospital reported an outbreak of acute febrile illness (AFI) in Pinjore, located in the Himalayan foothills, Haryana, North India. There was an upsurge of fever cases. Blood samples were taken from suspected patients ( n = 58) with AFI and subjected to serology of dengue, chikungunya, Japanese encephalitis, leptospira and scrub typhus. The samples were also screened for West Nile & Zika virus RNA using real-time PCR. Viral strains were characterized by sequencing. Of the 58 cases of AFI, Dengue could be identified in 45 (77.58%) followed by JE and Chikungunya in 2 cases each (3.44%), respectively. Among Dengue positive cases, 44 had monoinfection (97.77%) and 1 patient had dengue and JE. None were positive for Zika, West Nile, Scrub typhus, and Leptospira with the testing protocol. Four patients developed dengue with warning signs, such as abdominal pain in one patient and recurrent vomiting in the remaining three. The dengue serotype could be determined in 17 samples and revealed serotype 2. Molecular evolution analysis based on the complete envelope gene revealed that all DENV-2 strains ( n = 13) circulated in the outbreak area belonged to the DENV-2 cosmopoliton genotype. In the early stages of infection, relying only on clinical manifestations is ineffective, so both molecular and serological assays along with clinical diagnosis are noteworthy for determining the aetiology of AFI., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Satapathy, Goel, Sharma, Sarkar, Kang, Dhingra, Bora, Kaur, Arora, Aggarwal and Ratho.)

Background: Health technology assessment (HTA) is globally recognised as an important tool to guide evidence-based decision-making. However, heterogeneity in methods limits the use of any such evidence. The current research was undertaken to develop a set of standards for conduct of economic evaluations for HTA in India, referred to as the Indian Reference Case., Methods: Development of the reference case comprised of a four-step process: (i) review of existing international HTA guidelines; (ii) systematic review of economic evaluations for three countries to assess adherence with pre-existing country-specific HTA guidelines; (iii) empirical analysis to assess the impact of alternate assumptions for key principles of economic evaluation on the results of cost-effectiveness analysis; (iv) stakeholder consultations to assess appropriateness of the recommendations. Based on the inferences drawn from the first three processes, a preliminary draft of the reference case was developed, which was finalised based on stakeholder consultations., Findings: The Indian Reference Case provides twelve recommendations on eleven key principles of economic evaluation: decision problem, comparator, perspective, source of effectiveness evidence, measure of costs, health outcomes, time-horizon, discounting, heterogeneity, uncertainty analysis and equity analysis, and for presentation of results. The recommendations are user-friendly and have scope to allow for context-specific flexibility., Interpretation: The Indian Reference Case is expected to provide guidance in planning, conducting, and reporting of economic evaluations. It is anticipated that adherence to the Reference Case would increase the quality and policy utilisation of future evaluations. However, with advancement in the field of health economics efforts aimed at refining the Indian Reference Case would be needed., Funding: This research received no specific grant from any funding agency, commercial, or not-for-profit sectors. The research was undertaken as part of doctoral thesis of Sharma D, who received scholarship from the Indian Council of Medical Research (ICMR), New Delhi, India., Competing Interests: This research received no specific grant from any funding agency, commercial, or not-for-profit sectors. The research was undertaken as part of doctoral thesis of DS, who received scholarship from the Indian Council of Medical Research (ICMR), New Delhi, India (31/3/JRF-2016/SS/HRD-10211113). SP has formerly served as the Executive Director at the National Health Authority, India. All authors declare no other conflict of interest., (© 2023 The Author(s).)

Objectives: Despite most childhood infections being self-limiting, children are among the leading consumers of antibiotics. Little is known about parental expectations of antibiotics for childhood infections. A comprehensive systematic review and meta-analysis was conducted to explore the nature and extent of parental expectations of antibiotic prescriptions for children with respiratory infections., Design: Systematic review and meta-analysis., Methods: An extensive literature search using six major scientific databases was conducted for all published articles until 7 December 2022. Primary studies reporting parents' expectations of antibiotics for children with upper respiratory tract infections were included after assessment for quality. Heterogeneity between the studies was assessed using the I 2 statistic and publication bias was analyzed using funnel plots and Egger regression tests. The primary outcome was a summary estimate of the percentage of parents who expect antibiotics from their physicians when their child presents with an upper respiratory tract infection., Results: From a total of 4510 studies found in the initial searches, a final pool of 19 eligible studies with 15,664 individuals was included in this meta-analysis. Nine of the 19 studies were from the United States or Saudi Arabia. The pooled prevalence of parental expectations of antibiotics in the population reviewed was 55.78% (95% CI = 44.60-66.41). There was significant heterogeneity between the studies, but funnel plot and meta-regression did not detect any publication bias., Conclusion: More than half of parents expect antibiotics for their children during consultation for upper respiratory tract infections. Such practices may cause undue side effects among children, contribute to the growing burden of antibiotic resistance, and lead to treatment failure for many common infections in the future. To optimize efforts to tackle antimicrobial resistance, shared decision-making and education emphasizing the proper and judicious use of antibiotics are much needed in pediatric healthcare settings. This can also help to manage parents' expectations when seeking antibiotics for their children. Despite pressure from parents, pediatric healthcare providers should continue to advocate for antibiotic use only when warranted and help improve knowledge and awareness amongst parents., Registration: The protocol has been registered with PROSPERO (CRD42022364198)., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The Editor in Chief of Therapeutic Advances in Infectious Disease is an author of this paper. Therefore, the peer review process was managed by alternative members of the Editorial Board and the submitting Editor had no involvement in the decision-making process., (© The Author(s), 2023.)

Background: Healthcare workers (HCWs) are at the front line of the Coronavirus disease (COVID-19) outbreak response. They have faced great risks to both physical and mental health. We aimed to assess the psychological effect of COVID-19 among ancillary hospital staff., Methods: A cross-sectional study was conducted among 267 on-duty ancillary hospital staff using a semi-structured questionnaire to assess their psychological status and risk perception. In addition, their knowledge, attitude, and practices (KAP) and risk perception were also assessed. The General Health Questionnaire (GHQ-12) was used to screen for psychological distress., Results: Among 267 participants, the mean (±SD) age was 33.5 (7.6) years. The majority knew about the symptoms of COVID-19 (88.4%), droplet spread (99.3%), and the importance of isolation (99.3%). About 35.2% were worried about infecting family members, while 26.2% were worried about colleagues at the frontline. Only 38.9% of them had a good knowledge score. Participants with high school and above education level had significantly good knowledge about COVID-19 (OR = 1.99; 95% CI = 1.17- 3.39) than those with primary school or below. Being female (OR 1.99; 95% CI 1.17-3.39) and working with COVID-19 patients (OR 3.88, 95% CI 1.77-8.47, P = 0.001) was associated with psychological distress., Conclusion: The ancillary hospital staff had insufficient knowledge regarding the risk factors of COVID-19 but possessed positive attitudes and practices. Continued health education and appropriate psychological interventions may improve understanding and reduce psychological distress., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Family Medicine and Primary Care.)

