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Purpose: We present our analysis of the existing Paediatric High Dependency Unit (HDU) admission policy at our institution and discuss our thoughts for its revision in the context of paediatric supratentorial tumour surgery., Materials and Methods: We screened our prospectively maintained database of all children undergoing supratentorial craniotomy for resection of paediatric brain tumours over a fifteen-year period. The post-operative course of each patient was reviewed, assessing the number of patients who had true HDU needs in the immediate post-operative period, and the relative depth of input from paediatric HDU specialists that each patient received., Results: Forty-three patients underwent craniotomy for supratentorial tumour resections during the study period. The median age of the children was 8 years old. Forty-two patients in the study cohort did not require any HDU-level monitoring or treatment post-operatively; all these patients were able to be discharged from HDU to a standard ward bed very rapidly post-operatively. Only one patient (2%) from the study cohort had any tangible HDU needs in the acute post-operative period, comprising of invasive cardiovascular monitoring and repeated blood transfusions. This child's tumour was known to be large, highly vascular, and invasive pre-operatively., Conclusions: We would advocate a rational and nuanced approach with regards to predicting which children are most likely need paediatric HDU care following supratentorial craniotomy for resection of a brain tumour. This rationalisation could improve resource availability and reduce financial burdens upon paediatric neurosurgical units.

Background: Interventions with women's groups have been widely implemented to improve health outcomes in low- and middle-income settings, particularly India. While there is a large evidence base on the effectiveness of single interventions, it is challenging to predict whether a women's group intervention delivered in one setting can be expected to work in another., Methods: We applied realist principles to develop and refine a mid-range theory on the effectiveness of women's groups interventions, summarised key lessons for implementation, and reflected on the process. We synthesised primary data from several interventions in India, a systematic review, and an analysis of behaviour change techniques. We developed mid-range theories across three areas: maternal and newborn health, nutrition, and violence against women, as well as an overarching mid-range theory on how women's groups can improve health., Results: Our overarching mid-range theory suggested that effective interventions should: build group or community capabilities; focus on health outcomes relevant to group members; and approach health issues modifiable through women's individual or collective actions. We identified four key lessons for future interventions with women's groups, including the importance of skilled and remunerated facilitation, sufficient intensity, supply-side strengthening, and the need to adapt delivery during scale up while maintaining fidelity to intervention theory., Conclusions: Our experience demonstrated the feasibility of developing mid-range theory from a combination of evidence and insights from practice. It also underscored the importance of community engagement and ongoing research to 'thicken' mid-range theories to design effective and scalable women's groups interventions in India and similar settings., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

Background: Hysterectomy, particularly when conducted in women younger than 45 years, has been associated with increased risk of non-communicable diseases. In India, research indicates that hysterectomy is a common procedure for women, but there have been no studies on its long-term effects. We examined patterns of hysterectomy amongst women in India and associations with their health and well-being in later life., Methods: This analysis utilised the first wave of the Longitudinal Study on Aging in India, a nationally representative study of adults that included a module on health and well-being. We analysed data on 35,083 women ≥45 years in India. We estimated prevalence of hysterectomy and performed multivariable logistic regression to identify associated risk factors and to examine the association between hysterectomy status and eight self-reported chronic conditions, hospitalisation and mobility., Results: The prevalence of hysterectomy among women >=45 years was 11.4 (95% CI: 10.3, 12.6), with higher odds among urban women (aOR: 1.39; 1.17,1.64) and higher economic status (highest compared to lowest quintile: aOR: 1.95; 1.44, 2.63). Hysterectomy history was associated with four chronic conditions: hypertension (aOR: 1.51; 95% CI: 1.28, 1.79), high cholesterol (aOR: 1.43; 1.04, 1.97), diabetes (aOR: 1.69; 1.28, 2.24), and bone/joint disease (aOR: 1.54; 1.20, 1.97) and higher odds of any hospitalisation in the past year (aOR: 1.69; 1.36, 2.09)., Conclusions: In India, evidence suggests that hysterectomy is associated with major chronic conditions. The assessment for hysterectomy as a treatment option for gynaecological morbidity should consider potential health consequences in later life., (© 2023. The Author(s).)

Background: With less than 20% of people with hypertension achieving their target blood pressure (BP) goals, uncontrolled hypertension remains a major public health problem in India. We conducted a study to assess the effectiveness of a community-based education and peer support programme led by women's self-help group (SHG) members in reducing the mean systolic BP among people with hypertension in urban slums of Kochi city, Kerala, India., Methods: A cluster randomised controlled pragmatic trial was conducted where 20 slums were randomised to either the intervention or the control arms. In each slum, participants who had elevated BP (>140/90) or were on antihypertensive medications were recruited. The intervention was delivered through women's SHG members (1 per 20-30 households) who provided (1) assistance in daily hypertension management, (2) social and emotional support to encourage healthy behaviours and (3) referral to the primary healthcare system. Those in the control arm received standard of care. The primary outcome was change in mean systolic BP (SBP) after 6 months., Results: A total of 1952 participants were recruited-968 in the intervention arm and 984 in the control arm. Mean SBP was reduced by 6.26 mm Hg (SE 0.69) in the intervention arm compared with 2.16 mm Hg (SE 0.70) in the control arm; the net difference being 4.09 (95% CI 2.15 to 4.09), p<0.001., Conclusion: This women's SHG members led community intervention was effective in reducing SBP among people with hypertension compared with those who received usual care, over 6 months in urban slums of Kerala, India., Trial Registration Number: CTRI/2019/12/022252., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: None

Background: Direct-to-beneficiary communication mobile programmes are among the few examples of digital health programmes to have scaled widely in low-resource settings. Yet, evidence on their impact at scale is limited. This study aims to assess whether exposure to mobile health information calls during pregnancy and postpartum improved infant feeding and family planning practices., Methods: We conducted an individually randomised controlled trial in four districts of Madhya Pradesh, India. Study participants included Hindi speaking women 4-7 months pregnant (n=5095) with access to a mobile phone and their husbands (n=3842). Women were randomised to either an intervention group where they received up to 72 Kilkari messages or a control group where they received none. Intention-to-treat (ITT) and instrumental variable (IV) analyses are presented., Results: An average of 65% of the 2695 women randomised to receive Kilkari listened to ≥50% of the cumulative content of calls answered. Kilkari was not observed to have a significant impact on the primary outcome of exclusive breast feeding (ITT, relative risk (RR): 1.04, 95% CI 0.88 to 1.23, p=0.64; IV, RR: 1.10, 95% CI 0.67 to 1.81, p=0.71). Across study arms, Kilkari was associated with a 3.7% higher use of modern reversible contraceptives (RR: 1.12, 95% CI 1.03 to 1.21, p=0.007), and a 2.0% lower proportion of men or women sterilised since the birth of the child (RR: 0.85, 95% CI 0.74 to 0.97, p=0.016). Higher reversible method use was driven by increases in condom use and greatest among those women exposed to Kilkari with any male child (9.9% increase), in the poorest socioeconomic strata (15.8% increase), and in disadvantaged castes (12.0% increase). Immunisation at 10 weeks was higher among the children of Kilkari listeners (2.8% higher; RR: 1.03, 95% CI 1.00 to 1.06, p=0.048). Significant differences were not observed for other maternal, newborn and child health outcomes assessed., Conclusion: Study findings provide evidence to date on the effectiveness of the largest mobile health messaging programme in the world., Trial Registration Number: Trial registration clinicaltrials.gov; ID 90075552, NCT03576157., Competing Interests: Competing interests: All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare that the research reported was funded by the Bill and Melinda Gates Foundation. AG, SC, PD are employed by BBC Media Action; one of the entities supporting program implementation. The authors do not have other relationships and are not engaged in activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Efforts to understand the factors influencing the uptake of reproductive, maternal, newborn, child health and nutrition (RMNCH&N) services in high disease burden low-resource settings have often focused on face-to-face surveys or direct observations of service delivery. Increasing access to mobile phones has led to growing interest in phone surveys as a rapid, low-cost alternatives to face-to-face surveys. We assess determinants of RMNCH&N knowledge among pregnant women with access to phones and examine the reliability of alternative modalities of survey delivery., Participants: Women 5-7 months pregnant with access to a phone., Setting: Four districts of Madhya Pradesh, India., Design: Cross-sectional surveys administered face-to-face and within 2 weeks, the same surveys were repeated among two random subsamples of the original sample: face-to-face (n=205) and caller-attended telephone interviews (n=375). Bivariate analyses, multivariable linear regression, and prevalence and bias-adjusted kappa scores are presented., Results: Knowledge scores were low across domains: 52% for maternal nutrition and pregnancy danger signs, 58% for family planning, 47% for essential newborn care, 56% infant and young child feeding, and 58% for infant and young child care. Higher knowledge (≥1 composite score) was associated with older age; higher levels of education and literacy; living in a nuclear family; primary health decision-making; greater attendance in antenatal care and satisfaction with accredited social health activist services. Survey questions had low inter-rater and intermodal reliability (kappa<0.70) with a few exceptions. Questions with the lowest reliability included true/false questions and those with unprompted, multiple response options. Reliability may have been hampered by the sensitivity of the content, lack of privacy, enumerators' and respondents' profile differences, rapport, social desirability bias, and/or enumerator's ability to adequately convey concepts or probe., Conclusions: Phone surveys are a reliable modality for generating population-level estimates data about pregnant women's knowledge, however, should not be used for individual-level tracking., Trial Registration Number: NCT03576157., Competing Interests: Competing interests: All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare that the research reported was funded by the Bill and Melinda Gates Foundation. AG, SC, PD are employed by BBC Media Action, one of the entities supporting programme implementation. The authors do not have other relationships and are not engaged in activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Mobile phones are increasingly used to facilitate in-service training for frontline health workers (FLHWs). Mobile learning (mLearning) programmes have the potential to provide FLHWs with high quality, inexpensive, standardised learning at scale, and at the time and location of their choosing. However, further research is needed into FLHW engagement with mLearning content at scale, a factor which could influence knowledge and service delivery. Mobile Academy is an interactive voice response training course for FLHWs in India, which aims to improve interpersonal communication skills and refresh knowledge of preventative reproductive, maternal, neonatal and child health. FLHWs dial in to an audio course consisting of 11 chapters, each with a 4-question true/false quiz, resulting in a cumulative pass/fail score. In this paper, we analyse call data records from the national version of Mobile Academy to explore coverage, user engagement and completion. Over 158 596 Accredited Social Health Activists (ASHAs) initiated the national version, while 111 994 initiated the course on state-based platforms. Together, this represents 41% of the estimated total number of ASHAs registered in the government database across 13 states. Of those who initiated the national version, 81% completed it; and of those, over 99% passed. The initiation and completion rates varied by state, with Rajasthan having the highest initiation rate. Many ASHAs made multiple calls in the afternoons and evenings but called in for longer durations earlier in the day. Findings from this analysis provide important insights into the differential reach and uptake of the programme across states., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: India has become a lighthouse for large-scale digital innovation in the health sector, particularly for front-line health workers (FLHWs). However, among scaled digital health solutions, ensuring sustainability remains elusive. This study explores the factors underpinning scale-up of digital health solutions for FLHWs in India, and the potential implications of these factors for sustainability., Methods: We assessed five FLHW digital tools scaled at the national and/or state level in India. We conducted in-depth interviews with implementers, technology and technical partners (n=11); senior government stakeholders (n=5); funders (n=1) and evaluators/academics (n=3). Emergent themes were grouped according to a broader framework that considered the (1) digital solution; (2) actors; (3) processes and (4) context., Results: The scale-up of digital solutions was facilitated by their perceived value, bounded adaptability, support from government champions, cultivation of networks, sustained leadership and formative research to support fit with the context and population. However, once scaled, embedding digital health solutions into the fabric of the health system was hampered by challenges related to transitioning management and ownership to government partners; overcoming government procurement hurdles; and establishing committed funding streams in government budgets. Strong data governance, continued engagement with FLHWs and building a robust evidence base, while identified in the literature as critical for sustainability, did not feature strongly among respondents. Sustainability may be less elusive once there is more consensus around the roles played between national and state government actors, implementing and technical partners and donors., Conclusion: The use of digital tools by FLHWs offers much promise for improving service delivery and health outcomes in India. However, the pathway to sustainability is bespoke to each programme and should be planned from the outset by investing in people, relationships and service delivery adjustments to navigate the challenges involved given the dynamic nature of digital tools in complex health systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

The Kilkari programme is being implemented by the Government of India in 13 states. Designed by BBC Media Action and scaled in collaboration with the Ministry of Health and Family Welfare from January 2016, Kilkari had provided mobile health information to over 10 million subscribers by the time BBC Media Action transitioned the service to the government in April 2019. Despite the reach of Kilkari in terms of the absolute number of subscribers, no longitudinal analysis of subscriber exposure to health information content over time has been conducted, which may underpin effectiveness and changes in health outcomes. In this analysis, we draw from call data records to explore exposure to the Kilkari programme in India for the 2018 cohort of subscribers. We start by assessing the timing of the first successful call answered by subscribers on entry to the programme during pregnancy or postpartum, and then assess call volume, delivery, answering and listening rates over time. Findings suggest that over half of subscribers answer their first call after childbirth, with the remaining starting in the pregnancy period. The system handles upwards of 1.2 million calls per day on average. On average, 50% of calls are picked up on the first call attempt, 76% by the third and 99.5% by the ninth call attempt. Among calls picked up, over 48% were listened to for at least 50% of the total content duration and 43% were listened to for at least 75%. This is the first analysis of its kind of a maternal mobile messaging programme at scale in India. Study analyses suggest that multiple call attempts may be required to reach subscribers. However, once answered, subscribers tend to listen the majority of the call-a figure consistent across states, over time, and by health content area., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Traumatic brain injury (TBI) is associated with poor clinical outcomes; autopsy studies of TBI victims demonstrate significant oligodendrocyte progenitor cell (OPC) death post TBI; an observation, which may explain the lack of meaningful repair of injured axons. Whilst high-mobility group box-1 (HMGB1) and its key receptors TLR2/4 are identified as key initiators of neuroinflammation post-TBI, they have been identified as attractive targets for development of novel therapeutic approaches to improve post-TBI clinical outcomes. In this report we establish unequivocal evidence that HMGB1 released in vitro impairs OPC response to mechanical injury; an effect that is pharmacologically reversible. We show that needle scratch injury hyper-acutely induced microglial HMGB1 nucleus-to-cytoplasm translocation and subsequent release into culture medium. Application of injury-conditioned media resulted in significant decreases in OPC number through anti-proliferative effects. This effect was reversed by co-treatment with the TLR2/4 receptor antagonist BoxA. Furthermore, whilst injury conditioned medium drove OPCs towards an activated reactive morphology, this was also abolished after BoxA co-treatment. We conclude that HMGB1, through TLR2/4 dependant mechanisms, may be detrimental to OPC proliferation following injury in vitro, negatively affecting the potential for restoring a mature oligodendrocyte population, and subsequent axonal remyelination. Further study is required to assess how HMGB1-TLR signalling influences OPC maturation and myelination capacity.