Background: Mpox (formerly known as monkeypox) is a global public health concern, given the recent outbreaks in non-endemic countries where little scientific evidence exists on the disease epidemiology. Oral lesions among mpox cases have been poorly reported. Our aim was to estimate the overall prevalence of oral manifestations among patients with mpox globally., Methods: In this systematic review and meta-analysis, an extensive literature search in PubMed, Scopus, Web of Science, Embase, Cochrane, and preprint servers (medRxiv, arXiv, bioRxiv, BioRN, ChiRxiv, ChiRN, and SSRN) and assessment of all published articles, conducted across the world, until Nov 15 2022 as per the PROSPERO registration protocol (CRD42022371249), was undertaken. Primary studies (case series, cross-sectional, retrospective, prospective designs) that reported the oral/oropharyngeal symptoms among laboratory-confirmed mpox cases were included. The characteristics of the study, information on the number of cases, and symptomatic status were extracted from the included studies. The quality of the included studies was assessed for bias. Random-effects meta-regression with DerSimonian & Laird estimator, and subgroup analyses were conducted using STATA (v17.0). The degree of funnel plot asymmetry was assessed using Egger's test when at least 10 estimates were available. The heterogeneity between studies was assessed using the I 2 statistic. The primary outcome was the pooled prevalence of oral manifestations in the examined population., Findings: 19 studies were included with 4042 laboratory-confirmed patients with mpox for qualitative and quantitative synthesis. The pooled prevalence of oral manifestations in the investigated population was 36.75% (95% confidence interval [CI]: 23.77-50.65). Heterogeneity was found to be high in the current meta-analysis (I 2  = 98.24%; p < 0.001). Subgroup analysis revealed a pooled prevalence of 39.96% (95% CI: 21.42-59.91) of sore throat, 24.80% (95% CI: 8.14-46.32) of mouth sore, 18.24% (95% CI: 0.34-52.54) of tonsillitis and 17.99% (95% CI: 15.66-20.43) of mouth rash from the included studies., Interpretation: Oral manifestations are common in patients with mpox, with variations in prevalence across the sites within the oral cavity, and geography of the studies. Healthcare workers should be wary of the oral signs and symptoms of mpox in endemic and high-risk areas., Funding: None., Competing Interests: None of the authors has declared any competing interests., (© 2023 The Authors.)

Following the COVID-19 pandemic, there has been a sharp increase in rabies cases and deaths. Rabies outbreaks are being reported worldwide. Multiple disruptions in Rabies control occurred during the pandemic, significantly affecting lower-income countries. Countries need to develop specific action plans to become 'rabies free' by 2030., (© The Author(s) 2023. Published by Oxford University Press on behalf of International Society of Travel Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Health systems in developing countries suffers from both input and productivity issues. We examined the status of three domains of human resources for health, i.e., availability and distribution, capacity and productivity, and motivation and job-satisfaction, of the health-care workforce employed in the public health system of Haryana, a North Indian state., Methodology: The primary data were collected from 377 public health facilities and 1749 healthcare providers across 21 districts. The secondary data were obtained from government reports in the public domain. Bivariate and multivariate statistical techniques were used for evaluating district performances, making inter-district comparisons and identifying determinants of motivation and job-satisfaction of the clinical cadres., Results: We found 3.6 core health-care workers (doctors, staff nurses, and auxiliary nurses-midwives) employed in the public health-care system per 10,000 population, ranging from 1.35 in Faridabad district to 6.57 in Panchkula district. Around 78% of the sanctioned positions were occupied. A number of inpatient hospitalizations per doctor/nurses per month were 17 at the community health center level and 29 at the district hospital level; however, significant differences were observed among districts. Motivation levels of community health workers (85%) were higher than clinical workforce (78%), while health system administrators had lowest motivation and job satisfaction levels. Posting at primary healthcare facility, contractual employment, and co-habitation with family at the place of posting were found to be the significant motivating factors., Conclusions: A revamp of governance strategies is required to improve health-care worker availability and equitable distribution in the public health system to address the observed geographic variations. Efforts are also needed to improve the motivation levels of health system administrators, especially in poorly performing districts and reduce the wide gap with better-off districts., Competing Interests: None

Background: Monkeypox is a global public health concern, given the recent outbreaks in non-endemic countries where little scientific evidence exists on the disease. Specifically, there is a lack of data on asymptomatic monkeypox virus infection. This study aims to evaluate the overall prevalence of asymptomatic monkeypox virus infection. Methods: In this systematic review and meta-analysis, we performed an extensive literature search in PubMed, Scopus, Web of Science, ProQuest, EMBASE, EBSCOHost, Cochrane, and preprint servers (medRxiv, arXiv, bioRxiv, BioRN, ChiRxiv, ChiRN, and SSRN) and assessed all published articles till September 2022. Primary studies reporting monkeypox infections among asymptomatic participants were included after quality assessment. The characteristics of the study and information on the number of cases and symptomatic status were extracted from the included studies. The heterogeneity between studies was assessed using the I2 statistic. Publication bias was analyzed using funnel plots and Egger regression tests. The primary outcome was the pooled prevalence of asymptomatic infections within the examined population. Results: A total of 16 studies were included for qualitative synthesis, while five studies, including 645 individuals, were included for quantitative synthesis. There was substantial heterogeneity between studies (I2 = 94.86%; p < 0.01), with a pooled percentage of asymptomatic infections in the studied population of 10.2% (95%CI, 2.5−17.9%). Conclusion: This meta-analysis suggests that many people infected with the monkeypox virus are asymptomatic and difficult to detect. Therefore, prompt detection of these cases of monkeypox virus and appropriate subsequent management is of utmost importance to global public health., Competing Interests: None of the authors has declared any competing interest.

Competing Interests: None.