Adolescents are an increasing proportion of low and middle-income country populations. Their coming of age is foundational for health behaviour, as well as social and productive citizenship. We mapped intervention areas for adolescent sexual and reproductive health, including HIV, mental health and violence prevention to sectors responsible for them using a framework that highlights settings, roles and alignment. Out of 11 intervention areas, health is the lead actor for one, and a possible lead actor for two other interventions depending on the implementation context. All other interventions take place outside of the health sector, with the health sector playing a range of bilateral, trilateral supporting roles or in several cases a minimal role. Alignment across the sectors varies from indivisible, enabling or reinforcing to the other extreme of constraining and counterproductive. Governance approaches are critical for brokering these varied relationships and interactions in multisectoral action for adolescent health, to understand the context of such change and to spark, sustain and steer it., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Predictive factors for post-traumatic hydrocephalus (PTH) in adults have been elucidated but remain uncertain for children. We aimed to identify the prevalence of PTH in paediatric patients and identify clinical/radiological factors which may increase the probability of children developing PTH., Methods: This was a retrospective study of all patients < 16 years old admitted to our unit with traumatic brain injury (TBI) between March 2013 and June 2018, 108 patients in total. Patients were classified as mild (13-15), moderate (9-12) or severe (3-8) TBI based on admission GCS. Three independent reviewers collected data from case notes. CT scans were reviewed for hydrocephalus using Evan's index. Two-tailed Fisher's exact tests with a p value < 0.05 were considered statistically significant., Results: Median patient age was 7 years, and 65% were males (n = 70). PTH wasn't identified in any patients with mild/moderate TBI (n = 79). In cases of severe TBI (n = 29), three patients developed PTH requiring ventriculoperitoneal shunting (10%; p = 0.02). Radiological features which were significantly more common in the PTH group were intraventricular haemorrhage (p = 0.05) and subarachnoid haemorrhage (p = 0.03). There was also a trend towards a statistically significant association with subdural haematoma (p = 0.07). The need for other neurosurgical procedures, such as fracture elevation and craniotomy, did not increase the probability of developing with PTH (p = 0.08)., Discussion: The prevalence of PTH in our study is 2.7%. Factors which may be associated with a higher probability of developing PTH may include IVH, SAH, severity of TBI, and subdural haematoma. We propose a national prospective multicentre database of paediatric PTH. The data collected on prevalence, presentation, risk factors, and management could guide contemporary management and improve the outcomes of children with PTH.

Objectives  Controversy exists surrounding the optimal approaches to tuberculum sella meningioma (TSM) and planum meningioma (PM). Olfaction is infrequently considered within this context but is nonetheless an important quality of life measure. The evolution of olfactory outcomes following contemporary transcranial surgery remains unclear. This study reviews olfactory outcomes after supraorbital craniotomy for TSM or PM and defines temporal trends in its recovery. Study Design  A prospective study of a patients who underwent a minimally invasive supraorbital craniotomy for TSM or PM was conducted at a single neurosurgical center. Participants & Main Outcome Measures  All patients were questioned about olfaction at presentation 3 months postoperatively, 12 months postoperatively, and annually thereafter (median follow-up = 37 months). The olfactory status of patients was categorized as normosmia, anosmia, hyposmia, parosmia, (altered perception of odours), or phantosmia, (olfactory hallucinations). Results  Twenty-two patients were included in the study analysis, (range = 27-76). Precisely, 3 months after surgery, seven patients had normal olfaction (32%). Six patients were anosmic, (27%) four hyposmic, (18%), three parosmic, (14%), and two were phantosmic (9%). At 1-year follow-up, almost half of patients (10; 48%) were normosmic, while two patients (9.5%) were anosmic. There were no further improvements in olfaction between 1 year and long-term follow-up. Conclusion  Subfrontal transcranial approaches for TSM or PM appear to be associated with changes in olfaction that can improve with time; these improvements occur within the first year after surgery. Impacts upon olfaction should be considered when selecting a surgical approach and patients counseled appropriately., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Background: Cardiovascular diseases (CVDs) are the leading cause of mortality in India. India has rolled out Comprehensive Primary Health Care (CPHC) reforms including population based screening for hypertension and diabetes, facilitated by frontline health workers. Our study assessed blood pressure and blood sugar coverage achieved by frontline workers using Lot Quality Assurance Sampling (LQAS)., Methods: LQAS Supervision Areas were defined as catchments covered by frontline workers in primary health centres in two districts each of Uttar Pradesh and Delhi. In each Area, 19 households for each of four sampling universes (males, females, Above Poverty Line (APL) and Below Poverty Line (BPL)) were visited using probability proportional to size sampling. Following written informed consent procedures, a short questionnaire was administered to individuals aged 30 or older using tablets related to screening for diabetes and hypertension. Using the LQAS hand tally method, coverage across Supervision Areas was determined., Results: A sample of 2052 individuals was surveyed, median ages ranging from 42 to 45 years. Caste affiliation, education levels, and occupation varied by location; the sample was largely married and Hindu. Awareness of and interaction with frontline health workers was reported in Uttar Pradesh and mixed in Delhi. Greater coverage of CVD risk factor screening (especially blood pressure) was seen among females, as compared to males. No clear pattern of inequality was seen by poverty status; some SAs did not have adequate BPL samples. Overall, blood pressure and blood sugar screening coverage by frontline health workers fell short of targeted coverage levels at the aggregate level, but in all sites, at least one area was crossing this threshold level., Conclusion: CVD screening coverage levels at this early stage are low. More emphasis may be needed on reaching males. Sex and poverty related inequalities must be addressed by more closely studying the local context and models of service delivery where the threshold of screening is being met. LQAS is a pragmatic method for measuring program inequalities, in resource-constrained settings, although possibly not for spatially segregated population sub-groups.

Background: Expansion of telehealth is a high-priority strategic initiative for many health systems. Surgical clinics' implementation of video visits has been identified as a way to improve patient and provider experience. However, whether using video visits can reduce the cost of an outpatient visit is unknown., Methods: Prospective case study using time-driven activity-based costing at two outpatient surgical clinics at an academic institution. We conducted stakeholder interviews and in-person observations to map outpatient clinic flow and measure resource utilization of four key steps: check-in, vitals collection and rooming, clinician encounter, and check-out. Finally, we calculated the resource cost for each step using representative salary information to calculate total visit cost., Results: Video visits did not systematically reduce the amount of time clinicians spent with patients. Mean [standard deviation (SD)] visit costs were as follows: traditional clinic visits, $26.84 ($10.13); physician-led video visits, $27.26 ($9.69); and physician assistant-led video visits, $9.86 ($2.76). There was no significant difference in the total cost associated with physician-led traditional clinic visits and video visits (P=0.89). However, physician assistant-led video visits were significantly lower cost than physician-led video visits (P<0.001)., Conclusions: Using physician-led video visits does not reduce the cost of outpatient surgical visits when compared to traditional clinic visits. However, the use of less expensive clinician resources for video visits (e.g., physician-assistants) may yield cost savings for clinics., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/mhealth-20-33). DSP reports grants from Blue Cross Blue Shield of Michigan Foundation, during the conduct of the study; CE reports grants from MPrOVE Research Challenge Grant, during the conduct of the study. The other authors have no conflicts of interest to declare., (2020 mHealth. All rights reserved.)

Background: In 2017, India was home to nearly 20% of maternal and child deaths occurring globally. Accredited social health activists (ASHAs) act as the frontline for health services delivery in India, providing a range of reproductive, maternal, newborn, child health, and nutrition (RMNCH&N) services. Empirical evidence on ASHAs' knowledge is limited, yet is a critical determinant of the quality of health services provided. We assessed the determinants of RMNCH&N knowledge among ASHAs and examined the reliability of alternative modalities of survey delivery, including face-to-face and caller attended telephone interviews (phone surveys) in 4 districts of Madhya Pradesh, India., Methods: We carried out face-to-face surveys among a random cross-sectional sample of ASHAs (n = 1,552), and administered a follow-up test-retest survey within 2 weeks of the initial survey to a subsample of ASHAs (n = 173). We interviewed a separate sub-sample of ASHAs 2 weeks of the face-to-face interview over the phone (n = 155). Analyses included bivariate analyses, multivariable linear regression, and prevalence and bias adjusted kappa analyses., Findings: The average ASHA knowledge score was 64% and ranged across sub-domains from 71% for essential newborn care, 71% for WASH/ diarrhea, 64% for infant feeding, 61% for family planning, and 60% for maternal health. Leading determinants of knowledge included geographic location, age <30 years of age, education, experience as an ASHA, completion of seven or more client visits weekly, phone ownership and use as a communication tool for work, as well as the ability to navigate interactive voice response prompts (a measure of digital literacy). Efforts to develop a phone survey tool for measuring knowledge suggest that findings on inter-rater and inter-modal reliability were similar. Reliability was higher for shorter, widely known questions, including those about timing of exclusive breastfeeding or number of tetanus shots during pregnancy. Questions with lower reliability included those on sensitive topics such as family planning; questions with multiple response options; or which were difficult for the enumerator to convey., Conclusions: Overall results highlight important gaps in the knowledge of ASHAs. Findings on the reliability of phone surveys led to the development of a tool, which can be widely used for the routine, low cost measurement of ASHA RMNCH&N knowledge in India., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To evaluate overall survival for atypical teratoid rhabdoid tumors (ATRTs) in relation to extent of surgical resection., Methods: The neurosurgical tumor databases from three UK Pediatric centers (University Hospital of Wales, Alder Hey and Royal Manchester Children's Hospital) were analyzed. Patients with a diagnosis of ATRT were identified between 2000 and 2018. Data was collected regarding demographics, extent of resection, complications, and overall survival., Results: Twenty-four patients diagnosed with ATRT underwent thirty-eight operations. The age range was 20 days to 147 months (median 17.5 months). The most common location for the tumor was the posterior fossa (nine patients; 38%). Six patients (25%) underwent a complete total resection (CTR), seven (29%) underwent a near total resection (NTR), eight (33.3%) underwent a subtotal resection (STR), and three patients (12.5%) had biopsy only. Two-thirds of patients who underwent a CTR are still alive, as of March 2019, compared to 29% in the NTR and 12.5% in the STR groups. Out of the thirty-eight operations, there were a total of twenty-two complications, of which the most common was pseudomeningocele (27%). The extent of surgical resection (p = 0.021), age at surgery (p = 0.00015), and the presence of metastases at diagnosis (0.015) significantly affected overall survival., Conclusions: Although these patients are a highly vulnerable group, maximal resection is recommended where possible, for the best chance of long-term survival. However, near total resections are likely beneficial when compared with subtotal resections and biopsy alone. Maximal surgical resection should be combined with adjuvant therapies for the best long-term outcomes.

Introduction: Vitamin D deficiency is common in spinal surgery and critical care. Hypovitaminosis D may impact on outcomes in cranial neurosurgical care and play roles in underlying disease processes., Methods: A prospective observational cohort study was performed. All emergency cranial neurosurgical ward admissions from 1st January to 10th May 2017 were screened for inclusion (n = 406). Patients already receiving vitamin D supplementation, spinal patients and elective admissions were excluded. Admission vitamin D levels were checked for all remaining patients (n = 95). Patients with vitamin D <30 nmol/L were defined as "deficient" and those 30-50 nmol/L as "inadequate." All patients with levels <50 nmol/L were replaced, as per local guidelines. Descriptive analyses of the cohorts were undertaken, with multivariate regression used to assess the effect of vitamin D on length of stay, inpatient morbidity and mortality., Results: The median age of participants was 61 years (n = 95; 57% male, 43% female). The median vitamin D level was 23 nmol/L (deficient). 84% (n = 80) of patients had low vitamin D levels, with 61% (n = 58) classed as deficient (<30 nmol/L). Vitamin D deficiency rates were similar in those aged below 65 years (86%; n = 38/44) and those above 65 years (82%; n = 42/51). Deficient vitamin D level was associated with longer hospital stay ( P  = .03), and this relationship persisted after adjusting for potential confounders such as age, sex and preadmission Charlson co-morbidity index. No statistically significant association was seen with vitamin D status and inpatient morbidity or mortality., Conclusions: Vitamin D deficiency is common in cranial neurosurgical patients, even in predefined low-risk groups (age <65). Lower vitamin D level was associated with longer length of stay. This study supports the need for: (a) further investigation into the roles of vitamin D in neurosurgical pathologies and management and (b) an appropriately powered, randomised investigation into the impact of vitamin D status upon neurosurgical diagnoses and complications., Competing Interests: The authors have no conflicts of interests to report. The data that support the findings of this study are available from the corresponding author upon reasonable request., (© 2019 The Authors. Endocrinology, Diabetes & Metabolism published by John Wiley & Sons Ltd.)

A 69-year-old woman presented with an 8-month history of diplopia and examination findings consistent with a right third-nerve palsy. Head MRI identified the presence of a 5.8 mm, nodular, isointense lesion in the suprasellar cistern, which demonstrated enhancement with gadolinium contrast. The lesion did not show any evidence of growth over a 3-month follow-up period. These MRI findings, alongside the clinical features, suggest oculomotor nerve schwannoma. Oculomotor schwannomas are a rare cause of third-nerve palsy. The presenting features and management options for oculomotor schwannomas are discussed to provide a framework for the diagnosis and management of these patients., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The National Family Health Survey-4 in India provided the first nationally representative estimates of hysterectomy among women aged 15-49. This paper aims to examine the national and state-level age-specific prevalence of hysterectomy, individual and household level factors associated with the procedure, and state-level indicators that may explain variation across states., Design: Cross-sectional, nationally representative household survey., Setting: National Family Health Survey was conducted across all Indian states and union territories between 2015 and 2016., Population: The survey covered 699 686 women between the ages of 15 and 49 years., Methods: Descriptive analyses and multivariate logistic regression., Main Outcome Measures: Women who reported ever having a hysterectomy and age at hysterectomy., Results: Age-specific prevalence of hysterectomy was 0.36% (0.33,0.39) among women aged 15-29; 3.59% (3.45,3.74) among women aged 30-39; and 9.20% (8.94,9.46) among women 40-49 years. There was considerable variation in prevalence by state. Four states reported age-specific prevalence similar to high-income settings. Approximately two-thirds of hysterectomies were conducted in private facilities, with similar patterns across age groups. At the national level, higher age and parity (at least two children); not having had formal schooling; rural residence (adjusted odds ratio [AOR] 1.36; 95% CI 1.27,1.45; P < 0.01) and higher wealth status were associated with higher odds of hysterectomy. Previously sterilised women had lower odds (AOR 0.64; 95% CI 0.61,0,68; P < 0.01) of reporting hysterectomy. Exploratory analyses suggest state-level factors associated with prevalence of hysterectomy include caesarean section, female illiteracy, and women's employment., Conclusions: Hysterectomy patterns among women aged 15-49 in India indicate the critical need to ensure treatment options for gynaecological morbidity and to address hysterectomy among young women in particular., Funding: This study was part of the RASTA initiative of the Population Council's India country office under the Evidence Project supported by USAID., Tweetable Abstract: Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women., (© 2019 The Authors BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Health systems are critical for health outcomes as they underpin intervention coverage and quality, promote users' rights and intervene on the social determinants of health. Governance is essential for health system endeavours as it mobilises and coordinates a multiplicity of actors and interests to realise common goals. The inherently social, political and contextualised nature of governance, and health systems more broadly, has implications for measurement, including how the health of women, children and adolescents health is viewed and assessed, and for whom. Three common lenses, each with their own views of power dynamics in policy and programme implementation, include a service delivery lens aimed at scaling effective interventions, a societal lens oriented to empowering people with rights to effect change and a systems lens concerned with creating enabling environments for adaptive learning. We illustrate the implications of each lens for the why , what and how of measuring health system drivers across micro, meso and macro health systems levels, through three examples (digital health, maternal and perinatal death surveillance and review, and multisectoral action for adolescent health). Appreciating these underpinnings of measuring health systems and governance drivers of the health of women, children and adolescents is essential for a holistic learning and action agenda that engages a wider range of stakeholders, which includes, but also goes beyond, indicator-based measurement. Without a broadening of approaches to measurement and the types of research partnerships involved, continued investments in the health of women, children and adolescents will fall short., Competing Interests: Competing interests: None declared.