Background and Objectives: Pre-diabetes has been identified as an intermediate diagnosis and a sign of a relatively high chance of developing diabetes in the future. Diabetes has become one of the most frequent chronic disorders in children and adolescents around the world; therefore, predicting the onset of pre-diabetes allows a person at risk to make efforts to avoid or restrict disease progression. This research aims to create and implement a cross-validated machine learning model that can predict pre-diabetes using non-invasive methods., Methods: We have analysed the national representative dataset of children and adolescents (5-19 years) to develop a machine learning model for non-invasive pre-diabetes screening. Based on HbA1c levels the data (n = 26,567) was segregated into normal (n = 23,777) and pre-diabetes (n = 2790). We have considered eight features, six hyper-tuned machine learning models and different metrics for model evaluation. The final model was selected based on the area under the receiver operator curve (AUC), Cohen's kappa and cross-validation score. The selected model was integrated into the screening tool for automated pre-diabetes prediction., Results: The XG boost classifier was the best model, including all eight features. The 10-fold cross-validation score was highest for the XG boost model (90.13%) and least for the support vector machine (61.17%). The AUC was highest for RF (0.970), followed by GB (0.968), XGB (0.959), ETC (0.918), DT (0.908), and SVM (0.574) models. The XGB model was used to develop the screening tool., Conclusion: We have developed and deployed a machine learning model for automated real-time pre-diabetes screening. The screening tool can be used over computers and can be transformed into software for easy usage. The detection of pre-diabetes in the pediatric age may help avoid its enhancement. Machine learning can also show great competence in determining important features in pre-diabetes., Competing Interests: Declaration of Competing Interest No potential conflicts of interest relevant to this article were reported., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The share of expenditure on medicines as part of the total out-of-pocket (OOP) expenditure on healthcare services has been reported to be much higher in India than in other countries. This study was conducted to ascertain the extent of this share of medicine expenditure using a novel methodology. OOP expenditure data were collected through exit interviews with 5252 out-patient department patients in three states of India. Follow-up interviews were conducted after Days 1 and 15 of the baseline to identify any additional expenditure incurred. In addition, medicine prescription data were collected from the patients through prescription audits. Self-reported expenditure on medicines was compared with the amount imputed using local market prices based on prescription data. The results were also compared with the mean expenditure on medicines per spell of ailment among non-hospitalized cases from the National Sample Survey (NSS) 75th round for the corresponding states and districts, which is based on household survey methodology. The share of medicines in OOP expenditure did not change significantly for organized private hospitals using the patient-reported vs imputation-based methods (30.74-29.61%). Large reductions were observed for single-doctor clinics, especially in the case of 'Ayurvedic' (64.51-36.51%) and homeopathic (57.53-42.74%) practitioners. After adjustment for socio-demographic factors and types of ailments, we found that household data collection as per NSS methodology leads to an increase of 25% and 26% in the reported share of medicines for public- and private-sector out-patient consultations respectively, as compared with facility-based exit interviews with the imputation of expenditure for medicines as per actual quantity and price data. The nature of healthcare transactions at single-doctor clinics in rural India leads to an over-reporting of expenditure on medicines by patients. While household surveys are valid to provide total expenditure, these are less likely to correctly estimate the share of medicine expenditure., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: COVID-19 vaccination of the healthcare workers (HCWs) is a key priority in the fight against the SARS-CoV-2 pandemic. India launched its COVID-19 vaccination program in January 2021. We aimed to understand the trends in willingness to receive COVID-19 vaccines and its associated factors among HCWs in India., Methods: Using a repeated cross-sectional survey design, we collected information from HCWs in three critical time points: before ( n = 937, October 2020), during ( n = 1346, January 2021); and after ( n = 812, May 2021) the introduction of COVID-19 vaccines in India. The third survey coincided with the peak of the second wave of COVID-19 pandemic in India., Findings: Of the study participants, 43.7, 60.2, and 73.2% were willing to receive COVID-19 vaccines during the first, second and third rounds of surveys, respectively. In multivariable logistic regression analysis, participants who trusted the health care system were more likely to report willingness to receive a COVID-19 vaccine; medical trust emerged as a significant factor in all the three rounds of surveys (First survey-aOR: 2.24, 95% CI: 1.67-2.99; Second survey-aOR: 3.38, 95% CI: 2.64-4.33; Third survey-aOR: 2.54, 95% CI: 1.65-3.91). Having confidence in domestic vaccines (Second survey-aOR: 2.21, 95% CI: 1.61-3.02; Third survey-aOR: 2.05, 95% CI: 1.24-3.37); and high perceived risk of contracting COVID-19 (Second survey-aOR: 1.48, 95% CI: 1.13-1.93; Third survey-aOR: 2.02, 95% CI: 1.31-3.13) were found to be associated with willingness to receive vaccines. Among socio-demographic characteristics, being married (aOR: 1.71, 95% CI: 1.08-2.71) and having high socio-economic status (aOR: 3.01, 95% CI: 1.65-5.51) emerged as significant factors associated with willingness to receive COVID-19 vaccines in the third round of the surveys., Interpretation: Willingness to receive COVID-19 vaccine increased with time, as the severity of the pandemic increased. To increase COVID-19 acceptance and coverage among HCWs, it is important to instill confidence in domestic vaccines and assist in accurate assessment of risk toward contracting COVID-19 infection., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Padhi, Chakrapani, Gupta, Sharma, Patro, Kar, Singh, Pala, Sankhe, Modi, Bali, Rustagi, Jain, Vij, Satapathy, Goel, Rajagopal, Kiran and Aggarwal.)

Background: Chronic non-malignant pain is a disabling condition that results in a reduction in function and quality of life when inadequately managed. Sublingual ketamine has been shown to be efficacious for use in chronic pain. Despite its use for decades in chronic non-malignant pain, there is no published long-term data on safety, side-effects or adverse drug reactions., Aim: The aim of this case-series is to provide the initial evidence for safety and efficacy in this patient group., Methods: We present a retrospective review of 29 (n = 29) patients from a metropolitan tertiary pain service who have been receiving sublingual ketamine troches/lozenges between the period of 2012 and 2019. Patients were identified from the outpatient pain clinic, who had been admitted for inpatient subcutaneous ketamine infusions as part of opiate detoxification or management of central sensitisation due to a chronic neuropathic pain syndrome. An initial review was performed to check the patient started taking the ketamine troches. Each of these medical records was reviewed manually to extract information to a datasheet., Results: There was a wide range of dosages used from 25 to 600 mg in divided doses. The duration of treatment ranged 2-89 months. There was no association with either the dosage or duration of treatment and frequency of side-effects. There was an overall reduction in the use of opioids, gabapentinoids or benzodiazepines in 59% of patients with 39% having a complete cessation of an analgesic agent. Side-effects were reported in 24%, but only 7% discontinued the treatment due to the side-effect (drowsiness). There were no reports of renal impairment, cystitis or hepatotoxicity., Discussion: This retrospective case-series has demonstrated that sublingual ketamine is a safe and effective analgesic agent to use in chronic non-malignant pain management. It is indicated in a variety of chronic pain conditions and has an excellent safety profile, with no association between the frequency in side-effects and duration of therapy or total daily dosages. The study has also shown that the 'safe' dose may be higher than the previous consensus., (© 2021 Royal Australasian College of Physicians.)

Background: Vaccine hesitancy is of considerable concern as it threatens the great potential of a vaccine against COVID-19. This study aims to determine factors associated with community health workers' willingness to participate in clinical trials of COVID-19 vaccine, and their vaccination intention, in India., Methods: A cross-sectional study was conducted among 377 community health workers using self-administered anonymous questionnaire during the lockdown periods in India. Participant's socio-demographics, willingness-to-participate in COVID-19 vaccine trials, intention to accept COVID-19 vaccine were recorded in a Likert scale. Data were analysed descriptively, and a multivariate logistic regression model was used to investigate factors associated with willingness to participate and accept the vaccine., Results: Among 377 CHWs, 70 (19%) intended to participate in COVID-19 vaccine trial, 151 (40%) responded positively regarding their intention to get vaccinated. Those with knowledge on development of COVID-19 vaccine [aOR 3.05 (95% CI: 1.18-7.88), p = 0.021], and men [aOR 3.69 (95% CI: 1.51-8.97), p = 0.004] were more willing to participate in clinical-trial, while an undergraduate degree, and trust in domestic vaccines were identified as deterrents for the same. Perceiving COVID-19 as risk [aOR 2.31 (95% CI: 1.24-4.31), p = 0.009], and male gender [aOR 2.39 (95% CI: 1.17-4.88), p = 0.017] were factors associated with intention to get vaccinated. Respondents who had knowledge about COVID-19 virus were less likely to uptake the hypothetical vaccine [aOR 0.32 (95% CI: 0.12-0.88), p = 0.027]., Conclusions: Increasing knowledge regarding COVID-19 is not enough to improve vaccine acceptance rates. Targeted interventions addressing socio-demographic determinants related to COVID-19 vaccination should help improve acceptance., Competing Interests: The authors declare they have no competing interests., (© 2022 The Author(s).)

Background: Responding to the fast transmission rates and increasing fatality rates, countries across the world expedited the development and deployment of the vaccine for coronavirus disease 2019 (COVID-19). Evaluation of individuals' willingness to pay (WTP) would provide pertinent information regarding future demand and financing preferences, which shall help to devise the effective payment strategy for COVID-19 vaccination., Methods: A nationwide, cross-sectional, and self-administered online survey using a structured questionnaire was conducted to identify the sociodemographic determinants of willingness and extent to pay for COVID-19 vaccine in India. A non-probability convenience sampling followed by snowball sampling was employed to recruit participants ( n = 3,341). The likelihood of sociodemographic determinants to predict willingness and extent to pay was modeled using the multivariate binary logistic regression analysis., Results: Out of 3,341 participants, 68% ( n = 2,271) were willingness to pay for COVID-19 vaccine. Results showed significantly higher odds for willingness to pay among participants who were single [adjusted odds ratio (aOR) = 1.394, p < 0.01] and having a family size of 4 members (aOR = 1.346, p < 0.01). The adjusted odds ratio sizably increased from 1.396 for participants whose monthly income was between INR 10,000 and 20,000/month to 2.240 for participants whose monthly income was above INR 50,000/month. Further, out of 2,271 of those participants who were willingness to pay for COVID-19 vaccine, majority ( n = 1,246, 54.9%) of participants were willingness to pay below 50% of COVID-19 vaccine cost. This study found that those who are single (aOR = 0.688, p < 0.01), having an income between INR 20,000 and 50,000/month (aOR = 0.686, p < 0.05), and those who belonged to socially disadvantaged category (aOR = 0.450, p < 0.01) were estimated to have significantly lower odds of willingness to pay more than 50% of COVID-19 vaccine cost., Conclusion: This study observed that majority of those participants who willingness to pay for COVID-19 vaccine were willingness to pay only up to 50% of COVID-19 vaccine and income was observed as a precursor predictor of the willingness and extent to pay for COVID-19 vaccine. The understanding on the willingness and extent to pay for COVID-19 vaccine and its sociodemographic determinants will be helpful for making the strategic decisions related to the financing of COVID vaccine in India., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kiran, Junaid, Sharma, Jain, Vij, Satapathy, Chakrapani, Patro, Kar, Singh, Pala, Bali, Rustagi, Goel, Sankhe, Modi, Gupta, Aggarwal, Rajagopal and Padhi.)

Background: Despite the success of adult vaccination against COVID-19, providing vaccines to children remains a challenge for policymakers globally. As parents are primary decision-makers for their children, we aimed to assess parents' perceptions and intentions regarding COVID-19 vaccination in India., Methods: A cross-sectional web-based study was designed, parents or caregivers ( N = 770) were recruited through snowball sampling using Google form. Cross-tabulation was performed by parents' intention to vaccinate their children against COVID-19 virus with sociodemographic characteristics and their risk perception toward COVID-19, trust in the healthcare system, and their history of vaccine hesitancy behavior. Multivariable logistic regression analysis was performed to compute the predictors of child vaccination intention among Indian parents., Results: Seven hundred and seventy parents across the country have completed the survey. Of the 770 participants, 258 (33.5%) have shown intent to vaccinate their children. The stated likelihood of child vaccination was greater among parents who had a bachelor's degree or higher education (aOR: 1.98, 95% CI: 1.15-3.51); as well as among parents who intended to vaccinate themselves (aOR: 2.35, 95% CI: 1.30-4.67). Parental concerns centered around vaccine safety and side effects., Conclusion: Indian parents reported high knowledge of the COVID-19 virus and were aware of the development of a vaccine. However, about one-third of parents intended to vaccinate their children, and about half of them were not sure whether to vaccinate their children or not against the COVID-19 virus. The study highlighted the need for health promotion strategies that promote vaccine uptake among parents., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Padhi, Satapathy, Rajagopal, Rustagi, Vij, Jain, Chakrapani, Patro, Kar, Singh, Pala, Sankhe, Modi, Bali, Kiran, Goel, Aggarwal and Gupta.)