Introduction: Ventriculo-peritoneal shunts (VPS) are still the mainstay treatment for hydrocephalus in children. It is generally accepted that VPS failure and infection rates are higher for neonates than for older children. We compared our 1-year failure and infection rates in under 3-month-old children compared with older children in our department. Results: We identified 58 children under 3 months of age who underwent VPS insertion between January 2007 and December 2016. They had a 29.3% (17) shunt failure rate over the first year. There were two confirmed shunt infections (3.4%). Discussion: The 1-year shunt failure rate at our institution for VPS insertion in children over 3 months is 26.1% and the infection rate is 4.3% (9). The literature suggests that the outcome for VPS in younger children is worse than for older children. Our work shows similar outcomes for all children compared to those under 3 months at time of VPS insertion alone. Conclusion: Children under 3-months-old undergoing VPS insertion should not automatically expect an increased 1-year failure or infection rate compared with older children. The reasons for this may be as a result of increased subspecialisation, the more widespread use of antibiotic-impregnated catheters and improved neonatal care.

Background: Respectful maternity care (RMC) is a key barometer of the underlying quality of care women receive during pregnancy and childbirth. Efforts to measure RMC have largely been qualitative, although validated quantitative tools are emerging. Available tools have been limited to the measurement of RMC during childbirth and confined to observational and face-to-face survey modes. Phone surveys are less invasive, low cost, and rapid alternatives to traditional face-to-face methods, yet little is known about their validity and reliability., Objective: The primary objective of this study was to develop validated face-to-face and phone survey tools for measuring RMC during pregnancy and childbirth for use in India and other low resource settings. The secondary objective was to optimize strategies for improving the delivery of phone surveys for use in measuring RMC., Methods: To develop face-to-face and phone surveys for measuring RMC, we describe procedures for assessing content, criterion, and construct validity as well as reliability analyses. To optimize the delivery of phone surveys, we outline plans for substudies, which aim to assess the effect of survey modality, and content on survey response, completion, and attrition rates., Results: Data collection will be carried out in 4 districts of Madhya Pradesh, India, from July 2018 to March 2019., Conclusions: To our knowledge, this is the first RMC phone survey tool developed for India, which may provide an opportunity for the rapid, routine collection of data essential for improving the quality of care during pregnancy and childbirth. Elsewhere, phone survey tools are emerging; however, efforts to develop these surveys are often not inclusive of rigorous pretesting activities essential for ensuring quality data, including cognitive, reliability, and validity testing. In the absence of these activities, emerging data could overestimate or underestimate the burden of disease and health care practices under assessment. In the context of RMC, poor quality data could have adverse consequences including the naming and shaming of providers. By outlining a blueprint of the minimum activities required to generate reliable and valid survey tools, we hope to improve efforts to develop and deploy face-to-face and phone surveys in the health sector., International Registered Report Identifier (irrid): DERR1-10.2196/12173., (©Amnesty E LeFevre, Kerry Scott, Diwakar Mohan, Neha Shah, Aarushi Bhatnagar, Alain Labrique, Diva Dhar, Sara Chamberlain, Rajani Ved. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 25.04.2019.)

Background: India's accredited social health activist (ASHA) programme consists of almost one million female community health workers (CHWs). Launched in 2005, there is now an ASHA in almost every village and across many urban centres who support health system linkages and provide basic health education and care. This paper examines how the programme is seeking to address gender inequalities facing ASHAs, from the programme's policy origins to recent adaptations., Methods: We reviewed all publically available government documents (n = 96) as well as published academic literature (n = 122) on the ASHA programme. We also drew from the embedded knowledge of this paper's government-affiliated co-authors, triangulated with key informant interviews (n = 12). Data were analysed thematically through a gender lens., Results: Given that the initial impetus for the ASHA programme was to address reproductive and child health issues, policymakers viewed volunteer female health workers embedded in communities as best positioned to engage with beneficiaries. From these instrumentalist origins, where the programme was designed to meet health system demands, policy evolved to consider how the health system could better support ASHAs. Policy reforms included an increase in the number and regularity of incentivized tasks, social security measures, and government scholarships for higher education. Residential trainings were initiated to build empowering knowledge and facilitate ASHA solidarity. ASHAs were designated as secretaries of their village health committees, encouraging them to move beyond an all-female sphere and increasing their role in accountability initiatives. Measures to address gender based violence were also recently recommended. Despite these well-intended reforms and the positive gains realized, ongoing tensions and challenges related to their gendered social and employment status remain, requiring continued policy attention and adaptation., Conclusions: Gender trade offs and complexities are inherent to sustaining CHW programmes at scale within challenging contexts of patriarchal norms, health system hierarchies, federal governance structures, and evolving aspirations, capacities, and demands from female CHWs. Although still grappling with significant gender inequalities, policy adaptations have increased ASHAs' access to income, knowledge, career progression, community leadership, and safety. Nonetheless, these transformative gains do not mark linear progress, but rather continued adaptations.

Background: Telemedicine utilization, including use of video visits, is growing rapidly. While much enthusiasm surrounds telemedicine, the successful implementation of video visits within health systems requires providers to evaluate patient's experience with the implemented technology and workflow., Methods: Twenty patients who completed a video visit in the Department of Urology at Michigan Medicine were contacted and asked if they would be willing to share their experience. Patients underwent a semi-structured telephone interview. Using an interview guide, patients were asked questions about the enrollment process, their overall impression of the visit, and feedback to improve the visit. Interview comments were categorized into three primary themes: usability, quality of the visit, and comparison to a traditional in-clinic visit., Results: Most patients who underwent a urological video visit were highly satisfied with their experience. Most patients also reported being able to join the video visit with minimal issues. However, some patients expressed issues downloading the application and interpreting our educational materials. In regard to quality of the visit, most patients were impressed and pleased. While there was no criticism regarding the picture-quality of the video visit, a few patients reported issues with the audio. It was apparent that quality of video was dependent on quality of the patient's internet connection. When comparing the video visit to a traditional in-clinic visit, patients-especially parents with children at home-found the video visit to be more efficient., Conclusions: Our study found that patients were pleased with their urological video visit experience, and there were details about our workflow that would not have been evident without interviews. These findings suggest that while video visits are suitable alternatives to in-clinic appointments at academic medical centers, it is important for providers to obtain direct feedback from patients to identify workflow and technical issues., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

India's National Health Mission constituted Village Health Sanitation and Nutrition Committees (VHSNCs) as a key mechanism for community health governance. Health committees provide citizens with the opportunity to shape health systems and policies. Yet much remains to be learnt on how best to sustain health committees as vehicles for community health governance at scale. This paper reflects on the authors' experiences of introducing revised guidelines and an institutional support package for VHSNCs in two pilot settings in India and outlines lessons we learnt for sustaining community health governance at geographic scale. We describe the importance of ensuring norms for equitable participation, aligning committee rules with existing forms of decentralised government and providing key supports in terms of engaging NGOs as key implementation facilitators. Integration with rigid and unresponsive government administrative structures however remains a persistent challenge for scaling up health committees. With sustained financial support and strategic deployment of key personnel, VHSNCs could pave the way for more equitable and effective community participation in health governance at scale., Competing Interests: Competing interests: None declared.