Background: Students act as messengers in delivering effective messages for better uptake of health-promoting behavior. Understanding their knowledge about coronavirus disease 2019 (COVID-19), intentions to use the COVID-19 vaccine, and its associated factors will help develop promising strategies in vaccine promotion concerning the current COVID-19 pandemic. Methods: A cross-sectional online survey was carried out among students in the healthcare and non-healthcare sectors to assess their intentions to get vaccinated against the COVID-19. A non-probability snowball sampling technique was used to recruit study participants ( N = 655) through social media platforms and emails. Study participants were recruited across the country, including six major geographical regions (Eastern, Western, Northern, Southern, North-east, and Central) in India between November 2020 and January 2021 before the introduction of the COVID-19 vaccine. Descriptive statistics were used to present the sociodemographic, and vaccine-related behaviors of the study participants. Key determinants that likely predict vaccine acceptance among students were modeled using logistic regression analysis. For each analysis, p < 0.05 was considered significant. Results: A total of 655 students were recruited, 323 from healthcare and 332 from non-healthcare sectors, to assess their intentions to receive the COVID-19 vaccine. Of the 655 students, 63.8% expressed intentions to receive the COVID-19 vaccine. The acceptance was higher among non-healthcare students (54.07 vs. 45.93%). At the time of the study, 27.8% of the students indicated that they had been exposed to a confirmed COVID-19 patient. A vast majority (93.4%) of the students knew about the COVID-19 virus, and most (89.3%) of them were aware of the development of a COVID-19 vaccine. The history of vaccine hesitancy was found to be low (17.1%). Only one-third (33.4%) of the students showed concern about contracting COVID-19. Trust in the healthcare system [adjusted odds ratio (aOR): 4.13; (95% CI: 2.83-6.04), p < 0.00] and trust in domestic vaccines [aOR: 1.46; (95% CI: 1.02-2.08), p < 0.05] emerged as the significant predictors of student's intention to get vaccinated. Higher acceptance for vaccine was observed among students in the non-healthcare [aOR: 1.982; 95% CI: 1.334-2.946, p < 0.00]. Conclusion: This study shows that the Indian college students had relatively high levels of positive intentions to receive COVID-19 vaccines, although about one-third were not sure or unwilling to receive the vaccine, highlighting possible vaccine hesitancy. Informational campaigns and other strategies to address vaccine hesitancy are needed to promote uptake of COVID-19 vaccines., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Jain, Vij, Satapathy, Chakrapani, Patro, Kar, Singh, Pala, Sankhe, Modi, Bali, Rustagi, Rajagopal, Kiran, Goel, Aggarwal, Gupta and Padhi.)

Background and Objectives: Globally, a number of countries have developed guidelines that describe the design and conduct of economic evaluations as part of health technology assessment (HTA) or pharmacoeconomic analysis for decision making. The current scoping review was undertaken with an objective to summarize the recommendations made on methods of economic evaluation by the national healthcare economic evaluation (HEE) guidelines., Methodology: A comprehensive search was undertaken in the website repositories of the International Society for Pharmacoeconomic and Outcomes Research (ISPOR) and Guide to Economic Analysis and Research (GEAR), and websites of national HTA agencies and ministries of health of individual countries. All guidelines in the English language were included in this review. Data were extracted with respect to general and methodological characteristics, and a descriptive analysis of recommendations made across the countries was undertaken., Results: Overall, our review included 31 national HEE guidelines, published between 1997 and August 2020. Nearly half (45%) of the guidelines targeted the evaluation of pharmaceuticals. The nature of the guidelines was either mandatory (31%), recommendatory (42%), or voluntary (16%). There was a substantial consensus among the guidelines on several key principles, including type of economic evaluation (cost-utility analysis), time horizon of the analysis (long enough), health outcome measure (quality-adjusted life-years) and use of sensitivity analyses. The recommendations on study perspective, comparator, discount rate and type of costs to be included (particularly the inclusion of indirect costs) varied widely., Conclusion: Despite similarity in the overall processes, variation in several recommendations given by various national HEE guidelines was observed. This is perhaps unsurprising given the differences in the health systems and financing mechanisms, capacity of local researchers, and data availability. This review offers important lessons and a starting point for countries that are planning to develop their own HEE guidelines., (© 2021. The Author(s).)

Objective: To assess the adherence of economic evaluations to the recommendations on principles of economic evaluation as stated in the country-specific guidelines for three countries across different income groups, namely, Canada, South Africa, and Egypt., Methods: Searches were undertaken in three databases to identify economic evaluations meeting predefined inclusion criteria. Methodological and reporting standards listed in the country-specific guidelines were converted into discrete binary variables to calculate mean adherence scores. Quality appraisal was done using Drummond's checklist. Stratified analysis was undertaken to identify independent variables affecting adherence., Results: We identified forty-four, seventy-nine, and sixteen economic evaluations for Canada, South Africa, and Egypt, respectively. The mean adherence score was the highest for Canada (71%), followed by South Africa (65%) and Egypt (60%). Adherence to guidelines was positively correlated with quality of studies, r = .72. Furthermore, the mean adherence score was significantly (p < .05) higher for studies using a cost-utility analysis design (72%), having local/national funding aid (72%), undertaken by a health economist (71%) and for pharmacoeconomic evaluations (70%)., Conclusion: The quality of economic evaluations improves with adherence to country-specific guidelines. Locally funded and health-economist led health technology assessments (HTAs) should be encouraged for greater adherence to the guidelines. The HTA researchers and the HTA bodies should lay emphasis on adherence to the country-specific guidelines for improving the quality of HTA evidence.

Background: Patients with chronic disease in rural and remote regions endure limited access to specialised medicine. Telehealth has addressed this issue with demonstrable benefits such as a reduction in costs to patients., Aims: To explore the patient satisfaction of telehealth in Australia., Methods: Patients from all around Australia, including Queensland, Victoria, Tasmania, South Australia, Australian Capital Territory and even Western Australia were referred to a Sydney-based neurologist. After their initial face to face consultation, review consultations were performed by telehealth. All had chronic diseases (trigeminal neuralgia, facial pain or Parkinson disease) and received a standardised questionnaire comprising of demographics, satisfaction of technical aspects and quality of the consultation. The questionnaires were administered by the Practice Manager to remove observer bias., Results: Twenty-nine patient questionnaires were completed by 13 patients who had follow-up telehealth consultations. One hundred per cent of patients reported satisfaction with the overall telehealth experience and would use it again. All were satisfied with the specialist and the privacy. The majority were satisfied with the voice quality (86%), visual quality (79%), ease of connectivity (93%) and length of the consultation (97%). In total, they saved nearly $17 000 in travel costs and on average, each patient avoided 937 km and saved $550., Conclusion: Telehealth has proven to have multiple advantages, including improved access to healthcare, decreased costs, reduced inconvenience and improved management of chronic and complex conditions. The positive results advocate the use of telehealth for follow up of rural and remote patients with chronic disease., (© 2020 Royal Australasian College of Physicians.)