Background: Efforts to work with civil society to strengthen community participation and action for health are particularly important in Gujarat, India, given that the state has resources and capacity, but faces challenges in ensuring that services reach those most in need. To contribute to the knowledge base on accountability and maternal health, this study examines the equity effects of community action for maternal health led by Non-Government Organizations (NGOs) on facility deliveries. It then examines the underlying implementation processes with implications for strengthening accountability of maternity care across three districts of Gujarat, India. Community action for maternal health entailed NGOs a) working with community collectives to raise awareness about maternal health entitlements, b) supporting community monitoring of outreach government services, and c) facilitating dialogue with government providers and authorities with report cards based on community monitoring of maternal health., Methods: The study combined qualitative data (project documents and 56 stakeholder interviews thematically analyzed) with quantitative data (2395 women's self-reported receipt of information on entitlements and use of services over 3 years of implementation monitored prospectively through household visits). Multivariable logistic regression examined delivery care seeking and equity., Results: In the marginalised districts, women reported substantial increases in receipt of information of entitlements and utilization of antenatal and delivery care. In the marginalized and wealthier districts, a switch from private facilities to public ones was observed for the most vulnerable. Supportive implementation factors included a) alignment among NGO organizational missions, b) participatory development of project tools, c) repeated capacity building and d) government interest in improving utilization and recognition of NGO contributions. Initial challenges included a) confidence and turnover of volunteers, b) complexity of the monitoring tool and c) scepticism from both communities and providers., Conclusion: With capacity and trust building, NGOs supporting community based collectives to monitor health services and engage with health providers and local authorities, over time overcame implementation challenges to strengthen public sector services. These accountability efforts resulted in improvements in utilisation of public sector services and a shift away from private care seeking, particularly for the marginalised.

Competing Interests: Competing interests: All authors have completed the Unified Competing Interest form. We have read and understood BMJ policy on declaration of interests and declare no conflicts of interest. The authors alone are responsible for the views expressed in this article, which does not necessarily represent the views, decisions, or policies of the institutions with which the authors are affiliated.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Background: Xanthogranulomas are inflammatory masses most commonly found at peripheral sites such as the skin. Sellar and parasellar xanthogranulomas are rare and present a diagnostic challenge as they are difficult to differentiate from other sellar lesions such as craniopharyngiomas and Rathke's cleft cysts pre-operatively. Their radiological imaging features are yet to be clearly defined, and clinical outcomes after surgery are also uncertain. This study reviews clinical presentation, radiological appearances, and clinical outcomes in a cohort of patients with pituitary xanthogranulomas., Methods: A prospectively maintained pituitary surgery database was screened for histologically confirmed pituitary xanthogranulomas between May 2011-December 2016. Retrospective case note assessments were then performed by three independent reviewers. Patient demographics, clinical presentations, imaging, and clinical outcomes were analysed., Results: During the study period 295 endoscopic endonasal pituitary surgeries were performed. Six patients had confirmed pituitary xanthogranulomas (2%). Patients most commonly presented with visual field deficits and/or endocrine dysfunction. Common imaging features included: a cystic consistency, hyperintensity on T1-weighted MR images, and contrast enhancement either peripherally (n = 3) or homogenously (n = 3). The most common pre-operative endocrine deficits were hyperprolactinaemia and hypoadrenalism (at least one of which was identified in 4/6 patients; 66%). Thirty-three percent (2/6) of patients presented with diabetes insipidus. The most common post-operative endocrinological deficits were adrenocortical dysfunction (66%) and gonadotropin deficiency (66%). Visual assessments normalised in all six patients post-operatively. Gross total resection was achieved in all patients, and at median follow up of 33.5 months there were no cases of tumour recurrence., Conclusions: The prevalence of pituitary xanthogranulomas in our series is higher than that suggested in the literature. Surgery restored normal vision to all cases, however four patients (67%) required long-term hormonal replacement post-operatively. Imaging features such peripheral rim enhancement, a suprasellar tumour epicentre, and the absence of both calcification or cavernous sinus invasion were identified as potential indicators that together should alert clinicians to the possibility of pituitary xanthogranuloma when assessing patients with cystic sellar and parasellar tumours.

Background: Zingiber montanum (J.Koenig) Link ex A.Dietr. (Zingiberaceae), commonly known as cassumunar-ginger, is a folk remedy for the treatment of inflammations, sprains, rheumatism and asthma. The aim of the present study was to assess the chemical composition, and antibacterial, antifungal, allelopathic and acetylcholinesterase inhibitory activities of the essential oil of Z. montanum originating from India., Results: The hydrodistilled essential oil of Z. montanum rhizome was analyzed using gas chromatography-flame ionization detection and gas chromatography-mass spectrometry. A total of 49 constituents, forming 98.7-99.9% of the total oil compositions, was identified. The essential oil was characterized by higher amount of monoterpene hydrocarbons (32.6-43.5%), phenylbutanoids (27.5-41.2%) and oxygenated monoterpenes (11.4-34.1%). Major constituents of the oil were sabinene (13.5-38.0%), (E)-1-(3',4'-dimethoxyphenyl)buta-1,3-diene (DMPBD) (20.6-35.3%), terpinen-4-ol (9.0-31.3%), γ-terpinene (1.1-4.8%) and β-phellandrene (1.0-4.4%). The oil was evaluated against eight pathogenic bacteria and two fungal strains. It exhibited low to good antibacterial activity (minimum inhibitory concentration: 125-500 µg mL -1 ) and moderate antifungal activity (250 µg mL -1 ) against the tested strains. The oil reduced germination (69.8%) and inhibited the root and shoot growth of lettuce significantly (LD 50 : 3.58 µL plate -1 ). However, it did not demonstrate acetylcholinesterase inhibitory activity up to a concentration of 10 mg mL -1 ., Conclusions: The essential oil of Z. montanum can be used as a potential source of DMPBD, terpinen-4-ol and sabinene for pharmaceutical products. The results of the present study add significant information to the pharmacological activity of Z. montanum native to India. © 2017 Society of Chemical Industry., (© 2017 Society of Chemical Industry.)

Fish-mint (Houttuynia cordataThunb.), belonging to family Saururaceae, has long been used as food and traditional herbal medicine. The present study was framed to assess the changes occurring in the essential-oil composition of H. cordata during annual growth and to evaluate allelopathic, antibacterial, antifungal, and antiacetylcholinesterase activities. The essential-oil content ranged from 0.06 - 0.14% and 0.08 - 0.16% in aerial parts and underground stem, respectively. The essential oils were analysed by GC-FID, GC/MS, and NMR ( 1 H and 13 C). Major constituents of aerial-parts oil was 2-undecanone (19.4 - 56.3%), myrcene (2.6 - 44.3%), ethyl decanoate (0.0 - 10.6%), ethyl dodecanoate (1.1 - 8.6%), 2-tridecanone (0.5 - 8.3%), and decanal (1.1 - 6.9%). However, major constituents of underground-stem oil were 2-undecanone (29.5 - 42.3%), myrcene (14.4 - 20.8%), sabinene (6.0 - 11.1%), 2-tridecanone (1.8 - 10.5%), β-pinene (5.3 - 10.0%), and ethyl dodecanoate (0.8 - 7.3%). Cluster analysis revealed that essential-oil composition varied substantially due to the plant parts and season of collection. The oils exhibited significant allelopathic (inhibition: 77.8 - 88.8%; LD 50 : 2.45 - 3.05 μl/plate), antibacterial (MIC: 0.52 - 2.08 μl/ml; MBC: bacteriostatic) and antifungal (MIC: 2.08 - 33.33 μl/ml; MFC: 4.16 - 33.33 μl/ml) activities. The results indicate that the essential oil from H. cordata has a significant potential to allow future exploration and exploitation as a natural antimicrobial and allelopathic agent., (© 2017 Wiley-VHCA AG, Zurich, Switzerland.)