Abstract: C-reactive protein (CRP) is part of a battery of "routine bloods" performed by residents on patients when they are admitted into a rehabilitation unit. Generally, an elevated CRP is considered to be an indicator of an acute infective process. Numerous studies have indicated that the CRP peaks on the 2nd or 3rd day post total hip arthroplasty (THR) and total knee arthroplasty (TKR) and returns to normal by day 7. When the CRP level remains elevated, it is generally felt that infection should be excluded.We performed a prospective study on 45 consecutive patients admitted into a rehabilitation unit post hip and knee arthroplasty over a 6 months period, to evaluate the incidence of an elevated CRP on admission, to determine whether an isolated elevated CRP on admission to a rehabilitation setting should not be considered as an indicator of an infective process.We found all patients (100%) had elevated CRP's on admission, ranging from 8.6 mg/L to 139.2 mg/L, between days 5-7 post-operatively. By day 14, CRP's reduced, but 91% of patients still had elevated CRP's, ranging from 2.1 mg/L to 47.3 mg/L after THR and 4.8 mg/L to 40 mg/L after TKR at day 14.These results suggest that even in uncomplicated elective joint arthroplasty, CRP's can remain elevated up to 14 days post-procedure, in the absence of an infective process.An isolated elevated CRP on admission to a rehabilitation setting should not be considered as an indicator of an infective process, but rather part of the normal post-operative inflammatory response. The elevated CRP should be monitored and only an upward trend requires further investigation and management., Competing Interests: The authors have no funding and conflicts of interest to disclose, (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty., Setting: Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless., Participants: We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone., Results: Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment., Conclusion: A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The aim of the study is to identify the factors affecting students' satisfaction and performance regarding online classes during the pandemic period of COVID-19 and to establish the relationship between these variables. The study is quantitative in nature, and the data were collected from 544 respondents through online survey who were studying the business management (B.B.A or M.B.A) or hotel management courses in Indian universities. Structural equation modeling was used to analyze the proposed hypotheses. The results show that four independent factors used in the study viz. quality of instructor, course design, prompt feedback, and expectation of students positively impact students' satisfaction and further student's satisfaction positively impact students' performance. For educational management, these four factors are essential to have a high level of satisfaction and performance for online courses. This study is being conducted during the epidemic period of COVID- 19 to check the effect of online teaching on students' performance., Competing Interests: Conflict of interestThe authors declare no conflict of interest, financial or otherwise., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021.)

Background: Coeliac plexus block (CPB) is an interventional pain management option for patients with pancreatic or other upper abdominal malignancy., Aims: To assess the safety, utilization, and outcomes of CPBs in the local context., Methods and Results: We conducted a retrospective case series of all patients with cancer who underwent CPB at 4 Sydney teaching hospitals from March 2010 to February 2016. We recorded baseline demographic data, details of the injectate, procedural approach and survival, as well as pain scores and analgesic use at 4 time points of interest. Thirty-nine procedures were performed during the study period. Twenty-four were performed endoscopically, 14 were performed via a bilateral percutaneous posterior approach by Pain Specialists or Radiologists and 1 was performed intraoperatively by a Surgeon. Patients had experienced pain for a mean of 17 weeks prior to CPB. Prior to CPB, the mean pain score was 8.8 out of 10. The mean pain score was reduced at 48 hours, 2 weeks, and 4 weeks following CPB (P < .01). The mean oral morphine equivalent daily dose prior to CPB was 362 mg which was reduced at 48 hours and 2 weeks but increased at the 4 weeks following CPB. One patient developed a bacteremia but otherwise no complications were observed., Conclusion: CPB is performed by a number of approaches and is well tolerated. The approach selected appears to depend on patient anatomy, preference, and availability of local expertise. Local clinicians could consider CPB earlier in the management of malignant epigastric pain., (© 2020 Wiley Periodicals LLC.)

Introduction: Most of the neonatal and maternal deaths occur within the first 48 hours post-delivery. Hence, this time period is very crucial for the survival of newborns and mothers both. As per maternal and child health program guidelines in India, it is clearly mentioned that all the government health facilities should discharge the mother and baby only after 48 hours of delivery in case of normal delivery and after 7 days in case of delivery conducted by cesarean sections., Aim: The aim of the study was to find the various factors responsible for early maternity discharge (<48 h) of normal vaginal deliveries (NVDs) conducted at government health facilities., Material and Methods: The study was conducted in a rural block of Haryana, North India, from May to June, 2015. Postnatal women with NVD within 6 months of duration from initiation of the study were included after taking proper informed consent. A questionnaire was developed by the investigators to interview the women. The questionnaire consists of 26 items which included the socio-demographic details and questions on various factors affecting postnatal stay at the health facility., Results: A total of 40 postnatal women consented and participated in the study. Their mean age was 23.46 ± 5.63 years. Majority of them (24, 60.0%) were having their first child. Out of them, 12 delivered at primary health centers (PHCs), 18 at community health centers, and the rest at the district hospital. A total of 24 (60%) of them were discharged early (<48 h) as per laid guidelines. It was observed that primiparity, delivery at PHC, normal birth weight of baby, and term deliveries were significantly associated with early discharge. Among those who had NVD and stayed beyond 48 h, most of them mentioned that the round-the-clock availability of doctors/nurses was the main reason for their staying at the health facility., Conclusion: The proportion of postpartum women discharged early is high and alarming. There is a need for essential counseling to be imparted to the mothers by doctors/nurses at all the health facilities for staying till 48 hours and by health workers during the antenatal period of the importance of the stay at the facility post delivery., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Education and Health Promotion.)

Context Childhood obesity is defined based on body mass index (BMI) criteria. Asian adults have more abdominal adiposity as compared to Western people for an equivalent BMI. Similarly, children who are non-obese/overweight by BMI criteria may have abdominal obesity. It is important to identify and target this population to reduce future cardiovascular risk. Objective To evaluate and inter-relate the prevalence of obesity subtypes (generalized and abdominal) in school going adolescents. Methods A randomized cross-sectional community based study was conducted, which was carried out in 13 schools of Chandigarh, a North Indian city. 10,037 school going adolescents of age 10-18 years were evaluated. Results The prevalence of overweight and generalized obesity in present study was 9.3 and 4.9% respectively. Generalized obesity was observed in 4.2% of males and 5.7% of females (p-Value = 0.001). The abdominal obesity was noted in 5.4% of children and its prevalence increased progressively with age. The prevalence was highest in 16-18 years age-group (7.6%, p<0.001). 39.3% of abdominally obese subjects were not obese by BMI criteria, while prevalence of abdominal obesity in nonobese adolescents was 2.24%. It was more prevalent in females (3.7%) than males (3%, p=0.025). Prevalence of obesity was 7.9 and 1.8% in private and government schools respectively (p<0.001). Conclusions Abdominal obesity is more prevalent than generalized obesity and shows increasing trend with age. Interestingly, over one third of centrally obese adolescents are not obese by BMI criteria. This underlines the importance of waist circumference measurement in addition to BMI while assessing obesity.

Background: Globally, 16 billion injections are administered each year of which 95% are for curative care. India contributes 25-30% of the global injection load. Over 63% of these injections are reportedly unsafe or deemed unnecessary., Objectives: To assess the incremental cost per quality-adjusted life-year (QALY) gained with the introduction of safety-engineered syringes (SES) as compared to disposable syringes for therapeutic care in India., Methods: A decision tree was used to compute the volume of needle-stick injuries (NSIs) and reuse episodes among healthcare professionals and the patient population. Subsequently, three separate Markov models were used to compute lifetime costs and QALYs for individuals infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Three SES were evaluated-reuse prevention syringe (RUP), sharp injury prevention (SIP) syringe, and syringes with features of both RUP and SIP. A lifetime study horizon starting from a base year of 2017 was considered appropriate to cover all costs and consequences comprehensively. A systematic review was undertaken to assess the SES effects in terms of reduction in NSIs and reuse episodes. These were then modelled in terms of reduction in transmission of blood-borne infections, life-years and QALYs gained. Future costs and consequences were discounted at the rate of 3%. Incremental cost per QALY gained was computed to assess the cost-effectiveness. A probabilistic sensitivity analysis was undertaken to account for parameter uncertainties., Results: The introduction of RUP, SIP and RUP + SIP syringes in India is estimated to incur an incremental cost of Indian National Rupee (INR) 61,028 (US$939), INR 7,768,215 (US$119,511) and INR 196,135 (US$3017) per QALY gained, respectively. A total of 96,296 HBV, 44,082 HCV and 5632 HIV deaths are estimated to be averted due to RUP in 20 years. RUP has an 84% probability to be cost-effective at a threshold of per capita gross domestic product (GDP). The RUP syringe can become cost saving at a unit price of INR 1.9. Similarly, SIP and RUP + SIP syringes can be cost-effective at a unit price of less than INR 1.2 and INR 5.9, respectively., Conclusion: RUP syringes are estimated to be cost-effective in the Indian context. SIP and RUP + SIP syringes are not cost-effective at the current unit prices. Efforts should be made to bring down the price of SES to improve its cost-effectiveness.

Perceptions of psychological empowerment play a vital role in the way an individual perceives things at the workplace. In spite of this, there is scant research on the antecedents and consequences of psychological empowerment. This study is an attempt to fill this gap by analyzing the mediating role of psychological empowerment on the relationship between its antecedents (leader-member exchange) and its consequences (work engagement and psychological withdrawal behavior). Data were collected from 454 employees working in the Research and Development (R&D) departments of the information technology (IT) and pharmaceutical sectors operating in India. Results suggest that employees who have a high-quality relationship with their leader have high psychological empowerment, they are highly engaged at work, and their psychological withdrawal behavior is also low. In addition to this, high levels of psychological empowerment have a positive impact on their engagement toward work, which further leads to a low psychological withdrawal behavior. The theoretical and practical implications of these results are discussed., (Copyright © 2020 Aggarwal, Chand, Jhamb and Mittal.)

Background: Malnutrition is a major public health problem in India, especially among urban poor children. The objective of the study was to determine the effectiveness of a culturally appropriate nutrition educational intervention that can be delivered through health services and digitized child undernutrition tracking module for health workers to improve complementary feeding of infants of age six months to 12 months in Chandigarh, North India, to prevent malnutrition in infants., Methods: A quasi-experimental study was conducted in a non-randomized intervention (Burail) and control area (Maloya) among a vulnerable population in Chandigarh, North India. The mother-infant dyads (MIDs) in the intervention group(n = 202) received culturally appropriate nutrition educational intervention, were supported individually by trained health workers in infant feeding and followed up for six months. Health workers were monitored through a digitized tracking module. The MIDs in the control group (n = 202) received routine care under the national health program. The mean (±S.D.) age of infants in the intervention and control group was 5.4 (±0.8) months and 5.5 (±0.7) months, respectively. The data was collected using a pre-tested semi-structured questionnaire and anthropometry of infants at baseline and end line. The primary outcome was a mean change in weight. The effectiveness of the intervention was measured by conducting the difference in difference (DID) analysis in mean change in weight between intervention and control group., Result: At baseline, the mean (±S.D.) weight of infants was 6.6(±0.64) kg and 6.6 (±0.52) kg in the intervention and control group. The mean (±S.D.) length of infants was 64.3 (±2.0) cm in the intervention group and 65.1 (±1.7) cm in the control group. Out of 404, 190 and 191 MIDs in the intervention and control group completed the study, respectively. A significantly higher number of infants in the intervention group were started on complementary feeding at six months of age (72.6% versus45.5%, p<0.01) and received foods having thick consistency (82.1% versus 41.9%, p<-0.01). There was significant weight gain in intervention group infants (DID means = 0.27 kg, p<0.01) and length gain (DID means = 0.9 cm, p<0.01) from the baseline. Also, there was significant decline in the proportion of undernourished (10% versus18.8%, OR = 0.47, p = 0.01) and wasted infants (7.3% versus15.7%, OR = 0.42, p = 0.01) in the intervention group., Conclusion: Community-based nutrition educational intervention delivered through the routine health services and digitized tracking of malnourished children can effectively improve the complementary feeding and growth of children six months to one year among vulnerable populations., Competing Interests: The authors have declared that no competing interests exist.