Health committees are a common strategy to foster community participation in health. Efforts to strengthen committees often focus on technical inputs to improve committee form (e.g. representative membership) and functioning (e.g. meeting procedures). However, porous and interconnected contextual spheres also mediate committee effectiveness. Using a framework for contextual analysis, we explored the contextual features that facilitated or hindered Village Health, Sanitation and Nutrition Committee (VHSNC) functionality in rural north India. We conducted interviews (n = 74), focus groups (n = 18) and observation over 1.5 years. Thematic content analysis enabled the identification and grouping of themes, and detailed exploration of sub-themes. While the intervention succeeded in strengthening committee form and functioning, participant accounts illuminated the different ways in which contextual influences impinged on VHSNC efficacy. Women and marginalized groups navigated social hierarchies that curtailed their ability to assert themselves in the presence of men and powerful local families. These dynamics were not static and unchanging, illustrated by pre-existing cross-caste problem solving, and the committee's creation of opportunities for the careful violation of social norms. Resource and capacity deficits in government services limited opportunities to build relationships between health system actors and committee members and engendered mistrust of government institutions. Fragmented administrative accountability left committee members bearing responsibility for improving local health without access to stakeholders who could support or respond to their efforts. The committee's narrow authority was at odds with widespread community needs, and committee members struggled to involve diverse government services across the health, sanitation, and nutrition sectors. Multiple parallel systems (political decentralization, media and other village groups) presented opportunities to create more enabling VHSNC contexts, although the potential to harness these opportunities was largely unmet. This study highlights the urgent need for supportive contexts in which people can not only participate in health committees, but also access the power and resources needed to bring about actual improvements to their health and wellbeing.

Purpose: This study evaluates the quality of information available on the internet for carers of children with epilepsy considering treatment with Vagus Nerve Stimulation (VNS)., Methods: Selected key phrases were entered into two popular search engines (Google™, Yahoo™). These phrases were: "Vagus nerve stimulator", alone and in combination with "childhood epilepsy", "paediatric epilepsy" and "epilepsy in childhood"; "VNS", and "VNS epilepsy". The first 50 hits per search were then screened. Of 600 identified sites, duplicated (262), irrelevant (230) and inaccessible (15) results were excluded. 93 websites were identified for evaluation using the DISCERN instrument, an online validation tool for patient information websites., Results: The mean DISCERN score of all analysed websites was 39/80 (49%; SD 13.5). This equates to Fair to borderline Poor global quality, (Excellent=80-63; Good=62-51; Fair=50-39; Poor=38-27; Very poor=26-15). None of the analysed sites obtained an Excellent quality rating. 13% (12) obtained a Good score, 40% (37) obtained an Average score, 35% (33) obtained a Poor score, and 12% (11) obtained a Very poor score. The cohort of websites scored particularly poorly on assessment of whether reliable, holistic information was presented, for instance provision of reliable sources, (28%, SD 18) and discussion of alternative treatments, (30%, SD 14)., Conclusion: To facilitate patient-centred shared decision-making, high quality information needs to be available for patients and families considering VNS. This study identifies that such information is difficult to locate on the internet. There is a need to develop focussed and reliable online patient resources for VNS., (Copyright © 2017 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Purpose: The ventriculoperitoneal (VP) shunt has become the procedure of choice for treatment of idiopathic intracranial hypertension (IIH). We aimed to assess the efficacy of frameless stereotactic placement of VP shunts for the management of medically resistant IIH in children and to assess the role of gender and obesity in the aetiology of the condition., Methods: This is a retrospective analysis of the case notes of 10 patients treated surgically at the University Hospital of Wales in Cardiff, from May 2006 to September 2012., Results: VP shunts were successful in relieving headache, papilloedema and stabilising vision. No sex predilection was identified, and increased BMI was a feature throughout the population, regardless of age., Conclusions: Neuronavigated VP shunt insertion is an effective mode of treatment for medically resistant IIH in children. The aetiological picture in children does not seem to be dominated by obesity, as in adults. Literature on childhood IIH is sparse, and larger scale, comparative studies would be of benefit to treating clinicians.

Background: Convergence of sectoral programs is important for scaling up essential maternal and child health and nutrition interventions. In India, these interventions are implemented by two government programs - Integrated Child Development Services (ICDS) and National Rural Health Mission (NRHM). These programs are designed to work together, but there is limited understanding of the nature and extent of coordination in place and needed at the various administrative levels. Our study examined how intersectoral convergence in nutrition programming is operationalized between ICDS and NRHM from the state to village levels in Odisha, and the factors influencing convergence in policy implementation and service delivery., Methods: Semi-structured interviews were conducted with state-level stakeholders (n = 12), district (n = 19) and block officials (n = 66), and frontline workers (FLWs, n = 48). Systematic coding and content analysis of transcripts were undertaken to elucidate themes and patterns related to the degree and mechanisms of convergence, types of actions/services, and facilitators and barriers., Results: Close collaboration at state level was observed in developing guidelines, planning, and reviewing programs, facilitated by a shared motivation and recognized leadership for coordination. However, the health department was perceived to drive the agenda, and different priorities and little data sharing presented challenges. At the district level, there were joint planning and review meetings, trainings, and data sharing, but poor participation in the intersectoral meetings and limited supervision. While the block level is the hub for planning and supervision, cooperation is limited by the lack of guidelines for coordination, heavy workload, inadequate resources, and poor communication. Strong collaboration among FLWs was facilitated by close interpersonal communication and mutual understanding of roles and responsibilities., Conclusions: Congruent or shared priorities and regularity of actions between sectors across all levels will likely improve the quality of coordination, and clear roles and leadership and accountability are imperative. As convergence is a means to achieving effective coverage and delivery of services for improved maternal and child health and nutrition, focus should be on delivering all the essential services to the mother-child dyads through mechanisms that facilitate a continuum of care approach, rather than sectorally-driven, service-specific delivery processes.

Background: Longstanding overt ventriculomegaly in adults (LOVA) is characterised by chronic hydrocephalus presumed to begin during infancy, but arresting before becoming clinically detectable. Later in life clinical features of hydrocephalus ensue, typically in the 5th or 6th decades. Only a relatively small number of LOVA case series have been published, and ambiguity remains regarding optimal management. This case series describes a series of patients with LOVA treated successfully at a single neurosurgical institution using endoscopic third ventriculostomy (ETV)., Methods: A series of 14 patients were diagnosed with LOVA using established clinical and radiological criteria. All patients underwent an ETV and their clinical conditions were followed up for up to 5 years post-operatively., Results: Fourteen patients (100 %) reported either improvement or halt of progression in their presenting symptoms 3 months after ETV; 93 % of patients (n = 13) did not require any further surgical intervention. One patient (7 %) reported deterioration in symptoms beyond 3 months post-operatively, which necessitated further surgery (ventriculoperitoneal shunt). These promising outcomes after ETV are mirrored in numerous other LOVA case series. Other works have analysed the value of CSF shunting procedures in LOVA, with mixed results. A direct, prospective comparison of outcomes after shunt procedures and ETV, with a specific focus on LOVA patients, is yet to be completed. A minority of patients fail to respond, or develop recurrence of symptoms, months or years after initial surgical intervention., Conclusions: ETV is an attractive option for surgical treatment of LOVA. After surgical treatment for LOVA, long-term follow-up should be considered to screen for late recurrence of the condition., Competing Interests: Compliance with ethical standards Funding No funding was received for this research. Conflict of interest All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. The authors declare that they have no conflicts of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study.

The differential diagnosis for inflammatory neck swellings is vast. A swelling of dental origin should be considered because, while rare, they mimic more common causes of neck lumps. We report the case involving a recurrent submandibular swelling in a young female patient that was presumed to be an epidermoid cyst by her general medical practitioner. After 6 months of unsuccessful treatment in the community, an odontogenic source was identified and treated successfully following referral to a local Oral and Maxillofacial department., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

A 42-year-old man arrived at the emergency department in severe respiratory distress, requiring immediate intubation and ventilation. An emergency computed tomography (CT) neck scan identified a substantial haematoma within a multinodular goitre, necessitating an emergency total thyroidectomy. It was later discovered that the patient had been the victim of an assault involving blunt trauma to the anterior neck. Five days postoperatively the patient was extubated and was well enough to self-discharge the following day. Pathology revealed the lesion to be a ruptured follicular adenoma within his multinodular goitre. Signs of this rare but life-threatening condition may be subtle on initial presentation, particularly if the patient is obtunded. Patients with suspected blunt neck trauma should be observed for signs of respiratory distress. If this develops, the patient should be intubated to facilitate CT scan, and if thyroid haematoma is confirmed, emergency thyroidectomy is the definitive treatment.

Health committees, councils or boards (HCs) mediate between communities and health services in many health systems. Despite their widespread prevalence, HC functions vary due to their diversity and complexity, not least because of their context specific nature. We undertook a narrative review to better understand the contextual features relevant to HCs, drawing from Scopus and the internet. We found 390 English language articles from journals and grey literature since 1996 on health committees, councils and boards. After screening with inclusion and exclusion criteria, we focused on 44 articles. Through an iterative process of exploring previous attempts at understanding context in health policy and systems research (HPSR) and the HC literature, we developed a conceptual framework that delineates these contextual factors into four overlapping spheres (community, health facilities, health administration, society) with cross-cutting issues (awareness, trust, benefits, resources, legal mandates, capacity-building, the role of political parties, non-governmental organizations, markets, media, social movements and inequalities). While many attempts at describing context in HPSR result in empty arenas, generic lists or amorphous detail, we suggest anchoring an understanding of context to a conceptual framework specific to the phenomena of interest. By doing so, our review distinguishes between contextual elements that are relatively well understood and those that are not. In addition, our review found that contextual elements are dynamic and porous in nature, influencing HCs but also being influenced by them due to the permeability of HCs. While reforms focus on tangible HC inputs and outputs (training, guidelines, number of meetings held), our review of contextual factors highlights the dynamic relationships and broader structural elements that facilitate and/or hinder the role of health committees in health systems. Such an understanding of context points to its contingent and malleable nature, links it to theorizing in HPSR, and clarifies areas for investigation and action., (Copyright © 2015. Published by Elsevier Ltd.)

Importance: Patients with colorectal cancer with liver metastases undergo hepatic resection with curative intent. Positron emission tomography combined with computed tomography (PET-CT) could help avoid noncurative surgery by identifying patients with occult metastases., Objectives: To determine the effect of preoperative PET-CT vs no PET-CT (control) on the surgical management of patients with resectable metastases and to investigate the effect of PET-CT on survival and the association between the standardized uptake value (ratio of tissue radioactivity to injected radioactivity adjusted by weight) and survival., Design, Setting, and Participants: A randomized trial of patients older than 18 years with colorectal cancer treated by surgery, with resectable metastases based on CT scans of the chest, abdomen, and pelvis within the previous 30 days, and with a clear colonoscopy within the previous 18 months was conducted between 2005 and 2013, involving 21 surgeons at 9 hospitals in Ontario, Canada, with PET-CT scanners at 5 academic institutions., Interventions: Patients were randomized using a 2 to 1 ratio to PET-CT or control., Main Outcomes and Measures: The primary outcome was a change in surgical management defined as canceled hepatic surgery, more extensive hepatic surgery, or additional organ surgery based on the PET-CT. Survival was a secondary outcome., Results: Of the 263 patients who underwent PET-CT, 21 had a change in surgical management (8.0%; 95% CI, 5.0%-11.9%). Specifically, 7 patients (2.7%) did not undergo laparotomy, 4 (1.5%) had more extensive hepatic surgery, 9 (3.4%) had additional organ surgery (8 of whom had hepatic resection), and the abdominal cavity was opened in 1 patient but hepatic surgery was not performed and the cavity was closed. Liver resection was performed in 91% of patients in the PET-CT group and 92% of the control group. After a median follow-up of 36 months, the estimated mortality rate was 11.13 (95% CI, 8.95-13.68) events/1000 person-months for the PET-CT group and 12.71 (95% CI, 9.40-16.80) events/1000 person-months for the control group. Survival did not differ between the 2 groups (hazard ratio, 0.86 [95% CI, 0.60-1.21]; P = .38). The standardized uptake value was associated with survival (hazard ratio, 1.11 [90% CI, 1.07-1.15] per unit increase; P < .001). The C statistic for the model including the standardized uptake value was 0.62 (95% CI, 0.56-0.68) and without it was 0.50 (95% CI, 0.44-0.56). The difference in C statistics is 0.12 (95% CI, 0.04-0.21). The low C statistic suggests that the standard uptake value is not a strong predictor of overall survival., Conclusions and Relevance: Among patients with potentially resectable hepatic metastases of colorectal adenocarcinoma, the use of PET-CT compared with CT alone did not result in frequent change in surgical management. These findings raise questions about the value of PET-CT scans in this setting., Trial Registration: clinicaltrials.gov Identifier: NCT00265356.

Objectives: To document our experiences, technical procedure and outcomes of carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis., Material and Methods: A total of 49 consecutive patients underwent 53 CEAs (three bilateral, one redo) for severe carotid artery stenosis. There were 39 males and 10 females, with mean age of 63 years. All patients underwent neck Doppler, computed tomography/magnetic resonance angiography/digital substraction angiography and a detailed cardiological evaluation. Antiplatelet drugs were continued perioperatively. Surgery was performed under general anesthesia with propofol cerebral protection, mild hypothermia and continuous electroencephalogram monitoring. The procedure was done under microscope and closure was done using 6-0 prolene. Clinical and radiological follow-up was done., Results: Our mean follow-up was 4.69 years. All patients underwent primary suturing except one redo CEA done with venous patch graft. Three patients required intraoperative shunting. One patient died secondary to myocardial infarction peroperatively prior to carotid manipulation. One patient had stroke within 6 h, secondary to operative site intraluminal thrombus and was re-explored. Two patients had transient postoperative hemiparesis and aphasia while two patients had altered sensorium, all self-limiting, with normal imaging. One patient developed temporary twelfth-nerve paresis. One patient had persistent transient ischemic attack on the follow-up. Thus, the perioperative mortality rate was 1.89% and stroke rate was 1.89%., Conclusions: CEA for severe carotid stenosis is a safe procedure with good protection from ischemic events. Detailed preoperative cardiac evaluation and appropriate patient selection is essential.

Approximately one-quarter of all maternal deaths occur in India, far more than in any other nation on earth. Until 2005, maternal mortality reduction was not a priority in the country. In that year, the cause emerged on the national political agenda in a meaningful way for the first time. An unpredictable confluence of events concerning problem definition, policy alternative generation and politics led to this outcome. By 2005, evidence had accumulated that maternal mortality in India was stagnating and that existing initiatives were not addressing the problem effectively. Also in that year, national government officials and donors came to a consensus on a strategy to address the problem. In addition, a new government with social equity aims came to power in 2004, and in 2005, it began a national initiative to expand healthcare access to the poor in rural areas. The convergence of these developments pushed the issue on to the national agenda. This paper draws on public policy theory to analyse the Indian experience and to develop guidance for safe motherhood policy communities in other high maternal mortality countries seeking to make this cause a political priority.