India contributes a quarter of the global burden of multidrug-resistant tuberculosis (MDR-TB) and has inadequate diagnostic infrastructure and institutional capacities for drug susceptibility testing. Subsequently, this leads to a large number of undetected and untreated cases of MDR-TB. In this report, we describe a case of a 55-year-old man from rural North India presenting with complaints of continued symptoms of chronic cough, fever and dyspnoea despite being recently diagnosed with recurrent tuberculosis and receiving treatment from the local community health centre. MDR-TB was suspected, but confirmatory diagnostic capabilities were not available in the local setting. The patient was finally diagnosed with MDR-TB. Treatment was coordinated by the district tuberculosis programme officer. Through this case, we describe the various barriers to detecting MDR-TB in the rural regions of India. Prompt identification of patients with presumptive MDR-TB, diagnosis of the disease and initiation of treatment are crucial to preventing disease transmission and reducing morbidity and mortality., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: None

There have been limited attempts at measurement of health system performance at decentralized levels in low- and middle-income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain-specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action., (© 2019 John Wiley & Sons, Ltd.)

Competing Interests: There are no conflicts of interest.

A number of treatment options have been used over the years in short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) with variable results. The most common preventive treatments include carbamazepine, lamotrigine, indomethacin, gabapentin and topiramate. Ketamine is being increasingly used in the treatment of neuropathic pain. The parentral formulations are generally used as oral preparations have poor bioavailability. Recently, ketamine lozenges have been shown to have sufficiently high bioavailability to support their use as a preventive treatment in a number of conditions causing intractable neuropathic pain. We report a 58-year-old man whose symptoms of SUNCT were not responsive to conventional preventive treatments but responded well to a subcutaneous, sub-anaesthetic ketamine infusion and subsequently, sublingual ketamine lozenges., Competing Interests: None

Introduction: In this paper, we present district level out-of-pocket (OOP) expenditures with respect to outpatient consultation within last 15 days and hospitalization in last 1 year for Haryana state., Methods: The data from a large cross-sectional household survey covering all 21 districts of Haryana comprising of randomly selected 79 742 households were analyzed. Of the total sample, 56 056 households consisting of 314 639 individuals in 21 districts of Haryana state were surveyed to gather information on OOP expenditure incurred on outpatient consultation within last 15 days. Similarly, 59 901 households and 324 977 respondents were interviewed to elicit OOP expenditures for any hospitalization during the 1 year preceding the survey. Mean OOP expenditure per OP consultation, per hospitalization as well as per capita were computed. Mean OOP expenditure was also estimated by the type of provider, gender, and district., Results: The mean OOP expenditure for OP consultation and hospitalization in Haryana was Indian National Rupees (INR) 1005 (US Dollar [USD] 16.1; 95% CI: INR 934-1076) and INR 22 489 (USD 360.0; 95% CI: INR 21 375-23 608), respectively. Mean per capita OOP expenditure for OP consultation, which was INR 85 (USD 1.3) in Haryana, varied from INR 595 (USD 9.5) in district Panipat to INR 29 (USD 0.5) in district Kaithal., Conclusion: This is the first study to comprehensively present district level estimates for OOP expenditure for health care. These estimates are useful for policy planning, and preparation for district and state health accounts., (© 2018 John Wiley & Sons, Ltd.)

Background: The immunization coverage in India is far away from satisfactory with full immunization coverage being only 62% at national level. Targeting the intensive efforts to poor performing areas and addressing the determinants of nonimmunization and dropouts offers a quick solution. In this paper, we assess the inter-district variations in Haryana state, and the association of social determinants with partial and no immunization., Methodology: This analysis is based on data collected as part of a large household survey undertaken in the state of Haryana to measure the extent of Universal Health Coverage. A multistage stratified random sampling design was used to select primary sampling units (i.e., subcenters), villages, and households. A total of 11,594 mothers with a child between 12 and 23 months were interviewed on receipt of immunization services. Determinants of nonimmunization and partial immunization were assessed using multiple logistic regression., Results: About 21% of children aged 12-23 months were partially immunized, while 4.3% children aged 12-23 months had received "no immunization." While the coverage of full immunization was 74.7% at the state level, it varied from 95% in best performing district to 38% in poorest performing district. Odds of a partially immunized child were significantly higher in urban area (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.1-1.38), among Muslim household (OR = 3.52; 95% CI = 3.03-4.11), children of illiterate parents (OR = 1.58; 95% CI = 1.22-2.05), and poorest quintile (OR = 1.61; 95% CI = 1.36-1.89)., Conclusions: Wide interdistrict variations call for a need to consider changes in resource allocation and strengthening of the government initiatives to improve routine immunization in these districts., Competing Interests: There are no conflicts of interest.

Background: Several competing priorities with health and development sector currently deter research, and as a result of which evidence does not drive policy- or decision-making. There is limited operational research (OR) within the India's National Tobacco Control Programme, as it is in other middle- and low-income countries, primarily due to limited capacity and skills in undertaking OR and lack of dedicated funding. Few models of OR have been developed to meet the needs of different settings; however, they were found to be costly and time-consuming., Objective: To elucidate a cost-effective and less resource arduous training model for building capacity in OR focused on tobacco control., Materials and Methods: This 5½-day partly funded course enrolled 15 participants across the country and nine facilitators. The facilitator-participants interactions were initiated 2 weeks before the course, which enabled them to develop possible research questions and a plan for data analysis., Results: This article presents the new OR model along with experiences of the participants which will provide useful insights on lessons learned for planning similar courses in the future. While we faced several challenges in the process and the outputs were modest, several lessons were learned which will be instrumental in the future courses that we are planning to conduct., Conclusion: This low cost and less time intensive model can be applied in similar settings across range of public health issues., Competing Interests: There are no conflicts of interest.

Background: Limited efforts have been observed in low and middle income countries to undertake health system performance assessment at district level. Absence of a comprehensive data collection tool and lack of a standardised single summary measure defining overall performance are some of the main problems. Present study has been undertaken to develop a summary composite health system performance index at district level., Methods: A broad range of indicators covering all six domains as per building block framework were finalized by an expert panel. The domains were classified into twenty sub-domains, with 70 input and process indicators to measure performance. Seven sub-domains for assessing health system outputs and outcomes were identified, with a total of 28 indicators. Districts in Haryana state from north India were selected for the study. Primary and secondary data will be collected from 378 health facilities, district and state health directorate headquarters. Indicators will be normalized, aggregated to generate composite performance index at district level. Domain specific scores will present the quality of individual building block domains in the public health system. Robustness of the results will be checked using sensitivity analysis., Expected Impact for Public Health: The study presents a methodology for comprehensive assessment of all health system domains on basis of input, process, output and outcome indicators which has never been reported from India. Generation of this index will help identify policy and implementation areas of concern and point towards potential solutions. Results may also help understand relationships between individual building blocks and their sub-components.